28 Session Overview
CBT SESSION 6 OVERVIEW
Worry Exposure & Emotional Processing
Mood & Presentation: Maggie arrived on time, presenting with a calm, relaxed, and almost peaceful demeanor. Body language appeared less tense than in prior sessions, with open posture and brighter affect. She was fully engaged, reflective, and motivated, bringing her workbook and therapy binder prepared for review. Emotional expression was appropriate, with tearfulness when discussing family themes and humor when practicing self-affirmation.
CBT Skills
- Check in with Maggie
- Ongoing rapport building/therapeutic alliance
- Behavioral Activation
- Maggie reports laughing more, having more fun with the boys, and being less irritable.
- She engages in planned activities (relaxation, bath-taking).
- She takes meaningful action (talking with her mother) despite discomfort.
- Problem-Solving Skills
- She practiced problem-solving by initiating a difficult conversation with her mother.
- She strategized about how to support her mother seeking therapy.
- Cognitive Restructuring
- Automatic thought: “I’m not good enough.”
- Challenge with evidence: “I’m working on it… my scores have gotten better.”
- Exposure
- Worry Exposure (Imaginal Exposure)
- Writing a worry list, ranking items by intensity.
- Practicing imaginal exposure to feared scenarios.
- Imagine the worst-case scenario.
- Monitor anxiety levels before and after.
- Reciprocal Inhibition
- Pairing relaxation with exposure to anxiety triggers
- Relaxation Training
- Conducted relaxation exercise during the exposure session.
- Psychoeducation
- The connection between avoidance and anxiety.
- The purpose and process of worry exposure.
- The nature of automatic thoughts.
- Anxiety measurement (STAI scores).
- Explaining why family members should not share therapists.
- Tracking Anxiety with Measures
- Behavioral Experiments
- Maggie tests the belief “I should avoid difficult emotional conversations” by approaching instead of avoiding.
- Observes positive outcome, which counters avoidance beliefs.
- Exposure and Response Prevention to Avoidance Patterns
- Reinforce that avoiding emotional conversations is a form of experiential avoidance
- Maggie breaks the avoidance cycle with her mother
- Real-world exposure
Fill in the Blanks
Session Agenda
- Check in and review of homework (thought records, worry records, relaxation practice, worry exposure self-assessment, STAI).
- Discuss conversation with her mother on the anniversary of her father’s death.
- Review STAI results and reframe negative automatic thoughts.
- Introduce and practice worry exposure technique with reciprocal inhibition.
- Explore avoidance and family dynamics.
- Summarize session and assign homework.
Symptoms observed/reported:
- Cognitive: Catastrophic thinking, self-doubt, improved ability to identify and reframe automatic thoughts, decreased avoidance.
- Physiological: Moderate anxiety during mother conversation and worry exposure practice (peak 75/100), muscle tension, fatigue.
- Emotional: Tearfulness discussing father’s suicide and fear of mother’s depression; humor and pride in therapy progress; satisfaction at maternal validation.
- Behavioral: Confronted avoided topic with mother; practiced relaxation and journaling; active participation in in-session exposure.
Homework Review: Maggie completed all assigned homework.
- Average daily worry rating: 5/10; peak anxiety: 8/10 during conversation with her mother.
- Reported consistent use of adaptive responses (relaxation, baths) to reduce anxiety.
- Completed worry exposure self-assessment and noted reduced avoidance behaviors.
- STAI scores demonstrated improvement: S-anxiety 38 (68th percentile, moderate-severe) vs. prior 46 (82nd percentile); T-anxiety 52 (93rd percentile, severe) vs. prior 62 (100th percentile).
- Maggie identified initial disappointment with scores, then independently challenged her automatic thought of “I’m not good enough” by reframing: “I’m a work in progress.”
Key Clinical Moments
- Emotional disclosure with mother about father’s suicide; reported maternal pride in Maggie’s progress.
- Expressed pride in herself for confronting avoidance: “It was scary and I did it anyway.”
- Reviewed STAI results with initial negative reaction, followed by successful cognitive restructuring.
- Engaged in 20+ minute imaginal worry exposure exercise (performance review → catastrophic firing vs. successful evaluation with promotion). Anxiety reduced from 75/100 to 10/100.
- Insight into avoidance as a maintaining factor in family relationships and intergenerational patterns of emotional suppression.
- Reinforced motivation: “If I can find time for anxiety, then I can find time for recovery.”
Identified Barriers:
- Persistently elevated baseline anxiety.
- Strong caregiving responsibilities limiting self-care time.
- Tendency toward self-critical thoughts (“I’m not good enough”).
- Ongoing stress related to family history of suicide and avoidance of feelings.
- Core Beliefs: “I’m not capable,” “I’ll fail,” “Others will judge me,” “Feelings are dangerous.”
- Automatic Thoughts: Catastrophic fears about Theo’s CP and father’s suicide, self-doubt about therapy progress.
- Emotions: Anxiety, fear, shame, sadness, pride, satisfaction.
- Physiological: Muscle tension, fatigue, heightened arousal during exposure.
- Behaviors: Avoidance, worry, reassurance-seeking, but also growing approach behaviors (confronting mother, exposure practice).
- Maintaining Factors: Avoidance of difficult topics, self-critical thinking, high caregiving load.
- Change Factors Emerging: Improved metacognitive awareness, reduced avoidance, ability to reframe thoughts, increased emotional openness.
Resources & Strengths:
- Strong motivation and follow-through with assignments.
- Insight into avoidance and intergenerational family dynamics.
- Supportive peer (Sarah) and increasing maternal support.
- Capacity to reflect, challenge thoughts, and reframe beliefs.
Progress / Clinical Impressions:
Maggie demonstrates significant early progress: reduction in STAI scores, improved metacognitive awareness, and active engagement in difficult emotional conversations. She is increasingly capable of identifying and correcting maladaptive thoughts. Anxiety remains elevated but is more contained, and avoidance behaviors are decreasing. Emotional range broadening to include pride and satisfaction.
Multiple Choice
