I look at my schedule and see I have a new patient intake this week. I am going to meet with the parents of a girl in middle school and the brief description in my calendar states that she is experiencing anxiety, trouble sleeping and is looking for “someone to talk to”. I am looking forward to this meeting because intakes represent a new opening and a new opportunity, a new relationship with a client and his or her family and the opportunity to help someone grow, learn more about themselves and start feeling better. The parents are friendly and warm, they say that their daughter has been complaining of anxiety and difficulty sleeping lately, that she sometimes has trouble getting all of her schoolwork done and that she asked if she could talk to someone. In addition to what is happening now that is bringing them to treatment and the history of this problem, we also talk about how their daughter is doing in school, what her friendships are like and what she enjoys doing, what she is like outside of the problems that bring her to therapy. We talk about the parents’ relationship with their daughter, where there is closeness and where there is distance and conflict, and how the problems we are talking about affect the relationship between the parents and their daughter. At the end of the session I have a sense of what I will ask their daughter more about when I meet with her in the next session, what I am curious about and where I believe she needs help. I thank the parents and let them know that we will speak again after I meet with their daughter to give my impressions and talk about the treatment plan going forward.
The following week I meet with the client, her name is *Diana, she is a little bit hesitant at first but opens up and becomes more comfortable as our session progresses. She tells me that she feels anxious about a lot of things, but mostly school and her friends, and that she gets into fights with her parents about her schoolwork because they often catch her on her phone when she is supposed to be doing her homework. She tells me that she goes on her phone a lot because it helps take her mind off of things when she is feeling nervous, and that sometimes she gets so upset that she has no motivation to do her schoolwork and has a hard time focusing on it. She says that it is hard for her to fall asleep at night sometimes because that is often when she has the hardest time controlling her thoughts, and the anxiety makes it hard to fall asleep. We talk more about her feelings of anxiety, when it first started, what else triggers these feelings, what she does to cope when she is upset or anxious. At the end of our session I meet again with her parents to tell them that I believe Diana is struggling with anxiety, and that I believe weekly therapy sessions focused on Cognitive Behavioral Therapy (CBT), will help Diana to learn the skills and strategies she needs to manage these emotions.
I start treatment with Diana by explaining the connections between thoughts, feelings and actions. We talk about how it’s not possible to simply change how we feel, about how the phrase “stop worrying” never helped anyone, but how we can change our thoughts and what we do, and this can lead to a change in how we feel. We begin by working on some body and sensory based relaxation skills to help Diana calm her body and turn on her relaxation response when she is anxious and stuck in “fight or flight” mode. We come up with a list of triggers and decide what skills will help Diana in different situations. For example, taking deep breaths when she is anxious before a test and using something that is soothing to one of her five senses when she is feeling anxious while studying at home.
We also start talking and learning about Diana’s thoughts. I explain that we all have “automatic thoughts” about many different topics, and that sometimes these thoughts can lead to distressing feelings. Because these thoughts are automatic, we don’t always notice them at first and so Diana starts keeping a thought log, which is a way to increase awareness of and to keep track of her thoughts when she is feeling anxious or upset. We then learn about thought traps, or common ways that people filter their thoughts which lead to negative feelings. For example, when Diana is about to take a test and thinks “I am definitely going to fail”, she is engaging in a thought trap called “predicting the future”, where we predict what will happen based on little or faulty evidence. After Diana has improved at catching her thoughts and identifying what though traps she is getting stuck in, we talk about ways to challenge these negative thoughts by using strategies such as examining the evidence, looking at the probability, defining the terms and creating a spectrum. Based on these thought challenges, we then work on coming up with new, more realistic thoughts that Diana can focus on instead of the original automatic thought.
At first Diana has a hard time filling out the thought log and so we go over in session what she remembers from the week and come up with ways to increase the likelihood that she will fill out the thought log during the following week. We talk about what happened during the week, times that she felt anxious and used her skills, what was helpful and what didn’t work. When Diana comes up with a thought that she has a hard time challenging, we do it together in session. With continued practice, Diana gets better at recognizing her thoughts and challenging them when they occur, and she says this helps reduce her anxiety in the moment.
Diana and I also talk about her relationship with her parents and how it has been more difficult lately. Diana wants to talk with her parents about how she has been feeling because she doesn’t think they truly understand. She is reluctant to tell them on her own so we have a family session where she explains how anxious she has been feeling and how it is affecting her. Diana is nervous to have a session with her parents so we prepare beforehand by going over what she wants to communicate with them during the session. Diana’s parents are open to what she tells them about her experiences with anxiety and how it makes it difficult for her to focus on and complete her schoolwork at times. They want to help Diana to feel calmer and to complete her homework, so we all talk together about ways that they can support Diana such as listening without trying to fix things when Diana tells them about her anxious thoughts and coming up with small rewards that Diana can use to motivate herself when she is struggling to complete her schoolwork. The session goes well and we agree to all check in together again in a few weeks. We continue to have family sessions or parent sessions periodically to talk about how things are going at home.
Diana progresses and feels better able to control and manage her anxiety by using her cognitive and behavioral coping skills. She benefits from having “someone to talk to” and from the support and empathy inherent to the therapeutic relationship. The treatment components of CBT such as relaxation training and thought restructuring, as well as the increased openness and support from the relationship with her parents all lead to Diana’s overall improvement in how she feels.
*Diana is not the real name of a client
Written by Joshua Rosenthal, PsyD