Topic 9a: Case Formulation & Treatment Plan {by 4/2}

[Case Formulation & Treatment Plan] – There are multiple readings due this week (J. Beck – 2 Chapters & Appendix A; Volungis – 1 Chapter; Persons & Tompkins [2006]; Academy of Cognitive Therapy: Candidate Handbook – Appendix D & E).  For this discussion, share at least two main thoughts: (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)? (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

 

[Case Formulation & Treatment Plan] – Watch PDA-1: CBT Assessment – Presenting Problems (focuses on problem identification, frequency, duration, and intensity; impact on daily life). (1) What information provided in the intake support that Lindsey is having panic attacks and agoraphobic behaviors? (2) What additional information would you like to know about Lindsey’s presenting problems? (3) What are your concerns about how Lindsey’s presenting problems are impacting her daily life? (4) Are Lindsey’s husband’s behaviors (e.g., going to the grocery store) helpful to her? Explain.

 

Your original post should be posted by 4/2.  Have your two replies no later than 4/4.  *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. Monica K Teeven
    Mar 28, 2020 @ 17:49:24

    Case Formulation and Treatment Plan

    1. The CBT case formulation plan is important for effective therapy in many ways because it conceptualizes the clients’ presenting problems, related symptoms, and other influencing factors. Furthermore, if there is any supplementary information about the clients’ automatic thoughts, behaviors, and emotions, this information can be very beneficial when creating the treatment plan for the client. Knowing the possible obstacles or other factors the client will most likely face increases the chances of creating an effective treatment plan. The information the therapist gathers from their assessment is incorporated into the case formulation which is the basis for the CBT treatment plan. CBT clinicians develop case formulations for their clients by using effective treatments that are evidence-based. In particular, CBT therapists place a much higher value on evidence from controlled studies where the data was gathered systematically by using objective measures. This kind of methodological procedure suggests to the therapist that the treatment plan they created for a client using the evidenced based from these studies will be successful.

    2. It is necessary to have specific, concrete, and measurable treatment goals whenever possible because having a specific goal tells the client and therapist how they will reach their goal. In addition, having a measurable treatment goal is important because it allows the therapist to track how accurate the progress of treatment is going for both themselves and for the client.

    Case Formulation and Treatment Plan – PDA 1

    1. The information that Lindsey provided about her symptoms lead Dr. V to believe that she has a panic disorder. The physiological symptoms include: chest feels really tight, breathing becomes labored, hands begin to tremble, and the attack lasts between 10 to 20 minutes. When Lindsey is experiencing these physiological symptoms she keeps thinking that she is “losing control” since her panic attacks are unexpected and she has no explanation as to why they are occurring. On a few occasions, because of her physiological symptoms, she thought she was experiencing a heart attack and brought herself to the emergency room. Both times, the medical staff told her there was nothing physically wrong with her and to seek mental health treatment. Lindsey also exhibited some symptoms that she may have agoraphobia. For the past 6 to 8 months, she tries to stay at home if at all possible, because she feels safe there. She relies on her husband to go grocery shopping and to do the errands because she is fearful of having a panic attack while driving or in a public place where she believes she will be unable to get help.

    2. I would like to know exactly what her husband does that makes her feel better. I know he helps her by doing the driving and errands. She states that just knowing he is close by relaxes her. However, what does he say or physically do that relaxes her? I would also like to ask her if she noticed her panic attacks occurred at certain times of the day or on certain days of the week. Lastly, I would ask her if there was any life change of some sort a year and a half ago when the panic attacks began to occur or 6 to 8 months ago when the agoraphobia symptoms began to appear.

    3. From the intake interview, her behaviors do not seem to effect her work life, but it is affecting her social life and her classwork (she’s earning an MBA). In the interview, she mentioned that during her classes, she has a hard time focusing which leads her to miss information given by the professor. In addition, last time she had a panic attack during class, she just got into her car and left which also leads her to miss important material. She needs this class to get her degree so she will be promoted at work. However, if she continues to miss class time the likelihood of her being able to pass the class is low. This outcome will prevent her from earning her MBA and she will not be promoted at work.

    4. Lindsey’s husband’s behaviors such as going to the grocery store for her are not helpful for Lindsey. The husband means well because he is doing things to help lower the chances of his wife having a panic attack. However, by not allowing Lindsey to do any of the shopping or errands, he is allowing her maladaptive behaviors to be acceptable. However, making an effort to help decrease his wife’s likelihood of having a panic attack, shows Dr. V that he truly loves Lindsey and wants her to be happy. In addition, this information is helpful because Dr. V now knows that her husband is a key factor in Lindsey’s life and has an impact on Lindsey’s maladaptive behaviors. This information can be used to create a treatment plan for Lindsey that involves her husband since he is associated with her maladaptive behavior.

    Reply

    • Jessica Costello
      Mar 31, 2020 @ 10:26:01

      Hi Monica! A point you made about the case formulation that I really didn’t emphasize was how the information the therapist gathers in the initial sessions can point towards specific negative automatic thoughts and maybe some core beliefs that may be reinforcing the client’s distress. While these thoughts and beliefs aren’t the focus of the first few sessions, the therapist can still notice patterns that will be important to return to later on in treatment.

      I would also be curious to learn more about any major life events or changes for Lindsey that could’ve prompted her agoraphobia symptoms.

      Good work!

      Reply

    • Erin Wilbur
      Apr 01, 2020 @ 12:18:19

      Hey Monica!
      I like your point that goals should be measurable not only to track the client’s progress but for the therapist to see how they’re doing as well. If we aren’t aware of our own progress in treating the client, we can’t be as helpful. I also like your insight into what Lindsey’s husband does or says to calm her during panic attacks, I had the same thought. She said it’s comforting to know he’s nearby but also that he knows what to say to help her, so I’m interested in what that is.

      Reply

    • Ashley Foster
      Apr 01, 2020 @ 21:41:29

      Hey Monica!
      I like your point in examining what makes her feel better due to her husband. I think that examination of what may be behaviors or what he is saying to her that calms her down exactly would be helpful for the clinician in giving his client coping skills That she could implement in her own life on her own. I also think it’s important to examine more what happened 68 months ago as her symptoms of agoraphobia became worse and more apparent. This way if there is a root reason for why these experiences have gotten worse, they can be tackled in therapy and hopefully decrease the level of distress that she is having in hopes of getting her back to normal way of life. Great job with the post!

      Reply

    • Melanie Sergel
      Apr 02, 2020 @ 22:08:51

      Hi Monica! I think it would be interesting to know what her husband does that makes her feel better. It is clear that she uses her husband as a safety behavior, and she states that he relaxes her by knowing he is close. It is unclear what she means by this so I think it would be interesting information to gather and make insight on. I also think you make a good point about asking her if she notices any specific time that her panic attacks occur. Also, I really like that you thought of asking her if any significant event had occurred in her life around the time that her panic attacks started. This would be very interesting to know to help her and the therapist understand her panic attacks better.

      Reply

    • Renee Gaumond
      Apr 06, 2020 @ 11:40:58

      Hi Monica,
      I agree with you when you said that Lindsey’s husband’s behavior isn’t helpful to him. I think he wants to help his wife and relieve her anxiety, but he his behavior has been reinforcing her avoidance behavior since she’s able to avoid the grocery store and leaving her house when he does those things for her.

      Reply

    • Mariah Fraser
      Apr 06, 2020 @ 18:04:40

      Hi Monica!
      I also think it would be important to determine what it is exactly about the presence of Lindsey’s husband that makes her feel more relaxed, and if it is something in particular that he says or physically does that relieves her distress. I hadn’t thought to ask about a pattern of panic attacks in regards to days of the week. Information about that may also be helpful in determining if it’s part of her routine that elicits this reaction from her (e.g. Sunday’s are the days they go to the store for groceries). I also find it important to talk with Lindsey about what was happening in her life around the time her panic attacks started, as well as when symptoms of agoraphobia began to present.

      Reply

  2. Jessica Costello
    Mar 30, 2020 @ 17:11:35

    Case Formulation & Treatment Plan

    1. A CBT case formulation is important for successful therapy because it gathers information about the client’s history and presenting problems, while also providing a space for clinicians to speculate about the potential roots of their problems and the potential negative automatic thoughts and core beliefs that may be maintaining their distress. Especially when most clients may not realize what is actually “wrong” with them when they walk into the therapist’s office, a complete formulation provides a working hypothesis through which both the client and therapist can conceptualize how their problems may have started and why they have been so difficult to overcome. A complete formulation rooted in empirical evidence also naturally assists the clinician’s choice of specific interventions that will be helpful for the client’s particular presentation of his or her symptoms or problems.

    2. Beyond the need to demonstrate to managed care organizations that the client is progressing through therapy and the treatment has been “working”, specific and measurable treatment goals serve as indicators to both the client and clinician of how well the treatment is progressing. For example, the degree to which the client’s scores on the Beck Depression Inventory have lowered over the course of treatment is a sign of how well or how poorly he or she has responded to the interventions. Having a sense of how well treatment works can help the clinician and client plan the next steps in treatment.

    Operationalizing specific treatment goals simply makes it easier to track a client’s progress. To use the example about making and keeping two social engagements per week, that is easier to assess whether the client actually did it, and gives the client and clinician content to talk about such as thoughts and feelings surrounding those specific social engagements, how the client felt before as well as afterwards. This is much more specific and fruitful than if the treatment goal had been something vague like “be more social”. Having a specific goal would also probably increase the likelihood that the client would follow through on the behaviors required to meet it.

    PDA-1: Case Formulation & Treatment Plan

    1. Lindsey’s behaviors such as staying at home as much as possible because she fears what could happen in a public place suggests the diagnosis of agoraphobia. She has also reported physiological symptoms like struggling to breathe, shaking hands, and a racing heart in the absence of any medical problem like a heart attack, that suggests she has been having panic attacks. She has no explanation of why these panic attacks would be occurring.

    2. I would like to know more about how Lindsey reacted the first time she experienced her unexpected panic symptoms as well as what might have been going through her mind. if other people were present, I would also like to know if they observed anything about her or what they did.

    3. After having a panic attack at her new gym, Lindsey began staying home and working with her personal trainer. Her distressing symptoms experienced while driving on the highway also may have impacted her ability to go out to different places, especially in places where there is a high volume of traffic. While she can adapt to her circumstances and still accomplish things like working out at home and having her husband do the grocery shopping and most of the driving, she feels like she needs help since her problems are interfering with completing her schoolwork for her MBA. Lindsey needs to finish her program because she feels it will help her get promoted in her job. However, her panic attacks have caused her to leave class and miss important information, which has caused her to worry that she is falling behind and will fail the program.

    Lindsey’s problems impact her school functioning, social functioning, and general ability to leave the house. Every time she engages in a safety behavior, even if it was originally adaptive, it actually reinforces her avoidance and increases the detrimental effects her symptoms may have on her daily life.

    4. In her intake, Lindsey said that her husband has taken over most of the driving and errands since she has been feeling more anxious about leaving the house and says she feels safer at home. While her husband probably has good intentions and is probably just trying to help, and his behaviors do accomplish the goals and tasks they have set out to do, such as the necessary grocery shopping, Lindsey’s once-adaptive reliance on her husband has become a safety behavior that reinforces her avoidance of public places. In the larger picture of Lindsey’s case, though they help in the short-term, her husband’s actions hinder her improvement and ability to face the situations that cause her distress.

    Reply

    • Monica K Teeven
      Mar 31, 2020 @ 11:45:47

      Hi Jess! In your response to the second Case Formulation and Treatment Plan question, you discussed how documenting how the treatment is progressing overtime is an important aspect that I did not mention in my blog post. You even had an example by using the Beck Depression Inventory to see if the client’s score of depression has lowered over the course of treatment. In your response to the second PDA-1 question, you mentioned that you would want to know if there were people around Lindsey when she had her first panic attack, how they reacted, and what did they observe. I am glad you said this because this can be an important factor that may need to be included in the treatment plan and should be discussed in further detail in therapy. Great job Jess!!!

      Reply

    • Robert Salvucci
      Apr 01, 2020 @ 13:32:31

      Hey Jess!

      Good summary of the relationship between building hypotheses with a client and using these hypotheses to then test and implement interventions. I love the example of setting and keeping two social engagements a week vs. “being more social”. It reminds me of an example I always reference in goal setting, where someone says they’ll “clean their house today” which would be impossible to do in one day and doesn’t actually specify what they intend to do or what cleaning the house means.

      I didn’t think of asking other people how they may have noticed Lindsey behaving, but this could certainly be beneficial to getting a sense of how her anxiety is affecting her. I wonder if her husband could provide any insight on his interpretation of her anxiety symptoms and how she acts when she is anxious vs. more calm.

      Reply

    • Ashley Foster
      Apr 01, 2020 @ 21:45:52

      Hey Jess!
      I like the point where operationalizing specific treatment goals can help keep the client on track in progress. I think that we can get caught up in our psychological lingo where the client maybe loss on what they should be working towards. operationalizing treatment goals gives the client and the clinician a better understanding what needs to be worked on within each session in what pass they should be examining within these sessions. This helps also making the clinician look more “attractive” and more of an “expert”, while working with the client especially in the first few sessions. This will make the client more comfortable in exploring with the clinician and resulting in success throughout sessions. Great job with the post!

      Reply

    • Renee Gaumond
      Apr 06, 2020 @ 11:54:24

      Hi Jessica,
      I agree with you when you said that Lindsey’s behaviors suggest agoraphobia since she avoids going outside. I remember in abnormal psychology Dr. Doerfler talked about how people who experience agoraphobia have a boundary of where they are willing to go that is determined by where panic attacks have occurred. When the panic attacks happen in certain settings that shrinks the boundary that the person is willing to go and after a while the boundary confines the person in their own house. This reminds me of Lindsey’s behavior where she would have panic attacks at the grocery store and thus avoid going there because she was afraid that the panic attack with get triggered in the store.

      Reply

  3. Robert Salvucci
    Mar 31, 2020 @ 14:41:51

    Case Formulation

    1. A case formulation provides a framework to work with for a client, and outlines relevant goals to address during therapy. Understanding a client’s history helps to identify relevant areas to target during intervention. Placing there presenting concerns within a CBT framework allows for collaboratively setting goals and measuring improvements during therapy. This information will provide a basis for what thinking patterns and patterns are integral in the maintenance of client symptoms. It also serves as a reference point when coming up with examples or assessing the course of a presenting concern. This information can inform the intervention approach.

    2. Having tangible goals helps the therapist and client stay on the same page during treatment. It provides a client with a framework for treatment, and a sense that they are making progress towards achieving something. The therapist is able to track progress relevant to the goal, and reflect those improvements to a client and help them consolidate their gains. Goals focus treatment so that they can be as efficient as possible in addressing the sources of distress. They can also contribute to a sense of the therapist being professional and competent, and inform appropriate treatment course.

    CBT Assessment

    1. Lindsay has been having panic attacks with increasing frequency for about a year and a half, which have been exacerbated in the past half year. She is increasingly becoming more and more fearful of leaving her house. She avoids large crowds and many areas of her daily life are being affected, including her ability to go grocery shopping, go to the gym, and be attentive and present in class. She also notes that she tries to stay within a one mile radius when she is going for a walk. Her physical symptoms involve feelings of panic, shortness of breath, tightness of chest, hyperventilating, and trembling hands. She went to the emergency room at one point and they did not find any notable physical causes of her symptoms.

    2. I’m curious as to how her work is affected by these symptoms. She mentioned how some of her activities of daily living are affected, as well as school, but didn’t mention how her job is being impacted. I’m also curious to note any areas of her life that are being minimally affected, and getting her thoughts on why she is having an easier time functioning in certain areas than others. This could help her identify her triggers, and draw from those areas to help ease her panic and anxiety.

    3. Lindsey noted many areas of her daily life being affected. When her symptoms started, she began avoiding the gym. She notes that she is hyper vigilant and careful not to stray too far form her house when going for walks. She is unable to go to the grocery store alone. She is having trouble focusing in class and even leaving early at times. She notes that she isn’t going out with groups of friends unless there are certain safety measures in place. She has experienced anxiety while driving and drives as little as possible. Many areas of her life are being impacted.

    4. Lindsey’s husband’s behaviors are in some ways helpful and in some ways harmful. In relation to the development of her anxiety, they are making the problem worse, as his presence and support is reinforcing Lindsey’s anxiety and preventing her from re-developing confidence in approaching difficult situations. This is slowly increasing her agoraphobic symptoms. They are helpful in the sense that his compassion communicates to her that he really cares, and is providing short term anxiety relief. The strength of their relationship and strategically using her husband as a safe base could serve to assist Lindsey in overcoming her anxiety and panic, if done systematically and utilizing proper CBT techniques with her husband.

    Reply

    • Jessica Costello
      Apr 01, 2020 @ 08:25:47

      Hi Bobby! You made a good point about how having clear and concrete treatment goals can help the client feel like they are progressing towards a specific goal. This will probably benefit their self-efficacy and attitudes towards treatment in general, which is something I really didn’t touch on in my response. You’re also right to point out that modifying the case formulation will probably end up modifying the course of treatment that the client is receiving.

      You also had a good summary of how Lindsey’s husband is becoming a safety behavior and reinforcing the maladaptive avoidance in her agoraphobia. I liked your conclusion that if the husband changed his behavior he could actually help Lindsey using the strong base of their relationship that they’ve already built. Good work!

      Reply

    • Shelby Piekarczyk
      Apr 01, 2020 @ 11:33:24

      Hi Robert,

      I agree that Lindsey’s husbands behaviors can be harmful and helpful to her in this situation. She had explained that she felt the ER staff thought she was crazy and had not problems. Knowing that you have a support system can be a very positive factor during recovery, having Lindsey know that she is not alone. But his behaviors of running her errands for her (e.g. grocery shopping) and allowing her to stay in the home is greatly impacting her ability to adaptively cope with these stressful situations. Because Lindsey’s husband is running all of her errands, Lindsey does not need to leave the house for all of her basic needs to be met. This allows Lindsey to avoid these situations and never develop coping skills for them. I believe that if this continues her condition will worsen and she may begin avoiding additional places that she is comfortable going to at this moment in time.

      I am also curious as to how her work is impacted by these symptoms. In the session Lindsey talks about wanting to complete her MBA so she can get a promotion at work. So I am wondering if these symptoms are impacting her work or if she is still attending work normally. Great job!

      Reply

  4. Melanie Sergel
    Mar 31, 2020 @ 23:09:31

    Case Formulation & Treatment Plan

    (1) CBT case formulation is important for effective therapy and successful in treating a client for many reasons. CBT case formulations put together the information gathered from assessment and interview about the client’s history, presenting problems, associated symptoms, and contributing factors. The clinician uses the case formulation to put the information together to speculate how the client’s problems began and how they are being maintained, it is as if you are writing a story about the client. Case formulations help clients become “better” because they help the client see things that they have not seen but the clinician has hypothesized through the case formulation. Most of the time clients come into therapy not knowing what is wrong with them or why they feel the way they do. The case formulation helps fill in those missing holes that the client cannot figure out. Case formulations are always being modified when new information is discovered to work to help the client reach their goals. This is important to do because case formulations help the clinician determine what will be the best way of treatment for the client and since you have to modify the case formulation when new information is gathered, this could change the treatment that the client is receiving.

    (2) Treatment goals are the desired client outcomes. It is necessary to have specific, concrete, and measurable treatment goals whenever possible because it allows the client and therapist to accurately track the treatment progress.

    PDA-1: CBT Assessment – Presenting Problems

    (1) Information was provided in the intake to support that Lindsey is having panic attacks and agoraphobic behaviors. This information consisted of Lindsey explaining her symptoms. Lindsey explains that when she has panic attacks her chest gets tight, her breathing becomes heavier, her body shakes (specifically her hands), she feels like she is losing control, has out of body experiences, and feels like she is dying or having a heart attack. This description that Lindsey gives suggests that she is experiencing panic attacks. Lindsey also explains that for the past 6-8 months she does not want to leave her home because she feels safer there and that she tries to stay home as much as she can. She also states that she does not want to leave because she does not know if she will have a panic attack or not. She also does not like leaving the house without her husband and her husband does her errands for her. These statements made by Lindsey suggest and give information that she fits the criteria for agoraphobia.

    (2) Additional information I would like to know about Lindsey’s presenting problems is how it affects her at work. She has discussed how her school is being impacted by her presenting problems and expressed that she worries about failing out of school and not getting her promotion but does not get into detail about how she is impacted at work. I also would like to know if she is aware that she has been going out of her way to avoid places/situations. For example, she gets a personal trainer, so she does not have to go the gym. I would further like to know if she is aware that doing this does not help her.

    (3) A concern I have about how Lindsey’s presenting problems are impacting her daily life is that she finds ways to get herself to avoid triggering events. She has her husband run errands for her and drives for her. She also hired a personal trainer for her to come to her house because she was having panic attacks at the gym. This is a concern to me because her maladaptive behaviors are being reinforced and they will not get better if she continues to find ways to avoid places. She also is leaving class early to avoid traffic and now her grades are being impacted because of it. This is also a concern to me because her presenting problems are not only affecting her daily activities but now, she is having difficulty completing goals she sets for herself because she is trying to get her MBA to get a promotion at work.

    (4) Lindsey’s husband has been doing a lot for Lindsey because she struggles with errands and activities. Lindsey’s husband will go grocery shopping for her and do the driving to help her because she is very anxious about leaving the house. The husband wants to do what he can to help Lindsey and be there for her when she needs him, but I do not think that Lindsey’s husband’s behaviors are helpful to her. I do not think they are helpful to her because it seems that she has grown to rely on him. This shows because her safety behavior is using her husband. The husband is also reinforcing Lindsey’s’ maladaptive behaviors because now she does not have to go out if she does not want to. People are more likely to be able to participate in avoidance if they have someone in their lives that will help them, and Lindsey has her husband. If she did not have him, she would be less likely to avoid going out because she would need to buy groceries and complete other errands.

    Reply

    • Shelby Piekarczyk
      Apr 01, 2020 @ 11:39:31

      Hi Mel,

      I agree with your concern about Lindsey avoiding situations that impact her daily life. I feel as though if she does not develop adaptive coping skills during these situations it could worsen over time. I also agree that right now these maladaptive behaviors are being reinforced by her husbands behaviors and hiring a personal trainer to avoid going to the gym. Right now she can avoid these situations without extreme consequences, but I believe in time this will not be the case. Like you had stated she is beginning to not do as well in school as she has done in the past because of these symptoms. If she does not perform well in school then she will not receive the promotion from work, impacting her goals. I agree that this is a large area of concern.

      I also agree that Lindsey’s husbands behaviors are impacting her in a negative way by reinforcing her maladaptive behaviors. However, I feel that it can also be viewed as positive because it shows Lindsey that she has a support system, especially while going through the steps of therapy. However, I agree that in order for Lindsey to develop positive coping skills the behaviors of her husband (e.g. running her errands) needs to be stopped. Great job!

      Reply

    • Monica K Teeven
      Apr 01, 2020 @ 11:49:22

      Hey Mel! In your response to the second PDA-1 question, you mentioned that you want to know if her presenting problems are affecting her at work. From this session, it sounds like her presenting problems are most likely affecting her work life too since these issues are affecting her socially and academically. I did not mention this in my blog post, but I would also would want to ask Lindsey if her presenting problems are negatively affecting her husband and/or marriage. She says her husband now does the grocery shopping and other errands for them now since she is fearful of having a panic attack. This means her husband has to take on more responsibilities because of her presenting problems and taking on more responsibilities could cause stress on him and on the marriage. Great job on your blog post Mel!!!

      Reply

  5. Shelby Piekarczyk
    Apr 01, 2020 @ 11:28:25

    1. A CBT case formulation is important for effective therapy because it conceptualizes the clients past and present presenting problems, symptoms associated to their distress, and contributing factors. This information is gathered through intake, assessments, and other outlets throughout therapy. The therapist uses all these outlets to hypothesize what the underlying problem is and what steps to take moving forward. By developing a case formulation this allows the therapist and client to collaborate on an action plan based on the clients past and present problems and symptoms associated to their distress. Additionally, developing a case formulation allows the client to understand their distress and be a key component to their process towards change. Many clients go into therapy not knowing what is wrong, collaborating with the therapist allows the client to fill in the gaps and understand their distress. Allowing the client to be involved in this process it increases their motivation for change and increases the clients sense of hope. Furthermore, case formulations should be modified throughout treatment, allowing the therapist and client to see what has been effective thus far in treatment and what may need to be changed or modified moving forward.

    2. Specific, concrete, and measurable treatment goals are necessary whenever possible because it allows the therapist and client to keep track of the progress being made. It also allows the therapist and client to see areas that need more work and how to move forward in therapy. Additionally, it sets goals for the therapist and client to reach, allowing them to know exactly what therapy will entail.

    PDA-1
    1. During the intake Lindsey provides information to support her panic attacks and agoraphobia by explaining her symptoms. Lindsey explains that her chest becomes tight, her breathing becomes more difficult, her body begins to shake, and ultimately, she feels out of control. When Lindsey is feeling out of control, she feels dizzy and an outer body experience, and that she is going to have a heart attack. She states that she has had symptoms for about a year and a half but in the last 6-8 months they have began to increase. Additionally, Lindsey explains how she does not want to leave her home because she feels safer there. Lindsey does not want to leave the house alone in fear of a future panic attack. She has her husband do her errands for her (e.g. grocery shopping) and does not feel safe leaving the house without him. These symptoms support the hypothesis of Lindsey having panic attacks and agoraphobia.

    2. Additional information I would like to know about Lindsey is how these symptoms impact her work. She explains how she is struggling to complete her MBA but not much is stated about work. She wants to finish her program at school so she can get a promotion at work, so I am curious to know does she experience symptoms while at work. I would also like to know if every aspect of her life is being affected or if there are areas of her life that she is not experiencing these symptoms.

    3. My concerns for Lindsey are her avoidance for daily activities. Right now, she is using avoidance and using other to complete her tasks as her coping mechanisms. As Lindsey has states these coping skills at the beginning of her experiencing these symptoms seemed to effective, however now they are impacting her life greatly. My concern is that if she does not learn adapting coping skills in these situations, this area of concern (avoidance) will increase.

    4. Lindsey’s husbands’ behaviors are both helpful and harmful. I think these behaviors can be helpful because it shows Lindsey that she has a support system and that she is not alone. However, by her husband running all of Lindsey’s errands, he is ultimately magnifying her symptoms. He is aiding in her avoidant behaviors, allowing her to not have to leave the house for her basic needs. This is going to increase her symptoms and stop her from developing adaptive coping skills.

    Reply

    • Erin Wilbur
      Apr 01, 2020 @ 12:05:47

      Hi Shelby!
      I definitely think finding out more about aspects of Lindsey’s life where she might not experience panic attacks or agoraphobia would be really helpful toward her treatment. If for example she feels safe at her job, what’s different about that environment and why does she fear having panic attacks when she’s there? Learning more about how she’s feeling in all of her different environments could be beneficial for developing interventions to help her.

      Reply

    • Melanie Sergel
      Apr 02, 2020 @ 22:13:33

      Hi Shelby! I also wrote that additional information I would like to know about is how Lindsey is impacted at work by these symptoms. I think this would be very important to know because she explains that she fears that she will fail out of school and lose the promotion. If she is having trouble at work and leaving work constantly from her symptoms, her promotion might be on the line if this is happening at work. I also like that you wrote that you would like to know if every aspect of her life is being affected. I think it would be important to know what exactly is being impacted and soon so that all these areas can be worked on and not overlooked. Great job!

      Reply

  6. Erin Wilbur
    Apr 01, 2020 @ 11:53:41

    Case Formulation
    1. CBT case formulation is important for effective therapy because it offers a conceptualization of the client’s presenting problems, symptoms, and other factors that may contribute to the problem. By doing this, it aids in efficient and purposeful treatment. Case formulation relies on collaboration and input from the client, and allowing them to take part in the planning can increase their hope and motivation for change. By gathering information through assessments and intake sessions, the therapist develops a working hypothesis for how the client got to this level of distress. From there, the therapist will develop a tentative treatment plan with goals and interventions that will be most effective for the client. Case formulation is an important part of this because it creates the framework for the working hypothesis, and if this hypothesis doesn’t fit the client, the resulting interventions and goals won’t be as effective.
    2. It’s necessary to have specific, concrete, and measurable treatment goals whenever possible because this is how therapists measure client progress. Specific goals can help to reduce distress more than vague or immeasurable goals because the client knows exactly what to expect and can see their progress, which can increase their hope for change as well as their motivation.
    PDA-1
    1. The information from the intake that supports Lindsey’s panic attacks and agoraphobic behavior are her description of the symptoms. She describes the physiological symptoms of her panic attacks as her chest getting tight, labored breathing, her hands trembling, feeling lightheaded or dizzy, and like she’s having a heart attack. She also says that she feels like she’s losing control when the attacks start, and like she’s having an out-of-body experience. Lindsey also admits that she feels safer in the house because she’s afraid of having more panic attacks. She says that she can’t walk her dog outside of a one mile radius of her house, and that leaving the house to go to class is very stressful for her. She explains that she prefers to be home with her husband or best friend and can’t tolerate being in public places without them.
    2. Additional information I’d like to know about Lindsey’s presenting problems are possibly learning a little more about her environment when these panic attacks start, and where they most often happen. I noticed that she mentioned how it affects her in class and while driving, but didn’t explain how or if it impacts her job performance, so that would be interesting to learn more about. Does she feel safe at her job? And if she does, what’s different about her job compared to other public places? I’d also like to know the type of things her husband says to her when she is having panic attacks, because she says that he is able to calm her down and comfort her. This could be helpful for developing interventions for Lindsey.
    3. My concerns about how Lindsey’s behaviors are affecting her daily life include that she is unable to go many places without her husband, that her school performance is being affected by her fear of future panic attacks and can’t focus on her work, and that she can’t go out with friends from class. Lindsey’s agoraphobic behavior and fear of panic attacks keep her from doing anything that isn’t essential for her, like grocery shopping or going out to eat with friends. She has been tweaking more and more in her life to allow her to stay inside as much as possible, and she’s not realizing that she needs help to start going out again.
    4. Lindsey’s husband’s behaviors are not helpful to her from a therapeutic standpoint. While Lindsey feels that his behavior is helpful and comforting to her, by going to the grocery store and going everywhere with her, Lindsey’s husband is perpetuating her maladaptive safety behaviors and allowing her to avoid confronting the problem.

    Reply

    • Robert Salvucci
      Apr 01, 2020 @ 13:22:07

      Hey Erin!

      Good insight pointing out how case formulation capitalizes on the collaborative nature of CBT and helps make a framework for the client and therapist to work on collaboratively. You noted how this framework provides a sense of hope and continued motivation and progress over the course of therapy. I like how you highlighted missing information of Lindsey’s symptoms pertaining to areas of her life that provide comfort or in which she doesn’t feel much anxiety. Comparing environments that she feels safe in may help in identifying thoughts or environmental variables that contribute to distress. It would also be very helpful to try and take her husband’s supporting behave and have her internalize some of the things he says that she find comforting.

      Reply

    • Mariah Fraser
      Apr 06, 2020 @ 18:04:09

      Hi Erin!
      I liked how you mentioned that Lindsey seems to be adjusting pieces of her life to avoid having panic attacks, and that almost seems like it could be a goal that she might not even be aware of, or if she is aware, she doesn’t fully understand how that causes more harm than good. If she can realize that accommodating these behaviors is far from the solution, she may find it easier to spend time outside of her home. Staying inside may feel safe in the moment, but it is crucial for Lindsey to see that avoiding situations like the grocery store or being social with her friends only enhances her distress.

      Reply

  7. Ashley Foster
    Apr 01, 2020 @ 21:36:25

    Case Formulation & Treatment Planning

    1. Case formulation helps the clinician better understand why the client has come to therapy. This formulation gives the clinician the ability of getting demographics, past history, and symptomology of what has been going on with their client and ultimately why is lead them to therapy. Another reason why case formulation is important is it helps in treatment planning. This is done as the clinician and the client triage what is most important in tackling within the sessions going forward. This way Clients do not need to spend more time needed in therapy then they should, and they are given tools that are personalized for future experiences. This aids in making the client more autonomous throughout and after therapy.

    2. It is important to have specific, concrete and measurable treatment goals to show if the client is improving. Without these specific, concretes and measurable goals we cannot fully say as clinicians if we have “treated of helped the client”. This also helps with making sure the client is not in therapy longer than they need to be. CBT in nature, is a short-term therapeutic intervention. Part of keeping to these norms, having these goals, we can better examine when we should be moving forward in the next stages of treatment.

    CBT Assessment

    1. The client is having symptoms of chest gets tight, breathing labored, body shake and, in her hands, especially, feelings loss of control with out of body experiences, feeling of she’s dying, feelings of a heart attack, not know how to stop it, and lightheaded and dizziness. She has experienced this for the last for the year and a half, last 6-8 months has gotten worst. She experiences these attacks 2-3 a week lasting 10-25 minutes each with a 7-10 rating scale. It is worst now than before as it has become progressively worst.

    In the moment with clinician during session, just thinking about the attack, is having symptoms due to the fear of having another. She is scared of not knowing when they’ll come on, not knowing what triggers them and feels safer at home. She doesn’t like going anywhere without husband. The husband is going to grocery store for her and is even making sure he’s there to take the dog out and no longer than a mile radius. She Can’t go out and enjoy going out with her husband as he calms her. She is struggling with school as it is stressful and getting worst, use to be doing well but now is impacted. Can’t go out with peers unless it is a close friend or husband who knows how to respond. She has been cutting out early and as a result her grades are dropping as a residual effect. The fear is manifesting in all aspects of life.

    Going back when it first started, she was in a gym lifting weights engaged in physical activity looking in the mirror seeing how many people were there, high stress, heart racing and pounding, getting dizzy, loosing control, body shakes, feel embarrassed. At first, she tried to breath but hyperventilated and couldn’t control it, she put the weights back and went to the locker room and it continued to get worst, she went to the car and ended up going home. After, never went back to the gym and hired a trainer. She then had them when she was driving, she looked in the mirror and saw all the cars, body got hot, hands shaking, and had to pull over. Things got worst when she started using her hired trainer and using her husband to drive for her as she has become reliant on others.

    In more recent events, she had a negative automatic thought and feeling that snow balled till she ran out of class and got in her car to head home. While driving she felt like she loss control completely and felt she was going crazy. As a result, feeling like she was going to die, she went to the ER. At the ER the doctors said she was fine, but she felt that there is something wrong with her body. This was not her first trip to the ER; she has been there before for the same symptoms. She is having some catastrophizing in her thoughts leading to heightened feelings and behaviors.

    2. I would want to learn more of the client’s past history specifically areas involving family, interpersonal relationships, and trauma. I would want to know more about family history as if there is a genetic factor of if there is anybody else in her family unit that has exhibited symptoms or even diagnosis of agoraphobia or panic disorder. This way we can rule out if this is somewhat of a learned behavior to dealing stress. I would also want to examine interpersonal relationships and how she is built these relationships or issues had issues with other people in society before. this would help in knowing if these anxious thoughts and feelings have been building from something else. Lastly, I would want to examine any trauma history as agoraphobia and panic disorder has been seen in many clients with post-traumatic stress disorder. These different avenues would better help the clinician in determining what is most important in triage Ng what should be worked on in session to help break down fears.

    3. Looking at the client I’d be most concerned about how she is starting to skip out of class and leave work early to escape the situation she is in to get to a safe place which is her home. I would also be concerned on how much she is relying on her husband. This behavior is avoidant in nature as she pulls herself out of the situation rather than facing her fears in setting with her anxious thoughts and feelings which would ultimately help her in tackling what is going on. I would also I’ll be concerned and how her distress is progressively getting worse and more frequent in nature.

    4. The clients husband’s behaviors are not helping the client rather they are enabling her behaviors in avoiding her agoraphobic fears. As a result, in what has been shown thus far the clients do stress will increase as she is more enabled in order to stay in her safe spot of her home. The client is goal driven as she wants to finish her degree and get a promotion at work. With these enabling behaviors of her husband completing her daily living tasks that scare her this will only make matters worse. Without sitting with these fears the client’s distress will only rise as she will not know how to cope with these experiences.

    Reply

    • Madison Armstrong
      Apr 04, 2020 @ 20:14:40

      Hi Ashley,
      I think you make a really good point in wanting to learn more about her and her family’s past history. It would be interesting to see if any of her family members exhibit similar symptoms. I also agree with you that her husband’s behaviors are enabling her agoraphobic behavior. Ultimately, his behavior is harmful to her progress and it would be ideal to see him take on more of an encouraging role in her life. This way she can learn to properly cope with her triggers instead of engaging in her safety behavior.

      Reply

  8. Jenna Nikolopoulos
    Apr 01, 2020 @ 23:18:29

    Case Formulation

    1. A CBT case formulation is important for effective therapy because it pieces together the client’s information that is gathered from the assessment and intake interview, such as the client’s past and presenting problems, history, and any factors that could be contributing to their distress. By gathering all of this information, the clinician to tries to hypothesize what could be going on with the client, how it began, and how to move forward with treatment. The initial information that the clinician gathers will be used, in collaboration with the client, to develop treatment goals that the client wants to work towards and a plan that works best for the client. Case formulations help clients get “better” because it helps fill in the gaps that clients can’t figure out regarding why they feel a certain way or why they think certain things. By collaborating with their clinician, clients are able to understand their distress. Over time, as the clinician gathers new information from working with the client, the case formulation will be modified to better fit the client’s situation and to better address the goals that he/she wants to reach. Clinicians will be able to see which interventions work and don’t work for the client, which will help them in figuring out the most effective treatment for the client.

    2. It’s necessary to have specific, concrete, and measurable treatment goals because it allows the therapist to keep track of treatment progress not only for the client, but also for the therapist. Setting goals helps decrease clients’ distress because it informs the client what therapy will entail and they will be able to see the progress, or lack of progress, that they are making towards their goal.

    PDA- 1
    1. The information provided in the intake that supports that Lindsey is having panic attack and agoraphobic behaviors consists the physical symptoms that she experiences: her chest gets really tight, labored breathing, hands start to shake. Lindsey also said that when experiencing these symptoms she feels like she is having an out of body experience, is losing control, and feels like she is dying or having a heart attack. She also mentions that for the past 6-8 months, she doesn’t want to leave her home that much anymore because she feels safer there as she knows what to do when she feels a panic attack coming on. She’s afraid that if she leaves the house, if she were to have a panic attack in public she wouldn’t know how to handle it. She doesn’t like to go anywhere without her husband and he has been doing the grocery shopping lately because she can start to feel a panic attack when she goes to the grocery store. Also, Lindsey mentioned that when she walks her dog she can stick to about a 1 mile radius from her house before feeling like she is going to have a panic attack. All of this information provides support that Lindsey is having panic attacks and agoraphobic behaviors.

    2. I would like to know some of the things Lindsey is able to do without feeling like she is going to have a panic attack to see if there are similarities between these situations and the situations where she feels like she’s going to have a panic attack. Lindsey mentioned school and how these symptoms have been impacting her ability to do her schoolwork, but didn’t mention if it impacts her job; so I would like to know more about her work and if her symptoms impact her there as well. Lastly, I would like to know what was going on at the time of Lindsey’s first panic attack. If there were things happening in her personal, social, or work life that may have contributed to the onset of her panic attack.

    3. One of my concerns is that she is unable to do many things without her husband with her, which causes her to use him as a safety behavior. I think this makes her feel like she can only do things if her husband is with her. Another concern I have is how her panic attacks are affecting her school performance as she is unable to concentrate on her work because she is afraid of having a panic attack. Lindsey is also avoiding doing daily activities, such as grocery shopping, because she is afraid of having a panic attack or driving when there is a lot of traffic. She even hired a personal trainer so she wouldn’t have to go to the gym. All of these changes she is making in her life are only reinforcing her avoidance behaviors. Her presenting problems aren’t just impacting her daily life, but are also impacting her work life because if she isn’t able to finish her MBA then she won’t get the promotion at work.

    4. They are helpful because he is doing the things that Lindsey can’t really do anymore, like going grocery shopping or doing the driving because of her anxiety. From what Lindsey says about him, it seems like he is a supportive husband and is trying to help her in any ways that the can. However, Lindsey’s husband’s behaviors are ultimately hurting Lindsey. Lindsey has grown too dependent on him to because she doesn’t like to go anywhere without him due to the fact that he makes her feel safe. Also, by doing the things that Lindsey is too afraid to do, he is only reinforcing her maladaptive avoidance behaviors because now she doesn’t have to go grocery shopping or drive in traffic if she doesn’t want to; she knows that he will be there to do it for her. If Lindsey’s husband wasn’t in the picture, then Lindsey would have no choice but to confront her fears of leaving the house because she wouldn’t have anyone else to rely on to do things for her; but because he is there and more than willing to help Lindsey, she is able to rely on him so she can avoid doing the things she doesn’t want to do.

    Reply

  9. Renee Gaumond
    Apr 02, 2020 @ 06:18:48

    1.
    The CBT case formulation is important because it gives a summary of the client’s presenting problems, symptoms, and influencing factors. Clients can also have input about their automatic thoughts and core beliefs that influence them. It allows for the therapist to create a treatment plan that is relevant to the client.

    2.
    Having specific, concrete, and measurable treatment goals is important because it gives the client and clinician A plan to follow and guide treatment. It allows clinician and client to objectively monitor progress by having goals and seeing what goals have been made. When there is a measurable treatment goal it makes measuring therapeutic progress standardized. Objectivity is important when it comes to looking at if the treatment is effective. Clients can express that they are doing better, but having the confirmation of goal completion allows client and clinician the chance to see the progress in a measurable way.

    1.
    Lindsey’s physiological symptoms that included tightennes in the chest, irregular breathing, and the shaking of her hands gave insight into that Lindsey is having panic attacks. She also mentioned that during these moments that feel like heart attacks, she has the sense of losing control. These are signs of panic attacks. A lot of people who experience panic attacks can think that they are having heart attacks because of the physiological symptoms that accompany the attacks. Her anxious avoidant behaviors was a sign that she also experiences agoraphobia. She avoided leaving her house and had her husband shop for her. She expressed that she was nervous about having a panic attack at the grocery store.

    2.
    I would ask her about her first panic attack and what her life was like at the time to see if there was any triggering event or if she had distress about something specific. I’d also like to know about any possible patterns regarding the panic attacks such as if it’s usually when she is by herself or if specific times or places trigger them.

    3.
    My concerns about Lindsey’s presenting problems is that they significantly affect her daily life to the point that her avoidance behavior dictates her life. She avoids leaving her house and has trouble in class. She has found ways around leaving her home by getting a personal trainer, which just reinforces her avoidance behavior.

    4.
    Lindsey’s husband does a lot for her such as shopping for groceries and driving because he wants to help her with her anxiety, but these actions are reinforcing her avoidance behavior and making it easier for her to be able to continue avoiding leaving her home. Lindsey relies a lot on her husband since he does a lot for her, this has created stronger patterns of avoidance because it allows Lindsey to keep avoiding the things she’s anxious about rather than facing them.

    Reply

    • Jenna Nikolopoulos
      Apr 02, 2020 @ 14:46:41

      Hi Renee! I totally agree with your thoughts on additional information you’d like to know regarding Lindsey’s problems. I think assessing what was going on in her life around the time of her first panic attack is important because it could indicate any factors that could have triggered the start of her panic attack. If Lindsey had experienced any major life changes or stressors at work or home, those could have contributed to the onset of her attacks. I also think assessing any potential patterns that are occurring with Lindsey’s panic attacks would be beneficial as it would give her clinician further insight into what could be causing her panic attacks, which will be helpful in figuring out the next steps in her treatment.

      Reply

    • Taylor O'Rourke
      Apr 02, 2020 @ 19:35:20

      Hi Renee!

      I totally agree with you when you mentioned the additional information you would like to know about the occurrence of Lindsey’s panic attacks. I, too, think that getting some details about her very first panic attack would be helpful, as well as determining as possible patterns of symptoms that occur. By figuring out some of the antecedents that happen directly before her panic-like behaviors, I think this would be very telling as to how her panic attacks could possibly be avoided or helped by exposure therapy. Determining what these possible triggers are is so important for both the client and therapist to find out so they can do some exposure exercises to prevent them from happening anymore.

      Reply

  10. Madison Armstrong
    Apr 02, 2020 @ 12:28:13

    [Case Formulation & Treatment Plan]
    (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?
    CBT case formulation is an important aspect for effective therapy. CBT case formulation comes after the assessment in which the therapist and client work together to come up with an effective treatment plan. This targets the clients presenting problems, associated symptoms and contributing factors. As new information is gathered throughout time, modifications can be made to allow room to target new goals. Since CBT case formulation is collaborative, we can make sure that the client’s main concerns are addressed while increasing their motivation for change. The therapist can also use a working hypothesis to help the client better understand themselves, the way they see the world and their future.
    (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?
    It is helpful to have specific, concrete and measurable treatment goals because you will be able to accurately track the progress of the goal. This information allows both the therapist and the client to see if they are making progress toward a goal or not. If they are not seeing improvements, then they can look to see where there is room for modifications if something isn’t working for them. Being able to see the progress is important because then you are able to tell that the interventions are working. This can also contribute to the client’s motivation for change and continuing therapy. If the client sees these changes, then this could increase their self-efficacy for making effective changes in the future.
    [Case Formulation & Treatment Plan] – Watch PDA-1
    (1) What information provided in the intake support that Lindsey is having panic attacks and agoraphobic behaviors?
    Lindsey’s description of her symptoms makes it clear that she is experiencing panic attacks and agoraphobic behaviors. She describes her panic attacks as he chest gets tight, she starts to breathe really fast, feels as if she is losing control, her hands start to shake, she has almost an out of body experience, she feels light headed and dizzy, and she feels like she is going to die from a heart attack. She reports that she has been experiencing these symptoms for the last year and a half and has about 2-3 panic attacks a week. She also reports that she is often thinking about the next time she will experience a panic attack and that she feels safer at home. She avoids going many places without her husband and even avoids some places completely like the grocery store, the gym and going to restaurant’s with classmates. She reports feeling scared to leave the house because she does not know when the next panic attack will come and if she will be able to receive help from someone. Her description of her symptoms aligns very closely with the DSM criteria for panic disorder with agoraphobia.
    (2) What additional information would you like to know about Lindsey’s presenting problems?
    Some additional information that I would like to know about Lindsey’s presenting problems is a little bit more detailed information about the antecedents of her panic attacks. We have learned that she spends some time before thinking about the panic attack and expecting it to come on. I would like to know what else is going on that could be a potential trigger for the panic attack. I would also like to know more about her job. She mentioned that she works full time, but I would like to know more about what her job demands of her and if she is experiencing any of these symptoms at work.
    (3) What are your concerns about how Lindsey’s presenting problems are impacting her daily life?
    It appears that Lindsey has adapted to her panic attacks by avoiding things that may trigger them. I am mainly concerned that this avoidance has impacted her daily life in a significant way. She mentions that she is an MBA student and these panic attacks impact her capacity to learn. She is often distracted during class thinking about her panic attacks or what she would do if the teacher called on her. She is also partially avoiding class by leaving class early to get home and she is also not able to socialize with her classmates after work. It seems like she desires to be able to do these things but is unable to which could cause her even more distress. She also appears to be dependent upon her husband for many things. She is also not able to go to the grocery store alone and relies heavily on her husband doing this for her. One of my biggest concerns is her having a panic attack while she is driving, but she also will have her husband do the driving if she predicts heavy traffic.
    (4) Are Lindsey’s husband’s behaviors (e.g., going to the grocery store) helpful to her? Explain.
    I do not think that Lindsey’s husband’s behaviors are helpful to her. I think for now, they are helpful because he is able to do the things for her such as grocery shopping or driving that she is unable to do. However, ultimately these behaviors are not encouraging her to be an adaptive functioning individual. I see these behaviors as reinforcing to the panic attacks because they are allowing for the avoidant behavior to continue. It would be more beneficial for her husband to encourage her to do the things that she is nervous about to allow for exposure to these triggers.

    Reply

    • Taylor O'Rourke
      Apr 02, 2020 @ 19:31:49

      Hi Madi!

      I completely agree with you when you mentioned that Lindsey’s husband’s behaviors are not all that helpful to her. Although they provide her temporary relief so she does not feel the physiological symptoms of a panic attack or the worry and anxiety that one will occur, she is ultimately being negatively reinforced by her husband’s behaviors. By not encouraging Lindsey to get out of the house and start will small tasks, he is reinforcing her avoidant behaviors that are contributing to the agoraphobic symptoms she exhibits. I agree with you that her husband would be helping her more by being a collaborative partner and helping her along her journey of combating these panic attacks.

      Reply

  11. Taylor O'Rourke
    Apr 02, 2020 @ 14:38:07

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

    A CBT case formulation is important for effective therapy because it allows for efficient, purposeful and effective treatment planning. Without a solid plan for treatment, therapy itself will not be effective. This conceptualization includes presenting problems, associated symptoms, and contributing factors all conceptualized under the cognitive-behavioral approach. As new information is gathered from the client over time, the case formulation should be modified so it is as up to date as possible based on the progress the client is making towards their goal(s). Clients should also be involved in creating their case formulation because it can increase their motivation and hope for change. These points all work together to make therapy more effective and strive for clients to get “better.”

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

    It is necessary to have specific, concrete, and measurable treatment goals whenever possible because these treatment goals indicate how therapy is progressing by showing any reduction in symptom distress and improvement of one’s quality of life. Because they are therapeutic indicators, therefore they should be objective and measurable. These types of goals allow for clients and therapists to track treatment progress, which is beneficial for them, and managed care if it is involved. Effective goals are typically a phrase that includes more than “will be less sad” and involve some type of measurement. So, for this example, a better goal would add that depressive symptoms would be monitored by the BDI. Therapeutic interventions help clients achieve their desired outcomes by linking them to their effective goals.

    3. What information provided in the intake support that Lindsey is having panic attacks and agoraphobic behaviors? (PDA-1)

    Some of the information that was provided in the intake that supports the panic attacks and agoraphobic behaviors includes her chest tightening, faster breathing, bodily shaking (e.g., hands trembling), and she feels like she is out of control and dying, similar to the feeling of a heart attack. She has also mentioned feeling dizzy and faint; lightheaded. For agoraphobic behaviors, she feels safer at home because when she leaves, she never knows when the attacks will hit. Her husband has taken over most of the grocery shopping for this reason.

    4. What additional information would you like to know about Lindsey’s presenting problems?

    Some of the additional information I would like to know about Lindsey’s presenting problems is when they typically tend to occur. I think doing a type of ABC analysis would be helpful, because although her attacks are unexpected, some commonalities may surface. She did mention that one of her first panic attacks occurred when she went to a new gym, so this may be something to note. She may be most uncomfortable around a lot of people, in new places, in stressful environments, etc.

    5. What are your concerns about how Lindsey’s presenting problems are impacting her daily life?

    These symptoms have been going on for over a year, but most severely in the past 6-8 months. Lindsey typically has 2-3 of these attacks per week, lasting from 10-25 minutes each. She feels like they will never end and rates them as being from 7-10 in severity, so it is clear that her daily life is severely impacted. She also indicates that they are always seeming to get worse over time. They are largely unexpected so they scare her because she cannot tell what triggers them. Her symptoms also affect her schooling because her panic attacks might occur in class if a professor calls on her and she begins hyperventilating. She also cannot go out to eat with her classmates anymore, she only feels comfortable around her husband and best friend in public because she is most comfortable with them. She leaves class early sometimes to avoid traffic and being around more people, so her grades are suffering because she is missing material.

    6. Are Lindsey’s husband’s behaviors (e.g., going to the grocery store) helpful to her? Explain.

    Her husband’s behaviors are helpful to her in the “now” because they provide her relief since she does not have to leave home. However, from a therapist’s perspective, this is not helpful in the long-term because by her husband taking care of the grocery shopping, this is only reinforcing her avoidant behaviors.

    Reply

    • Tim Keir
      Apr 04, 2020 @ 12:59:29

      Hey Taylor!

      You’re spot-on in describing the case formulation as the plan for treatment. Without the organization that the case formulation gives, coming up with actual specific and concrete goals that actually apply to the client’s concerns would be near impossible. Excellent point in including the fact that it is a collaborative process. I like your example of how to make a vague goal more measurable using a measurement scale as well. That’s some good CBT!

      I also appreciate your interest in finding patterns to Lindsey’s panic attacks outside of specific environments. Time of day or even days of the week can have higher prevalence of attacks, and may help in pinpointing the scenarios that engender attacks. Anyway, great post!

      Reply

  12. Mariah Fraser
    Apr 02, 2020 @ 22:15:32

    Case Formulation

    It is important to use a case formulation in therapy because it provides a lot of detail about the client regarding their history, presenting problems, associated symptoms, and contributing factors. In order to determine what goals would be appropriate and necessary in treatment, the clinician must be able to fill in missing information through the telling of the client. Without knowing what to look for, the client may not be sure why they are feeling the way they are, therefore the clinician can put the pieces together and help to explain why these things are happening. Additionally, as more information is gathered throughout the sessions, the clinician and client can work together to modify the case formulation in order to work towards the treatment goals.

    It is important for the goals to be specific, concrete, and measurable because the clinician and client must be able to determine if the goals were met. Having goals that can be measured helps to see if more work must be done, if the goal must be modified, or if the client has been successful.

    PDA-1

    The description provided by the client would suggest that these are symptoms of panic attacks and agoraphobia. These symptoms included tightness of the chest, feeling lightheaded, and troubled breathing to name a few, and at first the client is worried that she is experiencing a heart attack. The client finds that when all of this is happening, the physiological sensations and the irrational thoughts, she feels like she has having an “out of body experience”.

    I would be interested in finding out when these experiences started, in addition to family history of similar symptoms (this way we can see if it’s a learned behavior). I would also want to know if these panic attacks and agoraphobia impact her job, as she seems as though holding down a job is not a concern. From that, I would be curious to know how she manages to cope with being at work, in relation to how that is different from other places outside of her home. I would also want to know if there were situations where Lindsey didn’t have any sort of agoraphobia or panic attack, and again, what makes that different from going to the grocery store, etc. Finally, I would want to clarify if her husband helps her feel safe because of his significant role in her life, or if there is something in particular that he says or does to make her feel safe (and if she could adopt some of those same things when she’s feeling triggered).

    I have a couple concerns about these problems impacting her daily life. One would be that her husband cannot possibly be with her all the time, because it’s not realistic, it could put a strain on their marriage (which is detrimental in a few ways), and it’s not helpful in the long-run. Another would be that she struggles to even walk her dog beyond a one-mile radius of her home, which is less than ideal because it puts into perspective how much she CAN’T do on her own. There aren’t too many things within a one-mile radius of her house, I’m sure. Further, Lindsey is missing out on being social and having people in her life other than her husband. It’s important for spouses to have their lives separate from each other, while also being able to come together. Unless her friends are within a one-mile radius or they are always traveling to her house, Lindsey is missing out on important events in life (birthday celebrations, etc). Those social events are important to look forward to.

    The role of Lindsey’s husband is ultimately doing a disservice to Lindsey. Her panic attacks and agoraphobia are being reinforced. Although in the short-term she is finding relief, in the long-run she is suffering because this behavior by both parties is preventing her from ever getting better. Having to rely on a person so often and putting an immense amount of pressure is not good for Lindsey, her husband, or their marriage.

    Reply

    • Jenna Nikolopoulos
      Apr 04, 2020 @ 12:00:04

      Hi Mariah! I definitely agree with what you said about Lindsey’s husband. Even though she is currently relying on him for everything, it is very unrealistic for him to be around all the time when Lindsey needs him. His behaviors are only reinforcing her maladaptive behaviors, which will only hurt Lindsey long-term because she won’t be able to get over her fears if she continues to avoid certain situations. I would like to hear her husband’s perspective on how he views the situation and how he feels about doing everything for Lindsey so she doesn’t have a panic attack. I would also like to know in what ways Lindsey’s problems impact her marriage because, like you said, this dependency that Lindsey has on her husband must be putting a lot of pressure on him, which probably impacts their relationship in some way. It would be interesting to know more about their relationship and how Lindsey and her husband view the situation.

      Reply

    • Tim Keir
      Apr 04, 2020 @ 12:49:28

      Hey Mariah!

      I agree with you that without the relevant information gained from a case formulation, therapists would be blindly searching for appropriate goals and treatment strategies. Knowledge is power!

      Lindsey’s self-imposed restrictions to her life are definitely heavily impacting her life quality, and I also think the husband isn’t doing her any favors. It certainly could be the end of the marriage if it continues, even though he is just trying to help! Fortunately, proper exposure therapy will be enough to help them both get past this challenge.

      Reply

  13. Tim Keir
    Apr 02, 2020 @ 23:57:34

    1. Why is a CBT case formulation important for effective therapy?

    More than anything else, the case formulation is the organization of an individual client’s information. A significant amount of information and observations are recorded throughout the assessment of a new client. That information is of limited value unless it is put into some context of a larger framework and set of ideas. The goals of CBT point towards certain information being sought after, like the automatic thoughts and immediate behavioral concerns. By properly shaping initial assessment into a case formulation, not only is the extensive information given put into a manageable organized format, but the important information to setting up CBT treatment goals are highlighted. Knowing where you want to go with the information helps the development of meaningful, client-focused treatment.

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

    CBT is designed to be an efficient form of psychotherapy. To that end, the efficacy of treatment is determined by the formation and ensuing treatment of specific goals. There is no scientific or therapeutic validity in setting a vague, unmeasurable goal like “feeling better” or “becoming a cool dude”, so the therapist and client should aim to create a goal or set of goals that are truly applicable to the present concerns of the client. They should be attainable, or at least incremental in an observable way. Being good at school is vague, but increasing one’s lowest grade by one letter? Super measurable. Providing this amount of structure to goals is incredibly beneficial for the therapist, but also for the client; there is nothing better than breaking down and concretely describing a goal in realizing that it is in fact completely manageable. And when the goals are accomplished in a certifiable way, the joy in accomplishment can be felt without self-criticism or uncertainty.

    3. What information provided in the intake support that Lindsey is having panic attacks and agoraphobic behaviors?

    Lindsey describes physiological symptoms of shortness of breath and tightness in the chest, alongside with shaking in the hands and lightheadedness. Loss of control is described, as well as the fear of a possible heart attack occurring. These symptoms last from 10-25 minutes, and occur roughly 2-3 times a week. The client mentions that they occur at random, and the unpredictable nature makes them more unnerving. The origin of these symptoms occurred in a crowded gym, where she began having symptoms and also became overwhelmed with not knowing anyone around her to ask for help. Lindsey had several other events that occurred in a similar fashion, all while she was outside of the home.
    However, Lindsey does describe herself as feeling “safer” at home, and has retreated from going outside for things like walking the dog or grocery shopping. Anything further than a 1-mile radius from her home increases her concern about having a panic attack. Lindsey noted having her husband or best friend nearby helps relax her fear of going out, and that she has come up with solutions like hiring an at-home gym instructor to help avoid excess trips outside of the home. Lindsey confirmed the agoraphobic thoughts that Dr. V suggested about who would help her if she had an intense attack out in public. Lindsey was able to connect a desire to escape from an uncomfortable situation lead to her having physical panic attack symptoms, which she went to the emergency room to check out.

    4. What additional information would you like to know about Lindsey’s presenting problems?

    I would like to know if Lindsey’s propensity to escape uncomfortable situations existed before her physical symptoms emerging. Furthermore, a closer look at what life events were occurring at the time the physical symptoms began could be enlightening in understanding what changed for her for these attacks to begin. Hopefully a greater understanding of the source would help direct treatment in turn.

    5. What are your concerns about how Lindsey’s presenting problems are impacting her daily life?

    Lindsey’s concerns around her panic attacks have severely impacted her independence in common chores, her ability to socialize with peers, and her academic success in college. Lindsey has become reliant on her husband being present with her or completing her tasks for her, allowing her to spend more time in the safety of her home.

    6. Are Lindsey’s husband’s behaviors helpful to her? Explain.

    Lindsey’s husband is of course trying his best to help his wife overcome her crippling fears. Unfortunately, he is only enabling her ‘safety behaviors’ – actions that decrease stress in the moment but reinforce the anxiety responses through avoidance. By completing grocery shopping for Lindsey and always being present when she leaves the house, Lindsey’s husband has only intensified the feeling that she cannot actually leave the house without her husband present. Fortunately, through proper psychoeducation about panic disorders and exposure techniques, Lindsey’s husband can be far more effectual in helping her through this difficult maladaptive thought pattern.

    Reply

    • Madison Armstrong
      Apr 04, 2020 @ 20:06:48

      Hi Tim,
      Interesting point you made about wanting to know about her life events at the time of her first set of symptoms. I think that this information could be very helpful in understanding her panic attacks. This would certainly have an impact on her treatment if there was a specific event that could have been the trigger. I also mentioned that I would like to know more about her work atmosphere and if she ever experiences these symptoms at work.

      Reply

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Adam M. Volungis, PhD, LMHC

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