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CBT First Session, FOCUS MORE DETAIL HERE AND USE YOUR NOTES BUT FOR NOW…

- - - - anxiety itself not inherently bad but good prepares us by tensing our muscles, elevating heart rate getting us ready to encounter a threat by either: fighting it, flee if we can't fight, or freeze up if we can do neither
    - - External
        
        Example
        
        giving a talk and noticing one person looking bored and catastrophizing
        
        doesn't notice all the people listening actively (safety cues)
      - internal (self-focused)
        
        Example
        
        focusing on fast heartbeat, sweating, feeling face redden etc
        * increasing perceived threat --> so anxiety!
    - - How to promt for safety behaviors
        
        lalala#
        
        lalala
        
        Laval
- - - - Automatic thought
        
        focus on thoughts (there might be multiple in situation) that indicate:
        
        :arrow_up: High threat
        
        :arrow_up: Severe negative consequences (threat)
        
        :arrow_down:Underestimation of coping ability
        #
        
        How to elicit
        
        What was going through your mind? (thought , image, obsessions)
        
        What were you thinking?
        
        Were you anticipating/expecting (was haben sie erwartet?) anything?
        
        What were you predicting (vorhergesagt das etwas passiert / was haben sie gedacht passiert?) would happen?
        
        What was the worst thing that could happen?
        
        What did you think about your ability to handle it / cope?
        
        specifically asking about their perceived resourced to cope :D!
        
        Strategies when client has difficulties
        
        1. Imagery
        
        2. Roleplay the conversation (if the situation was a conversation)
      - Emotion
        
        When you had this thought, what did you feel emotionally?
        
        Did you notice any other emotions?
        --> using emotion words (anxious, happy, sad, guilty etc..) maybe create a list for patients #
        
        Urges and Desires (dränge und wünsche)
        --> reflect desire to avoid, escape or engage in safety behavior (regardless if they actually do it or not)
        
        When you felt that way, what were you tempted to do? (als sie sich so gefühlt haben was waren sie geneigt/gedrängt zu tun?)
        
        What were you tempted to avoid or not do? (was waren sie in geneigt/in Versuchung zu vermeiden oder nicht zu tun?)
        
        Or, what did you want to do?
        
        Did you notice any other urges or desires? (haben sie andere dränge und wünsche wahrgenommen?)
      - Behavior
        --> just what they've been doing to deal with the thought
        --> can be actual avoidance or safety behaviors!
        
        When you had this thought, what did you do?
        
        Did you do anything to try to decrease your anxiety?
        
        What are you concerned would have happened if you hadn't [avoided]?
        
        What would have happened if you hadn't [used safety behaviors]?
        
        Did you worry or try to control your thoughts?
        
        What are you concerned would have happened if you hadn't [avoided]?
        
        What would have happened if you hadn't [used safety behaviors]?
      - Situation
        
        External/ Environmnental
        
        Internal / imagery / intrusive thoughts #
        
        Promts:
        
        when and where is your anxiety the most intense
        
        Which situations do you avoid, or partially avoid, because of anxiety?
        
        Do you notice any bodily sensations that make your anxiety worse after you notice them? (fühlen sie sachen / dinge in ihrem Körper) (internal)
        
        Do you have any thoughts, images, or impulses that are distressing alamierend / beunruhigend / schmerzlich)? (internal)
        
        this also to check for OCD in chief complaint section
        
        maybe also: nehmen sie die angst als Gefahr war?
        
        When anxiety shows up, what do you think the worst thing that can happen from being anxious is?
      - Meaning of the automatic thought
        --> (to infer core beliefs :D!!)
        
        If this automatic thought were true, what would that mean?
        
        What would be the worst part?
        
        If it were true, what would that mean or say about you? #
      - Physiological
        
        What did you experience in your body when you had that thought?
        
        list of common bodily symptoms
        
        muscle tension, feeling hot, sweating, butterflies in stomach, tightness in chest, lump in throat, dizziness or lightheadedness, numbness or tingling, wobbly legs, shaking or trembling, hyperventilation or difficulty breathing, nausea or indigestion #
    - - then relate it to parenting style
        
        how did their parenting show that?
        
        reality check eg. were they stingy because they were worried about money?
        
        when you do xxx how do you feel about yourself / think about yourself
      - how it affected their relationships with others
        
        how do you think that has affected your relationships?
      - how these beliefs affect the clients perception of other people + the likelihood of them judging the client (beurteilen)
        
        how do you think other people are towards you because of the way you are?
      - what are the believes about anxiety in general
        
        When anxiety shows up, what do you think the worst thing that can happen from being anxious is?
        
        And when the anxiety shows up, is it an uncomfortable experience for you?  
        
        What about those times when it gets more intense?  
        
        And if you didn’t alleviate it, what could happen?  
      - Begin by asking:
        
        when did anxiety first show up in your life?
        
        early on in childhood is there a point you can think of it first became an issue?
    - - Aspirations and Goals
        
        important to set treatment goals that are in line with goals and aspirations / motivation
        
        reminds me of motivational interviewing a bit
        
        Ask clients about their values (werte)
        
        "what is really important to you in life?"
        
        Three Categories of Values
        
        Labor
        
        work
        
        self-education
        
        volunteering
        
        Love
        
        intimacy
        
        friendships
        
        family
        
        spirituality or religion
        
        Leisure
        
        recreation
        
        entertainment
        
        health and fitness
        
        What are your aspirations (wünsche/bestrebungen/ziele)?
        
        "what do you want your life to look like?"
        
        "what do you want from life?"
        
        Visualize what it would be like to achieve their aspirations
        
        can you imagine achieving a life like this?
        
        what would your life look like?
        
        mention all three aspects (see right side)
        
        Leisure
        
        leisure activities and fun
        
        self care activities
        
        exercising, eating, sleep habits
        
        Labor
        
        what would your productivity look like?
        
        their job
        
        household management
        
        intellectual activities
        
        Love
        
        what would your social interactions and relationships look like?
        
        what would your spiritual or cultural activities look like?
        
        Use Imagery if clients have issues identifying aspirations and goals
        --> have clients describe exactly what they are imagining!
        
        close your eyes imagine its a day a year more into the future
        
        where would like to see yourself waking up?
        
        go step by step what they would like the day to look like until they go to sleep!
        
        ask about different value categories to sample all domains and make imagery more real! #
        
        Uncover the meaning behind the aspiration
        
        what would be good about achieving this?
        
        what would it mean to you?
        
        what would it mean about you?
        
        how would you feel about yourself?
        
        what would it suggest about your future?
        
        Try to let the client experience the positive emotion during the session
        
        how would you feel if this came true
        
        how can we get that feeling right now
        
        can you tell me about that feeling
        
        Setting Specific Goals
        
        making sure they are in line with goals and apsirations!
        
        make sure the client doesn't do the red things!!
        
        Begin by:
        
        have client talk about typical day in their life from the time they wake up till the time they fall asleep
        
        Is your current behavior in line with your values and aspirations?
        
        Thinking about your values and aspirations can we set some goals for treatment?
        
        how would you like to be different as a result from treatment?
        
        how would you like your life to be different?
        
        If goals too broad do this:
        --> ask questions to identify the specific behavioral goals!
        
        Example: "I want to feel less anxious."
        
        how would you like your life to look like "if you felt less anxious"
        
        what would you be doing differently this day, this week, this month, this year if anxiety weren't a problem in your life?
        
        answer: drive to my friends house every week --> can then be a goal :D!
        
        If goals are too big, break them up into smaller goals
        --> ask client if he thinks it might be better to break a large overwhelming goal into smaller more manageable chunks
        
        e.g finishing college is a very large goal --> break down into smaller chunks!
        
        enrolling in two classes
        
        learning study skills
        
        attending at least 90% of classes during next semester etc
        
        MAKE SURE GOAL IS UNDER THE CLIENTS CONTROL!!!!
        
        e.g "get my wife to be more patient with me when im anxious" --> is not in clients control
        
        --> Change to: learn to communicate more effectively with my wife when I'm anxious
    - - Maladaptive
        
        Helpless
        
        Unloveable
        
        Worthless
        
        Helpless
        --> main category for anxiety patients (vulnerability, incompetence and comparison to others)
        
        I am:
        
        incompetent
        
        inefficient
        
        can't do anything right
        
        helpless
        
        powerless/weak
        
        vulnerable/ a victim
        
        needy
        
        a failure
        
        trapped
        
        out of control
        
        defective (can't compare to other people)
        
        not good enough (achievement wise)
        
        a looser
        
        Unlovable
        
        I am:
        
        unlovable
        
        unlikable
        
        undesirable
        
        unattractive
        
        unwanted
        
        uncared for
        
        bad (others won't love me)
        
        not good enough to be loved
        
        I am bound to be:
        
        rejected
        
        abandoned
        
        to be alone
        
        Worthless
        
        I am
        
        worthless
        
        unacceptable
        
        bad
        
        waste
        
        immoral
        
        dangerous
        
        toxic
        
        evil
        
        I dont deserve to live
      - Adaptive
        --> look in the basics and beyond book there is a list there :D!! here they only mention the categories: effectiveness, lovability and worthiness
    - - Conditional Assumptions (if-then)
        
        Connection between Core beliefs and Coping behaviors
        
        (if-then statement that activates a core belief)
        
        client might phrase as rule or attitude = rewrite into if-then sentence
        
        Example client might say:
        
        Rule: "I have to worry"
        
        Attitude: "It's a good idea to worry"
        ---> rephrase into conditional sentence: If I worry I will be ok. If I don't worry then I won't be prepared for danger showing I am needy"
      - Beliefs about anxiety
        
        clients often think they can't tolerate feeling anxious
        
        its terrible feeling anxious
        
        if I dont leave an anxiety provoking situation it will get worse and worse until ill explode
        
        often think there's negative consequences
        
        Anxiety will turn into a panic attack
        
        Anxiety will leave me unable to function
        
        other people will see how anxious I am and judge me
        
        Promts:
        
        What’s so bad about experiencing anxiety?
        
        When you first notice anxiety getting intense, what goes through your mind about it?
        
        How does anxiety interfere with your life?
        
        What’s the worst that can happen if you feel more and more anxious?
      - Beliefs about negative emotions
        --> can also be rules and attitudes
        --> check for these and write them down to work on later :D!
        
        distress will cause my mind to go blank
        
        I won't be able to function because of emotions
        
        I shouldn't have any negative emotions
        
        feeling distressed means I'm weak
        
        I deserve to feel negative emotions all the time