19 Session Overview
CBT SESSION 3 OVERVIEW
Developing Metacognitive Awareness & Introducing Relaxation Training
Mood & Presentation: Maggie arrived on time with a more relaxed posture and softer facial expression than previous sessions. Affect was appropriate and slightly brighter, suggesting improved mood. She was fully engaged, motivated, and reflective, demonstrating continued investment in therapy. Observable reductions in physical tension were noted (less shoulder and facial tightness). Emotional range included brief, appropriate tearfulness when discussing long-term care planning for her son.
CBT Skills
- Check in
- Therapeutic alliance/rapport building
- Psychoeducation
- Cognitive restructuring
- Behavioral activation
- Relaxation practice
- Progressive muscle relaxation (PMR)
- Thought records and journaling
- Track anxiety levels and triggers
- Exposure therapy
- Maggie’s decision to visit a nursing home where Sarah’s son lives
- Problem solving
- Promotes development of self-efficacy
Fill in the Blanks
Session Agenda
- Check in.
- Review homework: scheduled worry time, worry records, therapy journal.
- Introduce psychoeducation on relaxation and its connection to anxiety reduction.
- In-session practice of Progressive Muscle Relaxation (PMR).
- Explore metacognition and observation of worry processes.
- Discuss supportive relationships and emotional regulation.
- Summarize session and assign homework.
Symptoms Observed/Reported
- Cognitive: Catastrophic thinking (fears about Theo’s future, self-doubt as a mother), high worry levels (70–100), evidence of metacognition, containment of worry.
- Physiological: Muscle tension, jaw clenching, fatigue; heightened anxiety during school-related incidents.
- Emotional: Tearfulness around long-term care decisions; guilt and jealousy regarding friend Sarah; insight into intergenerational themes.
- Behavioral: Prioritizes caregiving, left work to feed Theo; compliance with therapy homework.
Homework Review:
- Maggie completed scheduled worry time daily, reporting improved containment of worry.
- Noted increased presence with son during activities (e.g., science fair project).
- Completed worry records and therapy journal entries consistently; identified patterns (peak anxiety during conversations and workdays, not with children).
- Demonstrated metacognitive awareness: recognizing thought patterns and practicing containment strategies.
- Reflected on conversation with friend Sarah regarding Theo’s potential residential care; reported decreased shame and anxiety after addressing previously avoided topics.
Key Clinical Moments
- Successful implementation of scheduled worry time; reported improved presence and decreased intrusive thoughts.
- Emerging metacognitive awareness: observed and reflected on the process of worry without becoming overwhelmed.
- Actively engaged in guided 20-minute PMR exercise; reported physical relaxation and willingness to continue practice at home.
- Explored supportive relationships; recognized the value of Sarah as a consistent emotional support.
- Expressed motivation to continue therapy and reduce anxiety: “I really want to beat this anxiety.”
Identified Barriers
- Persistently high baseline anxiety (70–100).
- Reassurance-seeking tendencies and self-critical thinking (“I don’t want to waste your time”).
- Limited self-care time due to caregiving responsibilities.
- Emotional burden of caring for both children and supporting her mother.
Cognitive Behavioral Formulation
- Core Beliefs: “I’m not capable,” “I can’t do it,” “I’ll fail,” “Others will judge me.”
- Automatic Thoughts: Catastrophic worries about Theo’s future, adequacy as a parent, and social judgment.
- Emotions: Anxiety, shame, guilt, sadness.
- Physiological: Muscle tension, fatigue, jaw clenching.
- Behaviors: Worrying, avoidance, reassurance-seeking, irritability.
- Maintaining Factors: Avoidance of difficult topics, high self-expectations, reassurance-seeking.
- Change Factors Emerging: Metacognition, containment of worry, early approach behaviors (sharing with Sarah, visiting potential facility).
CBT Interventions
- Homework review: reinforced scheduled worry time, worry record, therapy journal.
- Cognitive restructuring: highlighted metacognition, reattributed worry as manageable rather than uncontrollable.
- Behavioral experiment: discussed talking with Sarah to reduce avoidance-driven anxiety.
- Psychoeducation: relaxation, tension–relaxation continuum, PMR, observation of worry processes.
- In-session skill practice: guided 20-minute PMR.
- Therapeutic reinforcement: validated insights, normalized emotional responses, encouraged persistence.
Resources & Strengths
- Strong intrinsic motivation and organizational skills.
- Supportive peer (Sarah) and therapy alliance.
- Increasing metacognitive awareness and insight.
- Ability to reflect on intergenerational themes and caregiving concerns.
Progress/Clinical Impression
- Early positive response to CBT: improved containment of worry, emerging metacognitive awareness, initiation of behavioral change.
- Beginning to reframe relationship with worry, reducing shame and avoidance.
- Emotional expression increasing but remains manageable.
- High baseline anxiety remains; further skills development needed.
- Prognosis: good, based on motivation, insight, and early gains.
Multiple Choice
