Topic 9: Behavioral Exposure & Case Formulation and Treatment Plan {by 3/31}

[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?

 

Your original post should be posted by 3/31.  Have your two replies posted no later than 4/2.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

39 Comments (+add yours?)

  1. Tressa Novack
    Mar 27, 2022 @ 20:44:58

    The client’s primary negative automatic thought was that she was going to have a heart attack in the middle of the aisle. She was worried she was going to have a heart attack in front everyone and that there would be no escape. I think a possible cognitive distortion is catastrophizing because a heart attack is probably the worst case scenario and scariest thing that the client can experience. The client’s response to her associated automatic thoughts and physiological arousal was to run out of the grocery store to the parking lot where her husband was waiting for her in the car. She states that as soon as she saw her husband she began to feel better. This can indicate that having her husband bring her to the store, and do the shopping for her, as she stated in the beginning of the video, are safety behaviors. She also states that she felt like she failed, because she thinks that it is silly that she was not unable to, indicating a negative emotional response after the panic attack had subsided.
    When doing the decatastrophizing worksheet, it was helpful starting with the worst-case scenario and ending with the most realistic scenario. This allowed me to see the two extremes of scenarios related to my automatic thought and see that not everything is all or nothing. It was anxiety reducing to know that there can be a realistic outcome that would not be upsetting even if it is not what I would hope for if things could go perfectly. Assessing the probability for each scenario did provide “data” to help me modify my negative automatic thought. It helped me see the reasons why my worst-case scenario is unlikely to come to light and that there is plenty of data to support my realistic scenario and even my best case scenario. For me, this technique did provide enough convincing information to help me form an alternative thought.
    A CBT case formulation is important for effective therapy because it provides the therapist with a history of the client’s past and current problems and how they are intertwined with each other. It also allows the therapist to look at every area of the client’s life and see how their distress affects these areas, and then how problems in various areas further the client’s distress. It allows the client and therapist to come up with concrete goals that they can use to then plan appropriate interventions to work towards achieving those goals and reducing distress. It is necessary to have specific, concrete, and measurable goals so that clients and therapists can track the clients progress and see actual results in whatever clients are working to achieve. It is also important for clients to have a clear understanding of the things that they can do to work towards reducing their distress and improving their quality of life. Furthermore, specific and measurable goals allow clients and therapist to see when the interventions they are using are working or not working in helping clients achieve their goals.

    Reply

    • Victoria Cestodio
      Mar 28, 2022 @ 14:06:33

      Hi Tressa,
      I feel like we had a very similar experience when working on the worksheet/technique. I felt similarly that helped me see the difference between the two extremes and how unlikely my extreme was. I also started to realize that not everything is black or white and there’s so much more gray area than we even realize.

      I like how you mentioned in regards to case formulation that it helps the therapist see the different areas of the client’s life and see how the distress effects the different areas, I think that is a very good way to put it and its very relevant to case formulation.

      great post!!

      Reply

    • Vanessa Nichols
      Mar 29, 2022 @ 12:10:12

      Hi Tressa,
      Great post!
      I think you did a great job explaining Lindsey’s situation. I also thought that Lindsey dealt with catastrophizing. I can understand why she would think she was having a heart attack. However, on some level, Lindsey knew she wasn’t, but she could not shake the worst-case scenario thought that she was dying.
      I like how you explain the worksheet as seeing the two extremes: the worst-case scenario and the best-case scenario. I agree that it opened my eyes to some of my own all-or-nothing thinking.
      You did a great job explaining the importance of CBT case formulation. I think that the case formulation is essential for effective therapy because therapy would be a disorganized mess without it. I agree that it allows you to see what areas of life are affected by their current distress, which can be important when moving forward with therapy. CBT Case formulation also allows the therapist and client to work collaboratively to develop important treatment goals that work for both the client and the therapist.

      Reply

    • Jeremy
      Apr 02, 2022 @ 23:16:59

      Hi Tressa,
      I really liked your discussion post,

      Your discussion on the safety behaviors was excellent and she was very capable find identifying where their issues could go wrong. I appreciate hearing about your experience filling out the worksheet, being able to see how quickly thoughts run away from us is very insightful.
      I also like how you pointed out the therapist’s role as an outside observer being able to take into account many facets of the client’s life that may have been unconsidered by the client.

      Reply

  2. Vanessa Nichols
    Mar 28, 2022 @ 12:34:17

    The client’s primary automatic negative thought falls under the catastrophizing cognitive distortion. The client often views situations in the worst-case scenario. The client had tried to go into the grocery store alone in this situation. Her primary negative automatic thought was, what if she had a heart attack and nobody could help her because she was in this crowded grocery aisle. Her thoughts are often associated with a lack of control and the fear of no escape. After this event, the client also dealt with different negative automatic thoughts about how she responded to her anxiety in the grocery store. The client’s thinking revolved around her feeling silly, maybe embarrassed, but also like a failure because she felt she couldn’t complete what should be an “easy” task.
    The client demonstrated a couple of safety behaviors. The first safety behavior was bringing her husband with her. I think it is great that her husband is so supportive, but I believe it is essential for the client to one day complete these tasks 100% on her own and without a support system there. I don’t think this needs to be addressed first because I think having the support will be helpful in the beginning. The next safety behavior is leaving the situation. Fight or flight is a natural way the body and brain adapt to dangerous or fearful situations. The client even says that her body told her to leave and get out of there. However, leaving and retreating to the safety of her home is not the best way. It could be beneficial if the client left, took a second in the parking lot, and tried again. Overall I saw two substantial safety behaviors: the supportive husband and then fleeing.
    I thought it was helpful to start with the worst and end with the most realistic. Starting with the worst is the best thing to do because then you are only talking about somewhat positive things that could happen. Every other option looks better when you have already talked about the worst. It was good to end with the most realistic because this is what is most likely to happen. Ending on the worst or the best may lead a client into a false reality of thinking while thinking of the most realistic prepares them for what will probably happen. It helped me realize that my automatic thoughts were a little silly and a little unrealistic, but I still struggle with their modification. I feel like it discredited them, but I don’t necessarily feel like I entirely bought the alternative thoughts I came up with.
    I don’t necessarily feel like it provided enough convincing information to develop an alternative thought. I think it helped me develop them, but I do not necessarily believe it. However, maybe I need to use this more and then have to follow up experiences that back the new ways of thinking for it to convince me.
    CBT case formulation is essential for effective therapy to ensure that you are working towards the most important goals for the client. This means you are not starting with the most challenging goal and expecting an immediate result. A good counselor will use case formulation to set realistic goals that lead up to the most distressing goal. Second case formulation is important to make sure that all-important information has been discussed or is going to be discussed. Going into counseling without a plan or an idea is bad because the client can lead the therapist down rabbit holes that are not significant for the client’s current distress or goals. Case formulation provides a clinician with an organized, clear, and efficient plan for therapy. It helps the clinician know that they are on track and what they are working towards.
    It is necessary to have specific, concrete, and measurable treatment goals whenever possible so that the client knows what is expected of them and what they are trying to achieve. Specific goals help create motivation and success for the client, and it helps the clinician have a clear indication of what steps should be taken to achieve this goal and overall improvement from the client. It is also beneficial to the clinician to see if progress and objectives are being achieved. For example, a goal of I want to have a job that pays this amount by this date is an excellent goal because not only are we looking for a job, but we are looking for somewhat of a specific job by a particular date. This goal clarifies what we are working towards, what steps we should be taking, and if this goal is achieved. Having a goal like I want to be happy is tricky because there is no end date, there are lots of steps to try and take to achieve this goal, and it would be tough to know when this goal will be achieved.

    Reply

    • Victoria Cestodio
      Mar 28, 2022 @ 14:19:26

      Hi Vanessa,

      Great post!
      I really like how you gave some insight on what could benefit the client when she is in fight or flight and leaves the store, you mentioned stepping outside of the store taking a second and then going back in, and eventually I do see her being able to do that. I definitely agree with the safety behavior of her husband, which I stated in my post that this can be very harmful to her long term. I agree that it was helpful for me to start with the worst case too, taking the worst case and only going to more positive thoughts from there like you said is helpful. I totally agree that ending on the worst scenario might really end up putting the client into a ‘false reality’

      Victoria

      Reply

    • Lexi
      Apr 01, 2022 @ 12:33:27

      Hi Vanessa

      I like your last section, it is important to have specific and concrete goals for not only the reason that it gives treatment a structure, but also that it provides the client with a set of expectations – I think that in thinking about this deeper I realize that a client with expectations may feel more motivated and also more empowered in their treatment. If they are able to achieve goals that are set in a realistic and collaborative way then they are more likely to have an increased perception of their self-efficacy and perhaps even be more willing to challenge themselves with “loftier” goals in the future. I agree with you too that any treatment goals should be set with the “bigger picture” in mind, never losing site of the wholistic nature of a larger treatment plan. I would echo your point as well that goals should be specific and measurable so that they are objectively either reached or not reached, this objective look into treatment effectiveness can help the clinician be aware if and when adjustments need to be made in terms of approach. It also gives the client clarity as to what they need to be striving for, without any confusion.

      Reply

  3. Victoria Cestodio
    Mar 28, 2022 @ 14:00:18

    The client’s most present negative automatic thought was her fear that she was going to have a heart attack when in the grocery store. She thought that once she was in the store there were going to be people around and that they were going to have to witness this which in turn gave her more anxiety and that she wouldn’t be able to get out. Obviously, she was catastrophizing , and most likely was not going to have an actual heart attack, however this felt like the true reality for her, even though it sounds unrealistic. Her response to this event was leaving the store quickly and went outside to her husband waiting. Like Dr. V mentioned in the video, it seems as though her husband is like a safety blanket for her which can be somewhat damaging at times, as he will do the shopping for her so she could avoid the store, however it is not helpful for her anxiety long term. She felt previously before going in the store really confident and ready and felt like she could do it, and then after she felt like she was a failure by not being able to complete the shopping and running out.

    I think when doing this worksheet it was good to start with the worst case and end with the most realistic because we see the difference of the two extremes and the likelihood of the worst case actually happening. It made me see the situation more clearly and gave me a different outlook, while if you ended with the worst case I may have fixated on that. Assessing the probability for each scenario did provide supportive “data” to help modify my negative automatic thought because I slowly started to come to the conclusion that the probability of the things I am most scared of are slim, but in regards to seeing a more positive thought the likelihood of that felt greater. Providing data for both made me realize my thought didn’t have much evidence at all. I do think this worksheet made me have enough convincing info to make me develop an alternative thought, or atleast have less of a negative one.

    CBT case formulation is crucial and important because as therapists we want to make sure we are actually trying to formulate progress, and want to work on the goals the client wants. Having this info and plan can guide the therapist to what treatment will be most effective, and you also get to know your client much better and understand where these problems may have come from (precipitating factors) and that could lead to much better treatment. It is important to have concrete, measurable treatment goals because that not only helps the therapist but also the client. Having these concrete goals will help the client strive for them and making sure they are measurable is important because we don’t want to shoot for the stars and not be fully realistic with ourselves. It gives the therapist a better step by step process and makes each session more clear and what to focus on mainly. Having these treatment goals helps to also see if our client is making progress, or plateauing, or not making any at all which we would want to be aware of.

    Reply

    • Tressa Novack
      Mar 29, 2022 @ 09:49:50

      Hi Victoria,
      Great post! I agree with your take on the client’s automatic thought being that she was worried she was going to have a heart attack in the grocery store. I also said that she was probably catastrophizing in this situation which is not uncommon for panic disorder. I also pointed out that her husband being with her probably serves as a safety behavior. I like what you had to say about doing the decatastrophizing worksheet on yourself. I also found that it pointed out that what I was worried about is way more unlikely to come to light than my realistic and best outcome scenarios. I also enjoy your points about CBT case formulation and goal setting in treatment. It is important that we remain realistic in therapy so that we can set our clients up for success.
      Tressa

      Reply

    • Emily Barefield
      Mar 30, 2022 @ 18:50:04

      Hi Victoria,

      I also had that her present negative automatic thought was that she was going to have a heart attack in the grocery store. Being around other people and the possibility of being trapped definitely increased her anxieties. As you mentioned, this is a great example of catastrophizing. I also had that her husband is a safety behavior for her. He of course means well but is actually reinforcing her anxiety.

      I also found that the worksheet helped me see the situation more clearly instead of fixating on the worse case scenario. I also found that assessing the probability for each scenario did provide evidence for modifying my negative automatic thought.

      Specific and measurable goals are beneficial for the therapist and the client. I like how you highlighted the importance of being realistic. This helps the client feel a sense of accomplishment and encouragement instead of feeling demoralized. Great post this week!

      Reply

    • Jeremy
      Apr 02, 2022 @ 23:28:08

      Hi, victoria,

      Great discussion post! I agree with all of your discussions on the client’s safety behaviors. This worksheet was beneficial for analyzing what evidence there is to support the different scenarios that we can think up and can largely help us when the source of our worry has no or little basis in reality.
      I especially liked your point about the case formulation needing to have concrete measurable goals so that the therapeutic alliance can make sure progress is being made.

      Reply

  4. Emily Barefield
    Mar 28, 2022 @ 15:36:40

    Lindsey’s primary negative automatic thought was “what if I have a heart attack in the middle of the isle.” When she begins to feel warm, have sweaty palms, experience her chest tightening, and heart racing, she begins to interpret this as a heart attack even though she knows cognitively that it is a panic attack. Being aware of others around her who may be able to tell she is struggling increases her symptoms and causes nausea, choking, and feelings of loss of control. In response to her negative automatic thought telling her she was having a heart attack, Lindsey attempted to remind herself that she was not having a heart attack but rather a panic attack. Although she repeatedly attempted to tell herself she was not having a heart attack and knew this cognitively, she still found herself with a strong urge to get out of the grocery store and left. In this case, Lindsey’s safety behavior is seeing her husband. Upon seeing her husband, Lindsey instantly feels relief from her panic symptoms. Although he is trying to be helpful, in this instance, her husband reinforced her leaving the grocery store.

    It was helpful to start with the worst-case scenario and end with the most realistic scenario. I found myself laughing a little bit when I was writing down the worst-case scenarios and the best-case scenarios. Assessing the probability of each scenario did provide evidence to modify my negative automatic thought. My least probable scenario is the best-case, then the worst-case, and then the most realistic. However, the realistic was twice as high as the worst-case. Yes, the technique provided enough information for me to develop an alternative though reflective of the most realistic scenario.

    A CBT case formulation is important for effective therapy because it provides the therapist with an in-depth understanding of the client’s symptoms and the contributing factors to their distress. The background information provided in the case formulation allows the therapist to have a better understanding of potential obstacles for treatment for the client and potential factors that could improve the course of treatment. The case formulation is also one of the first times the client and the therapist engage in collaborative empiricism. Having the client help with the case formulation conveys that the therapist truly cares about the client, and it provides the client with agency and can help provide motivation. Additionally, the case formation provides information about current negative automatic thoughts, emotions, and behaviors, and potentially even core beliefs that need to be targeted throughout the course of therapy. The working hypothesis, how the client came to their current distress, is also a key aspect of CBT case formulation that helps the client improve. The working hypothesis helps guide the treatment plan, which is designed to help the client get better. It is important for treatment goals to be specific, concrete, and measurable because these goals are indicators of therapeutic progress. It is necessary for goals to be specific, concrete, and measurable so that the therapist and the client can determine if the goal has been met or if more progress on a given goal is necessary.

    Reply

    • Tressa Novack
      Mar 29, 2022 @ 10:38:14

      Hi Emily,
      Great post! I like how you point out the physical symptoms that accompany the client’s automatic thought of having a heart attack. We can see how that automatic thought and those physical symptoms go together. I also pointed out that her husband is her safety behavior. I also had the experience with the decatastrophizing worksheet that my worst-case scenario was the least likely to happen and my realistic scenario was the most likely to happen. I agree with many of your points on CBT case formulation and the importance of setting concrete, specific, measurable goals. A good CBT case formulation allows us a full picture of our client, which will help us treat them effectively, and goals allows us to track client’s progress and adjust treatment when clients do not seem to be progressing towards their goals.
      Tressa

      Reply

    • Vanessa Nichols
      Mar 29, 2022 @ 11:57:06

      Hi Emily,
      Great post this week!
      I think you did a great job at explaining Lindsey’s behaviors and situation. I agree that the husband is a safety behavior for Lindsey. I think it’s important to know that before she had a panic attack, her husband was outside waiting for her. It felt kind of like a self-fulling prophecy. I completely understand why the husband would want to be there and support his wife. However, this dependency is doing more harm than good for Lindsey in the long run.
      You did an excellent job explaining the importance of CBT case formulation. I really like that you reference how the background information can provide details about potential obstacles and strengths. I think potential strengths often get overlooked, but I believe they are very important, especially if you play into them well in formulating their specific case.
      I also agree with you that measurable, specific goals are essential for measuring progress as therapy goes on.

      Reply

    • Lauren Pereira
      Mar 30, 2022 @ 16:45:51

      Emily,

      You did a great job including lots of detail about Lindsey and the symptoms she has been portraying. Regardless of trying to motivate herself into better thoughts and feelings, she still envisioned herself having a heart attack in front of everybody in the grocery store. I like how you express that her husband is actually reinforcing her in this case. It is because he is her safety net so she knows that she has him to fall back on. Rather than doing the task herself to try and overcome her anxiety, she goes back to her husband knowing that he will do what he needs to in order to help her.
      Starting off with more negative scenarios can get clients to think more realistically by the end of it. In this case, negative automatic thoughts are being modified and this begins to change perspectives into more positive outcomes at times.
      CBT case formulations help the therapist have better insight on situations. I like that you mentioned that they are also in-depth understandings of the symptoms and the contributing factors to clients distress. The way the information is presented is more beneficial for both the client and therapist. In this way, the treatment plan is more organized and guided which indicates for a better and quicker positive outcome. Great post!

      Reply

    • Will Roche
      Mar 31, 2022 @ 19:22:57

      Emily,

      I think you did a great job in detailing why case formulations are so important for therapy. Not only does it give a better understanding using background info, but it really hones in on what specific factors contribute to the client’s distress. Case formulation also helps the therapist figure out certain goals and where to move forward with treatment. I also love how you brought up collaborative empiricism and how it’s one of the first times the client and therapist start working together to achieve the client’s goals. This is such a huge step in therapy so it’s important that case formulation is created effectively and in a collaborative manner. Without collaboration, the client or therapist might be confused on what goals to achieve or want to achieve different goals. Overall, collaborative empiricism is so important for case formulation. Great job!

      Reply

  5. Monika
    Mar 30, 2022 @ 12:18:32

    The client’s primary negative automatic thought was, what if she has a heart attack in the middle of the aisle, she won’t be able to get help because the store was very crowded. She also kept getting thoughts that she needs to get out of there. People noticing her discomfort just made the symptoms worse for her and she started to feel nauseous. One obvious cognitive distortion is catastrophizing, where she imagines the worst possible outcome like having a heart attack in the middle of the aisle. I think another possible cognitive distortion that client is having is labeling where she is reducing herself to a single negative characteristic of “failure” based on one incident at the grocery store. The client’s response in this situation was to run away from the grocery store. When people started to notice her discomfort she got nauseous, sweaty, tightness in the chest, and her heart raced. She mentions that felt relieved the moment she saw her husband sitting in the car. So we can see two main safety behaviors here, taking her husband along so that she has support and fleeing from the store without going through with her plan of shopping(avoiding).

    The decatastrophizing worksheet was definitely helpful as it prompted me to think and helped me bring my thoughts into focus, examine them for irrational thinking or cognitive distortions. And realizing what cognitive distortions I tend to have, also helped me question my thoughts and change them. When we spend a lot of time worrying about worst-case scenarios, it makes it more difficult to overcome challenges so this worksheet was a good way to understand and talk down catastrophic thinking. Ending with the most realistic scenario is great because it forces us to think beyond the worst-case scenario and not just react emotionally. Thinking of realistic scenarios helps us understand that there is more than one way a situation can turn out and the possibility of what we are thinking of happening is very low as compared to a realistic one. Plus it provides a lot of data to support this as we come up with different scenarios for the same situation and develop alternative thoughts.

    A case formulation is like a hypothesis about psychological mechanisms that we come up with to describe the cause of a client’s symptoms and problems. The working hypothesis is an overall summary of the CBT case formulation and the working hypothesis has a direct influence on the development of the treatment goals and interventions. Also, case formulation will contain a formal diagnosis which helps the client understand the sources of their distress as it contains multiple symptoms impacting their daily functioning. Treatment goals are desired outcomes for the client and they are indicators of therapeutic progress and improved quality of life. And for this exact reason, it’s important that they are objective and measurable. If we don’t set measurable goals then there is no way of tracking the progress of the clients.

    Reply

  6. Monika
    Mar 30, 2022 @ 12:20:13

    The client’s primary negative automatic thought was, what if she has a heart attack in the middle of the aisle, she won’t be able to get help because the store was very crowded. She also kept getting thoughts that she needs to get out of there. People noticing her discomfort just made the symptoms worse for her and she started to feel nauseous. One obvious cognitive distortion is catastrophizing, where she imagines the worst possible outcome like having a heart attack in the middle of the aisle. I think another possible cognitive distortion that client is having is labeling where she is reducing herself to a single negative characteristic of “failure” based on one incident at the grocery store. The client’s response in this situation was to run away from the grocery store. When people started to notice her discomfort she got nauseous, sweaty, tightness in the chest, and her heart raced. She mentions that felt relieved the moment she saw her husband sitting in the car. So we can see two main safety behaviors here, taking her husband along so that she has support and fleeing from the store without going through with her plan of shopping(avoiding).

    The decatastrophizing worksheet was definitely helpful as it prompted me to think and helped me bring my thoughts into focus, examine them for irrational thinking or cognitive distortions. And realizing what cognitive distortions I tend to have, it also helped me question my thoughts and change them. When we spend a lot of time worrying about worst-case scenarios, it makes it more difficult to overcome challenges so this worksheet was a good way to understand and talk down catastrophic thinking. Ending with the most realistic scenario is great because it forces us to think beyond the worst-case scenario and not just react emotionally. Thinking of realistic scenarios helps us understand that there is more than one way a situation can turn out and the possibility of what we are thinking of happening is very low as compared to a realistic one. Plus it provides a lot of data to support this as we come up with different scenarios for the same situation and develop alternative thoughts.

    A case formulation is like a hypothesis about psychological mechanisms that we come up with to describe the cause of a client’s symptoms and problems. The working hypothesis is an overall summary of the CBT case formulation and the working hypothesis has a direct influence on the development of the treatment goals and interventions. Also, it will contain a formal diagnosis which helps the client understand the sources of their distress as it contains multiple symptoms impacting their daily functioning. Treatment goals are desired outcomes for the client and they are indicators of therapeutic progress and improved quality of life. And for this exact reason, it’s important that they are objective and measurable. If we don’t set measurable goals then there is no way of tracking the progress of the clients.

    Reply

    • Lauren Pereira
      Mar 30, 2022 @ 16:27:28

      Monika,

      You make several great points in your post. An obvious cognitive distortion presented here is catastrophizing because the client is imagining the worst possible scenario and she thinks this will happen to her. Another factor that plays a role in this is the fact that she is afraid that people will watch her and it will become very embarrassing for her. The easiest way out of this situation would be to have her husband do the grocery shopping for her which is a safety behavior. This will not make her feel better in the long run because her anxiety will still be there and she would rather avoid the entire situation rather than try to manage it.
      I agree that the decatastrophizing worksheet is helpful because it prompts you to change your negative ways of thinking. It allows you to start off by explaining negatives but then while interpreting more positive approaches, they become more realistic. This helps adjust peoples negative automatic thoughts.
      A case formulation does help to describe the clients symptoms and problems they are facing. I like how you mention that it tries to influence the development of treatment as it does this as well as organizes our thoughts. This prepares for a more successful outcome. Great post!

      Reply

  7. Lauren Pereira
    Mar 30, 2022 @ 15:27:22

    The clients primary negative automatic thought was that she would have a heart attack while shopping at the grocery store. Her anxiety came from the fact that everybody around her would witness it. This client tends to think of the worst case scenarios and envision that happening to her. This would be categorized as catastrophizing. Even though she would most likely not have a heart attack just by going to the grocery store, this is still what she thought would actually happen to her in real life. The clients response to this act was quickly leaving and walking outside to her husband. Safety behaviors are present in this scenario because the client will easily go to her husband and immediately feel better. Instead of facing her fears, her husband would simply do the grocery store shopping for her so she can avoid the situation at hand. Having her husband as a backup plan when things go wrong is where her safety behavior comes into play because this will not always be the solution in the future. In order to feel better, she is going to have to complete the grocery shopping in order to feel successful and face her anxious fears.

    I feel as though it is helpful to start off the worksheet with some worst-case scenarios and ending with most realistic ones. This allows for the two extremes to be separated, but to also focus on all the negative ones first. After getting more negative thoughts out of the way, it is then easier to see a more realistic point of view. Assessing the probability for scenarios did provide supportive data to modify negative automatic thoughts. This factor helps identify the more realistic scenarios and it helps you come to terms with the fact that the negative thoughts actually start to seem less realistic and more evidence supports the more positive scenarios. Regardless of how much it can make an impact, I still believe that this technique provides a good amount of convincing information to develop alternative thoughts. It helps your mind stray away from the negative and start to think outside of the box.

    A CBT case formulation is important because therapists need to have solid evidence that their client is progressing. Having the set goals at hand can help better identify how therapy is going and what adjustments might need to be made. Case formulations help the therapist with their planning as it can help become a guide throughout each session. In having set and specific goals to overcome, it is necessary to create a doable path to follow along in. This makes the process a lot smoother for both the client and therapist when trying to reach towards their goals. This also makes an easier access in overcoming each and every goal included. Being able to identify if our clients are making progress is a significant part in therapy and if we can not track this information, it will make the process a lot longer to accomplish.

    Reply

    • Emily Barefield
      Mar 30, 2022 @ 18:04:23

      Lauren,

      I agree that her primary negative automatic thought was she was going to have a heart attack in the grocery store. Her anxiety surrounding having a heart attack was certainly increased by the possibility of others being able to see her struggle. I appreciate that you identified and labeled her cognitive distortion, catastrophizing. I also agree that her husband is functioning as a safety behavior in this scenario. The immediate reassurance she feels when she sees him functions as a reward for her leaving the grocery.

      I like how you phrased doing the worst case scenario first and getting it out of the way. This helps shift the focus away from the worst case scenario the person has likely been ruminating on to more positive and realistic outcomes.

      Setting goals is absolutely necessary for therapist to be able to determine if their client is making progress. I agree that it does help make the process easier for the therapist and the client. Great post this week!

      Reply

    • Madelyn Haas
      Mar 31, 2022 @ 15:23:43

      Hi Lauren,
      I enjoyed reading your post. You did a great job summarizing Lindsay’s automatic thoughts, the reasoning behind them, and her safety behaviors. It was also good that you pointed out that she will not always have her husband be there when she panics. Sometimes he will be out of town, or she will be away from home on her own. Because of this, the safety behavior of relying on her husband’s presence is not adaptive. I also think the Decatastrophizing Worksheet was helpful for me, and I imagine it would be more helpful for clients who have not yet learned to decatastrophize on their own. It provides the clients a way to “ground” themselves and consider that the worst-case scenario will likely not come true. Your point about the percentage probability was also good, as it does likely help clients see the more realistic scenario as more probable.

      You summed up well why CBT case formulations are important. They help the therapist better conceptualize the client’s case and find the most appropriate interventions. They also allow both the client and therapist to track the client’s progress. These are both great points to show why CBT case formulations should be implemented.
      -Madelyn Haas

      Reply

  8. Will Roche
    Mar 31, 2022 @ 08:18:02

    The client’s primary negative thought was the fear that she was going to have a heart attack in the middle of the grocery store. This clearly stemmed from her fear and panicking symptoms that she feels prior and during her panic attacks. The client begins to talk about her symptoms of abnormal warmth, sweaty palms, heart racing, etc. The feelings that she would be unable to escape exacerbated her symptoms and the thoughts racing through her head. This is certainly a cognitive distortion that she was going to have a heart attack despite knowing that she’s actually having a panic attack instead which encompasses all of the symptoms of a heart attack. She voices this thought in therapy with Dr. V, but it was still too much for her to experience and had to leave the grocery store to find her husband. Finding her husband is one of her safety behaviors when she is experiencing these panic attacks. Despite the fact that her husband remains at the store for a safety behavior, it limits the client’s ability to be independent. Similarly, they ended up not returning to the grocery store, so her avoidance of returning also contributes to a safety behavior, which will just worsen her condition going forward.
    I think the decatastrophizing worksheet was helpful, particularly completing it in that order because I typically think the worst case scenario is the most realistic scenario, and never think otherwise. Having to fill out two other options, (best case and realistic case) helps you realize that there are other alternatives to the scenario than you may think. I think negative automatic thoughts make you believe a certain thing and then you never go back to address the possibility of it being something else, or you’re certain it’s what you initially believed that contrary thoughts do not pull as much weight. I also think that addressing the probability was another important factor that one might not address unless they were doing a decatastrophizing worksheet. When I really thought about what the chances were of the worst case scenario, it really help placate the strong concerns that I had. Ultimately, the most realistic scenario “statistically” made the most sense, which definitely helped calm those fears and anxieties I had. Combined, this information did help me get a better overall picture of the realism of each proposed scenario and made me realize that when I think about certain scenarios, I mistakenly think the worst case scenario is the most realistic when in reality, the worst case scenario happens very rarely.
    I believe a large portion of case formulation and having specific, concrete goals is to help illustrate the effects of therapy and show the client that certain needs are being address and how these concrete aspects of their issues can be improve upon. Not only is it beneficial for the client, but also beneficial for the therapist that there are clear, written issues and goals that can be address. Having these written goals provides concrete evidence for what the problems are, what can be assessed to fix them, and what activities can be done to alleviate their biggest concerns. Overall, having specific, concrete and measurable treatment goals allow the non-expert client to visually identify how their concerns are being worked on, and it helps the therapist keep a physical and clear record of their progress and what needs to be highlighted and improved upon going forward with therapy.

    Reply

    • Sandra Karic
      Apr 03, 2022 @ 03:25:55

      Hi Will,
      Great job explaining Lindsey’s thoughts and their connection to her physical symptoms. I agree that seeking her husband is a safety behavior. I also liked the order of the different possible scenarios in the decatastrophizing work sheet and found it helpful to think of a best case and most realistic scenario. While I personally did not find the probability section as helpful, you did a great job explaining its benefits. Lastly, I really like how you explained that clear goals benefits both the client and the therapist

      Reply

  9. Sandra Karic
    Mar 31, 2022 @ 14:58:52

    Lindsey’s primary negative automatic thought was that she was going to have a panic attack in the middle of the grocery store. This is an example of catastrophizing, because a heart attack is one of the worst/scariest explanations for the physical symptoms she was experiencing. Her response was to run out of the store to her husband. It seems like leaving/avoiding public spaces and seeking comfort from her husband are some of Lindsey’s main safety behaviors. I think the order of worst case, best case, and most realistic scenario is helpful. I think starting with the best case scenario would just lead to me wanting to argue against it. I also think ending with the most realistic scenario is helpful because I kind of naturally thought about how much space was between my worst and best case scenarios. The difference between them highlighted how extreme the worst case scenario was and made it easy to transition into thinking about more realistic outcomes. I didn’t like coming up with probabilities as much because I started getting hung up on the numbers not adding up to 100% and I ended up losing focus. However, I do think coming up with alternate scenarios and the “how to cope” section helped me come up with an alternative thought.

    A case formulation is an important aspect of CBT because it takes into consideration a client’s past, present problems, strengths, etc, and uses this information to create measurable treatment goals. Having a case formulation provides the therapy with structure and helps the therapist and client track progress. Additionally, evaluating all of this information and how different aspects of a client’s life interact helps the therapist have a thorough understanding of the client, their problems, and how different approaches may impact them. I think having specific measurable goals is necessary for evaluating whether or not treatment interventions have been effective and knowing whether a different approach is needed. I think it is similar to keeping track of wins and losses in gambling; it’s easy to make assumptions about how someone is doing but if you have specific goals and concrete data to compare them to, it’s easier to stay more objective.

    Reply

    • Madelyn Haas
      Mar 31, 2022 @ 15:13:12

      Hi Sandra,
      Great post this week! I think you explained Lindsay’s automatic thoughts and safety behaviors well. As clinicians, it is important for us to consider every way a client copes with their thoughts/behaviors so that we can find the best way to modify them. I think your response to the Decatastrophizing Worksheet was interesting as well. I could definitely see a client arguing with their therapist if they started with the best or most realistic scenario first. That was a great reason to consider starting with the worst-case scenario first. I also did not find the probability percentages very helpful, but it was because I was already talking myself into more adaptive thoughts from the beginning. I think the percentages could be helpful to those who like more concrete representations of odds and who have not learned to decatastrophize on their own yet.

      I think your explanation of the importance of CBT case formulation was great. It is incredibly important to consider a client’s past, strengths, and other factors when looking at their presenting problem. They are also helpful because they allow the therapist to pick the most appropriate/helpful interventions for each client’s case. Finally, your example on tracking gambling wins and losses was both useful and funny. Good job!
      -Madelyn Haas

      Reply

    • Moises J Chauca
      Apr 01, 2022 @ 23:24:55

      Hello Sandra,
      Great post! Your description of Lindsey’s negative thoughts and her behaviors about going to the store. In addition, I share a similar experience with you on the worksheet. I found myself focusing on the difference between the worst case scenario and the most real one because I started realizing that the real one made more sense. I do believe that coming up with alternative scenarios definitely help modify the thought but for me, practice will help me more. Lastly, you made great points about case formulations and goal setting. I agree that without case formulations the therapist would not be able to have an efficient treatment and without specific goal you will not be able to track your win or losses like in gambling games.

      Reply

    • Monika
      Apr 03, 2022 @ 09:24:19

      Hi Sandra,
      Great post, I think you explained Lindsey’s negative automatic thoughts and safety behaviors to the point. In some situations I tend to catastrophize too and so just thinking of the worst, best and realistic scenarios helped me realize that there is more than one possibility of things happening rather than the worst one that I am thinking of. Starting with the worst but then thinking of the best and most realistic scenarios can help clients to feel a little relieved because they’ll realize that the chances of the worst scenario happening are low. I agree with you that case formulation is an important aspect of CBT and helps in creating measurable goals, giving the therapeutic process a structure and tracking progress. Without specific goals, we are just treating the client and hoping that they’ll get better.

      Reply

  10. Madelyn Haas
    Mar 31, 2022 @ 15:02:01

    Lindsay’s primary negative automatic thought is that she is going to have a heart attack in the store. This thought is an example of the cognitive distortion catastrophizing. Although she has never had a heart attack (and is young and likely in good health), she worries that she will have a heart attack. When she feels the physical symptoms of her panic attack, she believes that the worst-case scenario is going to happen: that she is going to have a heart attack and even perhaps die. Rationally, she probably knows that is not going to happen, but in the moment, it feels like a real possibility to her. In response to the physical symptoms and her negative automatic thought, she leaves the store, reinforcing escape behaviors in response to panic attacks. She also uses her supportive husband coming with her as a safety behavior. When she knows he is nearby/with her, she feels less anxious. It is good that she has a supportive partner, but if he is always with her, she will not learn how to deal with anxiety and panic on her own.

    Starting with the worst-case scenario and ending with the most realistic scenario helped. It let me address the most anxiety inducing possibility first, and it let me consider how the most realistic possibility was probably the most likely outcome. Honestly, it made me feel a little silly for thinking so negatively in the first place. Assessing the probability of the potential outcomes did help though I will say it was not AS helpful as just going through the worst-best-most realistic options. I can see how it would be helpful for someone who was in a worse/more anxious state than I am in currently, however. I think the Decatastrophizing Worksheet did help provide enough convincing information to develop an alternative thought. Truthfully, I did already have alternative thoughts in my head already, but it helped solidify my realization that I was catastrophizing the situation. I imagine it can be very helpful to clients who have not yet developed the skill to decatastrophize on their own as it honestly is a learned skill.

    CBT case formulations are incredibly important for therapy. By collaborating with your client to come up with a solid case formulation, you as the therapist can make the most informed decisions on what interventions to use to best help the client. Instead of just throwing random interventions at them and hoping they work, you can tailor your interventions to the specific behaviors, core beliefs, and automatic thoughts the client has. This works to make therapy more efficient and effective. When coming up with a case formulation, it is important to make sure treatment goals are specific, concrete, and measurable. Specific goals are important so that you and the client can target specific maladaptive behaviors/thoughts/beliefs. For example, “become less depressed,” while nice in theory, does not mean much. Depression presents in so many ways. A better goal would be “go out with friends twice a week” if the client struggles with isolation. Concrete goals are important because they are more understandable/achievable than abstract goals. “Get healthy” is a nice idea, but it does not say much and can be daunting. Instead “go on a 10 minute walk every day” or “eat at least one fruit/vegetable a day” would be better. Finally, goals should be measurable so that you can monitor the client’s progress. If a client deals with panic attacks, the goal should not just be “decrease panic attacks”, instead it should be “decrease panic attacks from 7 days a week to 2 days a week,” for example.

    Reply

    • Will Roche
      Mar 31, 2022 @ 19:28:05

      Madelyn,

      I really like what you focused on in CBT case formulations. It’s definitely very important to work collaboratively with your client so that you each understand what goals you’d like to achieve and what certain issues the client wants to be assessed. Without proper collaboration (client voices concerns, but not heard or remembered by therapist or therapist decides what goals are going to be achieved without client’s thoughts or approval) would be detrimental to the limited time spent together. Defining these specific goals together will certainly help building a therapeutic rapport and start actively working to improve the client’s symptoms. Also, great point on making sure that the client’s goals are measurable so that you can concretely tell if progress has been made. Great work!

      Reply

    • Lexi
      Apr 01, 2022 @ 12:53:55

      Hi Madelyn

      I like your discussion about tailoring treatment approaches to the specific needs, abilities, personality etc., of the client. Dr. V talks a lot about “matching to” and I think that idea can be applied to ever aspect of therapy including how we interact and also how we formulate the plan and approach for treatment as well as choosing assessments and intervention strategies. The experience of a personalized approach I think is really integral to the overall success and also to retaining clients for the duration of treatment. I also like that you point out the relationship between abstract or more broad reaching goals like “fins happiness” and how those larger goals can be accomplished by a series of organized smaller more concrete goals that can be conceptualized at stepping stones, or puzzle pieces that together make up the larger goal of “happiness” as an example.

      Reply

    • Moises Chauca
      Apr 01, 2022 @ 23:40:35

      Hello Madelyn,
      Great job on your post! I liked how you pointed out that the worksheet help you solidify alternative thoughts for the scenario. I had a similar experience with the worksheet, it definitely helped me identify the best alternative thoughts and reinforce for future similar experiences. Lastly, your examples for specific goals were a nice touch to understand the difference between a vague and a specific goal. As you said a vague goal can sound nice, but a specific goal can be more achievable and measurable.

      Reply

  11. Jeremy
    Mar 31, 2022 @ 15:56:43

    The most obvious negative automatic thought was that she would have a heart attack and be unable to escape. She was concentrating on the worst-case scenario causing her to get worked up, demonstrating signs of catastrophizing. She became very aware of other people and their possible thoughts towards her and felt like she was losing control and sought to leave the environment. She is typically reliant on avoidant behaviors and her partner for support these safety behaviors have allowed her to cope with immediate stress of her thoughts and emotions but now reinforce the longer term negative coping behaviors.
    IT was definitely easier to start with worst-case scenario the best case and then I am naturally drawn to the negative lines of thinking. And then it is easier to base the more realistic expectations after getting the negative thoughts out of the way. Assing the probability fore each scenario didn’t mean much to me, I am not personally confident on my probability guesses so the extra data didn’t help me to much. I can clearly see all scenarios side by side but this method did not provide convincing data to me.

    Reply

  12. Lexi
    Mar 31, 2022 @ 16:31:35

    Lindsay is clearly a very anxious person, and has a fear of going grocery shopping alone. She has a fear that she will enter a panic state, suffer a heart attack and that no one will be able to save or assist her in a crowded store aisle. She clearly has a fear of losing control, and of being in a dangerous or potentially deadly situation and not receiving help. This struck me as feeling a lack of control and perhaps a lack of trust in her abilities to cope with her panic state. Lindsay clearly has a tendency to catastrophize, and to jump to an objectively unrealistic “worst case scenario” in her head. She thinks there is no escape, and that this event is much more likely to occur than it is in reality. This is a form of cognitive distortion which we have learned in this and other classes as a common style of dysfunctional thinking. Lindsay responds to these negative thought patterns and high level of anxiety with feelings of failure. She feels silly and I think is ashamed to some degree of her inability to do something so routine as visit the grocery store. This is something every person does and so I think Lindsay is really struggling with her level of fear and anxiety with respect to the store.
    Safety behaviors are sometimes used as attempts to prevent fears from coming true, or to avoid anxiety provoking situations. In Lindsay’s case an example of using safety behaviors would be avoiding the grocery store or similar environments, or only going into stores while her husband is with her…. As we have talked about in class this type of safety behavior can often cause more harm than good because it means that the client does not actually need to face their fear so to speak, which can sometimes increase rather than decrease the level of anxiety or fear associated with the stimulus or situation that the client is trying to avoid.
    It can be helpful to start with the worst-case scenario and move towards the best-case scenario when working with anxious clients because I think you start by “meeting them where they are at” already mentally. Starting with the worst and then moving forward means that the thinking gets more positive rather than less which I think is helpful – this is also effective in some instances in bringing a client to realize the unrealistic nature of their “worst case scenario”. This was definitely true in my own experience. Ending on a positive note with the best case makes so much sense if you start with the worst, you are able to gradually see better, more positive and more realistic scenarios or outcomes. Assessing the probability of these scenarios is extremely helpful and was effective in this case because it helps to reduce anxiety about the worst-case scenario – which is typically NOT the most likely or most probable outcome. The client is forced to kind of reevaluate the risk associated with the feared situation or stimulus. In my experience this was definitely the case and I was able to giggle a bit at the unlikeliness of my “worst case” and greatly reduce my level of anxiety. This exercise changed my thoughts about the situation, and boosted my ability to feel confident in my own ability to handle “whatever comes my way” when compared to my initial level of anxiety. My alternative thought became – “you’re ok, you can navigate this” rather than the initial anxiety.
    Case formulation is everything in CBT and in therapy in general, it helps clients because ideally a treatment plan and case formulation involves collaboration and appropriate and realistic goal setting. This is important for effective therapy, and goals should be fluid and change as the client either experiences big wins or setbacks. Having concrete and measurable treatment goals is important for tracking progress and building client self-efficacy / confidence. This also helps the clinician evaluate the effectiveness or ineffectiveness of the treatment approach and make adjustments as needed.

    Reply

    • Sandra Karic
      Apr 03, 2022 @ 03:35:00

      Hi Lexi,
      Great job explaining Lindsey’s thoughts and her tendency to catastrophize. I liked that you included the feelings of shame aspect when discussing her anxiety. I agree that avoidance and seeking her husband are safety behaviors for Lindsey. I also really liked how you described starting with the worst case scenario as meeting clients where they are at and emphasized how that order involves thinking getting more positive instead of less. Finally, I agree with your points about how it is important that goals are concrete, measurable, but also fluid.

      Reply

  13. Moises J Chauca
    Mar 31, 2022 @ 22:02:31

    After watching the video, we see how the client’s primary negative automatic thoughts in the response to the event were catastrophic thinking. The client tried to enter a grocery store and started having negative thoughts about the future and worried about having a panic attack in the store without being able to escape the place. We can see how she starts to catastrophize about her situation and only think about the worst-case scenario which is having a panic attack. These thoughts and fearful emotions lead her to engage in avoidance behavior to remove the negative experience like leaving the store. The client shares that she goes to her husband and feels relieved. In addition, in the video, we see that the client’s husband is the one that buys the groceries most of the time. This behavior can be considered safety and protective behavior as the client does not need to experience these events. Lastly, the client felt regretful and shameful after leaving the store because she was not able to do the task.
    After practicing the decatastrophizing worksheet. It is really helpful for me to start with the worst-case scenario because I had so much to say about the scenario first. Then, when it got to the most realistic scenario, I found myself reflecting back on the worst-case scenario and crossing out the evidence that supported that scenario. The use of probability of each scenario was extremely important to the supportive evidence and modify my thoughts because it made me think about how much I believe that scenario will happen and how possible it is to happen. Lastly, I would say that this technique helped me develop alternative thoughts, but I need to exercise these thoughts, so I can believe them.
    For an effective therapy outcome, a concise and strong CBT case formulation is needed, so the therapist is able to identify the client’s psychological, medical, social factors that affect their case. In these factors, we can find specific events, thoughts, and core beliefs that can tell the therapist about the client’s current and past situation. In addition, the case formulation provides specific goals and interventions that align with the client’s problems. The case formulation needs specific, measurable, and concrete because the goals need to match the client’s problems and be able to track the client effectively. A measurable goal is crucial for the therapy outcome so the therapist and client can use modify their interventions to reach the goal. Lastly, a specific, concrete, measurable goal keeps the therapist and client on the same track and path to reach their goal.

    Reply

    • Monika
      Apr 03, 2022 @ 09:33:12

      Hi Moises,
      You made some really good points! I like how you mentioned that when Lindsey was in the grocery store she was only thinking of the worst-case scenario. She was so fixated on the thoughts that she is going to have a panic attack that she couldn’t think of any other possible scenarios. Her physiological arousal led her to believe she was having a heart attack which caused her to run to her husband in order to feel relieved. But she felt guilty when she couldn’t complete the task, this happens to me as well sometimes and it causes me to feel worse than when I started the task. So it’s important to make sure we get through with it to break this cycle and I feel a decatastrophizing worksheet is a great way to do that. I really liked how you explained all the points. Great Job!

      Reply

  14. Lexi
    Apr 01, 2022 @ 13:04:42

    Hello Moises

    I had a very similar experience with the worksheet and the process of working from “worst case” back to best case – I particularly found it helpful to assign probabilities to the various imagined outcomes. I personally felt like this was really effective in calming the anxiety that I felt about my predicament. I felt like the process made me really evaluate the cost benefit relationship of each outcome in a much more analytical and subjective way and so I can see how this process could be extremely helpful to clients who suffer from more severe and chronic anxiety, or difficulty making decisions as well was a thought I had in regards to depressed clients as an example.

    Reply

  15. Pilar Betts
    May 03, 2022 @ 12:42:25

    The clients primary negative automatic thought was what if she falls out and has a heart attack, when she was in the store she felt as if this was what was going to happen and while she was in the store she tried to remember that it wasn’t a heart attack that was occurring but it when she started to panic and had of sweaty palms, test tightening, heart racing and felt as if she was choking and that other people could see her struggling it was to much and she ran out of the store and wanted to go home. When she got to the parking lot and saw her husband there that gave her a sense of relief. Her husband is her safety behavior, she feels relief when he is there with her, in the video Dr. V brings this up and expresses that they will get to the point where she can do the tasks without her husband being there and that it could be a good idea to get him to come to a session and form a plan to work towards that.

    I can see how it would be helpful to decatastrophize and start with the worse case scenario and then end with the realistic case scenario because it is a process-oriented activity. Once you go through each part and kind of think it through further you become more relaxed and start to realize well maybe it is not as bad as I might have thought. I really liked that there was a section on how to cope and to address possible barriers that may come up. For me personally I probably should have picked a different thought to decatastrophize because I just kind of stayed in the worst case scenario, put even if that happens with a client it is still a helpful activity to help process those thoughts and examine possible evidence against the worst case scenario actually happening.

    CBT case formulation is important to have effective therapy because it allows for you to look at all aspects of the client’s life. You can examine the factors that are encouraging the behaviors or thoughts to continue, from across sectional and longitudinal view. The case formulation will help to keep information about the client organized looking at all the aspects of the case formulation such as the working hypothesis and precipitating factors allows you to build a treatment plan that suits the client best. It is important that your treatment goals are measurable, because you need to have a way of knowing whether there has been progress otherwise if not you can reassess and form a new plan or try something different. A measurable goal is something like the completion of activities. Not only should the goal be measurable it also should be specific, if the goal is to reduce the number of panic attacks then set a goal for how many a week the goal is.

    Reply

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Adam M. Volungis, PhD, LMHC

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