CBT Backwards: An Example

As a follow-up to my last blog, Doing CBT Backwards: Using Journaling to Change Thinking, I present an example of an 85-year old, female client experiencing thoughts of anxiety. Through journaling between sessions, we are able to make changes to her thought patterns that help alleviate her anxiety.

In session

Therapist: How are you feeling today?

Patient: I am anxious about running out of money in my old age.

T: What do you do to cope with your anxiety?

P: I take a Xanax in the morning and another in the evening. My doctor prescribed it for me. I’ve been taking it for years and it seems to help a little, but I’m still always anxious.

T: Why?

P: My mother taught my sister and me to think about the worst-case scenario so we can prepare for it. For example, after the war, food was rationed and we never knew if we were going to have enough.

T: So, you focus on the worst-case scenario?

P: Yes. She also taught us that by being anxious we can make it less likely that the bad thing will happen.

T: Do you think that’s true? How does thinking about the worst case actually make you feel?

P: It makes me feel anxious.

T: What do you tell yourself when you get anxious?

P: I tell myself that there is not much I can do about it.

T: What is the anxiety telling you? Each emotion tells us something. Anxiety tells us that we are anticipating some future negative event or consequence. [pause] Let’s stop our session here. I’d like you to record in your journal events that happen during the week that cause you to be anxious.

Step 1: Have the patient record events in her journal.

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In session

T: I read your journal entries. Let’s talk about entry 2. What thoughts did you have at the dinner about what was going on?

P: Everyone in the restaurant was looking at us, and the waiters were mad at us.

Step 2: Have the patient record thoughts along with events in her journal.

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In session

T: I read your journal entries. What feelings did you have at the doctor’s office?

P: I was scared and angry. They knew I was coming in and they have been treating me for this problem, so they know I am in pain and need medication. But if I make a scene, I was afraid that the receptionist would not let the doctor know I was there.

T: So your interpretation of the situation was that they receptionist was being unhelpful and was unwilling to let the doctor know you were there. Can you come up with an alternate explanation?

P: Perhaps he was busy with an emergency case.

T: That is a good alternative, and it might cause you to feel differently. This next week, continue recording events and your thoughts about them, but now I would also like you to record what feelings you had?

Step 3: Have the patient record events, thoughts, and resulting feelings.

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In session

T: I read your journal entries. By journaling on your thoughts and feelings, are you starting to see the connection between them; that is, how thoughts cause feelings?

P: In some cases, yes.

T: Let’s review your journal entry “Missed my ride.”

P: I can’t believe they just left me without ride. But I was afraid they would drop me if I argued.

T: Would you have preferred to be not anxious, not afraid?

P: Yes. Then I would have given them a piece my mind.

T: OK, then, what thoughts could you have had that would have made the anxiety go away?

P: I could have told myself that even if they drop me, I can find another ride service?

T: OK. What else? What other thoughts?

P: I could have told myself that they won’t drop me because I have a contract for a year of service.

T: Have you heard of the expression, “EGBOK”, everything is going to be OK?

P: No.

T: Can you imagine, that even if you have no ride, or are late, or miss your appointment, eventually everything is going to work out OK? If you did imagine that, how do you think you would feel?

P: Probably a lot better.

T: I agree. So now you are beginning to see you can use your thoughts to influence your feelings. This gives you a powerful tool. If you want to feel calm, then you can create thoughts that lead to feeling calm. If you focus on the worst-case scenario the way your mother taught you, you’re going to be anxious. So, now you have a choice. Also, even if you still have some anxious thoughts coming into your mind, you can practice calming thoughts to create a pathway to calming yourself. This takes time and practice. And we have work to do to learn relaxation methods, increase your confidence, and build your social support resources. But you have made a great start.

Step 4: As the patient comes to understand the linkage between his/her thoughts (interpretations, assumptions) and feelings, challenge him/her to create alternate interpretations of the events; that is, different ways to explain them. To help my patients better manage their thinking, I use a product called CaseKeepers that gives me visibility into their journal and the ability to shape their thinking between sessions, thereby accelerating the process.