22 Session Overview
CBT SESSION 4 OVERVIEW
Identifying Core Beliefs & Practicing Cognitive Flexibility
Mood & Presentation: Maggie arrived on time, appearing more relaxed in posture and with reduced facial tension compared to prior sessions. Affect was appropriate, slightly brighter, and engaged, indicating positive mood shifts. She brought her workbook and therapy journal neatly organized and displayed motivation, openness, and reflective engagement throughout the session.
CBT Skills
- Check in
- Therapeutic alliance/rapport building
- Psychoeducation
- Normalize CBT process – no quick fixes
- Relaxation physiology; tension–relaxation continuum; introduction to core beliefs.
- Identified automatic thoughts
- Risk assessment
- Cognitive restructuring
- Begin identifying and challenging assumptions about worry, control, and responsibility; reframing
- Behavioral: Continue scheduled worry time, journaling, and in-session PMR practice.
- Coping Skills: Normalize shame and guilt in caregiving; reinforce social support with Sarah; cultivate metacognitive awareness through journaling and flexible thinking exercises.
Fill in the Blanks
Session Agenda
- Review homework: scheduled worry time, worry record, therapy journal, relaxation self-assessment.
- Psychoeducation: relaxation physiology and tension–relaxation continuum.
- In-session practice: Progressive Muscle Relaxation (PMR).
- Discuss supportive relationships and emotional regulation.
- Introduce core beliefs and cognitive flexibility.
- Assign homework and summarize session.
Symptoms Observed/Reported
- Cognitive: Emerging metacognition; increased awareness of thought patterns and containment strategies; reassurance-seeking around homework; persistent anxious thoughts.
- Physiological: Chronic muscle tension (neck, shoulders, jaw); high baseline anxiety (70–100).
- Emotional: Shame and guilt regarding residential care considerations; relief and hope after disclosure and planning; increased confidence in progress.
- Behavioral: Consistent homework completion; reduced avoidance of difficult topics (conversation with Sarah, facility planning); active practice of PMR, worry time, and journaling.
Homework Review
- Practiced daily scheduled worry time after dinner; reported increased ability to contain worry.
- Completed worry records and therapy journal nightly; observed trends such as higher anxiety on workdays and peak anxiety during conversations.
- Noted that worry intensity was lower when engaged with children.
- Reflected on discussing residential care for Theo with friend Sarah; initial peak anxiety (100) reduced following action plan to visit the facility.
- Completed relaxation self-assessment; identified persistent jaw clenching and difficulty achieving physical relaxation.
Key Clinical Moments
- Recognition that scheduled worry time allowed greater presence with her son.
- Insight that peak anxiety occurred during conversations, not while with children, challenging assumptions.
- Disclosure and reframing of guilt/shame about residential care.
- In-session PMR practice produced noticeable muscular relaxation and body awareness.
- Initial exploration of core beliefs underlying anxiety, such as perfectionism, over-responsibility, and fear of failure.
Identified Barriers
- Morning time constraints may limit consistent PMR practice.
- High baseline anxiety persists despite progress.
- Emotional avoidance of difficult topics remains a challenge but is improving.
Cognitive-Behavioral Formulation
- Core Beliefs: “I must protect others at all costs.” / “If something bad happens, it’s my fault.” / “I’m not good enough.”
- Cognitive Distortions: Catastrophizing, personalization, emotional reasoning, perfectionism.
- Maintaining Cycle: Intrusive anxious thoughts → shame and guilt → heightened physiological arousal (tension, insomnia, panic) → avoidance or overcontrol behaviors → reinforcement of belief in lack of control.
- Emerging Change Factors: Metacognition, containment of worry, structured behavioral experiments, and exploration of cognitive flexibility.
Resources & Strengths
- Motivation and commitment
- Consistent homework practice
- Increased self-awareness/insight and self-efficacy
- Expresses understanding of anxiety on cognition
- Use of coping skills and emotional regulation practices
- Strong support system
Progress/Clinical Impressions
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Positive Gains: Maggie continues to show improvements in symptom containment, demonstrating greater control over anxiety and increased awareness of automatic thoughts.
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Emotional Growth: While the risk assessment exercise was distressing, it facilitated important insights into her catastrophic thinking patterns and provided opportunities to recalibrate her response to perceived threats.
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Ongoing Work: High baseline anxiety remains, but Maggie is making steady progress in recognizing distorted thinking and practicing new coping strategies. She is engaged, motivated, and ready to face more emotionally challenging topics in future sessions.
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Prognosis: Good, with continued development of emotional regulation skills, risk assessment, and gradual reduction of anxiety-related avoidance.
Multiple Choice
