Treatment of Generalized Anxiety Disorder: A Case Study of a 17-Year-Old Female

An Empirically Supported Treatment Case Study

Submitted to the Faculty
of the Psychology Department

of

Washburn University

in partial fulfillment of
the requirements for

MASTER OF ARTS

Psychology Department

By

Kaitlinn D. Chase

Topeka, Kansas

April 4, 2022
 Acknowledgments

I would like to acknowledge the many people who have made this document possible. Thank you

to my chair, Dr. Cynthia Turk, and the members of my committee, Dr. Dave Provorse and Dr.

Angela Duncan, for their guidance throughout this process. Second, I would like to thank my

cohort members and best friends, Laurrel Huffman and Kyra Miller, for their relentless support,

encouragement, and the joy they bring to my life. Finally, I would like to thank my family,

specifically my mom who has provided unconditional love and support throughout my

education. I could not have done it without you all.

TREATMENT OF GAD USING CBT 4

Abstract

The following is a de-identified case study that presents the treatment process and outcome for

Jenny, a 17-year-old female with a primary diagnosis of generalized anxiety disorder. Names and

other details of the case have been changed to ensure client confidentiality. Jenny is a high

school student residing in a midsize city in Midwest America. Jenny was seen at a community

mental health center for therapy and was occasionally accompanied to session by her adoptive

mother (who will be referred to as ‘mother’ henceforth). Jenny presented with moderately severe

anxiety symptoms that caused her significant distress. Jenny’s anxiety often manifested initially

in negative cognitions, followed by emotional outbursts, irritability, uncomfortable physiological

sensations, and avoidant behaviors. The therapist utilized Cognitive Behavioral Therapy (CBT),

an empirically supported and highly effective treatment of anxiety for adolescents. To best

conceptualize Jenny’s case and increase the likelihood of treatment progress, the therapist

reviewed relevant psychological literature and gathered information pertaining to Jenny’s

biological, psychological, social, and medical history. This case study reviews scholarly

literature relevant to Jenny’s case, and the processes of clarifying diagnosis, developing

treatment goals, applying interventions, and discussing barriers to treatment. A complete therapy

session transcription is included to illustrate client engagement and insight, as well as how the

therapist utilized CBT interventions in-session. The transcript is followed by a self-critique of

therapist’s strengths and areas for improvement. Jenny was engaged, cooperative, and compliant

with completing homework throughout her treatment. After eight sessions, Jenny’s self-reported

anxiety score on a validated measure showed decreased anxiety symptoms, and she reported

minimal life interference.

TREATMENT OF GAD USING CBT 5

Treatment of Generalized Anxiety Disorder: A Case Study of a 17-Year-Old Female

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American

Psychiatric Association, 2013) describes Generalized Anxiety Disorder (GAD; 300.02) as an

anxiety disorder characterized by chronic, excessive worry about several domains or activities.

The worries are difficult to control and are associated with at least three of six symptoms (e.g.,

tension) with some of these symptoms present more days than not for at least six months. The

worries and associated symptoms must cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning. Additionally, a diagnosis of GAD

requires that anxiety and worry do not occur exclusively during a mood or psychotic disorder

and are not the result of substance use or some other medical condition (American Psychiatric

Association, 2013). Epidemiological studies have found GAD to have a lifetime prevalence

between 3.7% and 5.7%, affecting women twice as often as men (Perrin et al., 2019; Stein &

Sareen, 2015). A meta-analysis conducted by Gale & Millichamp (2016) found that GAD affects

about 1% of children and 3% of adolescents.

Clinical research on GAD has not been prioritized as highly as other anxiety disorders

due to the outdated assumption that GAD only causes minimal impairment (Ruscio et al., 2017).

When treating anxiety disorders, particularly GAD, early intervention may prevent long-term

consequences and mitigate the chances of comorbid disorders developing (Brenes et al., 2008).

GAD is highly comorbid with other mental health disorders including mood, disruptive

behavioral and substance-related disorders. GAD is also associated with increased risk for self-

harm and suicide (Compton et al., 2010). Gale and Millichamp’s (2016) meta-analysis revealed

that GAD in children and adolescents is highly comorbid; in one survey, only 14% did not have a

comorbid anxiety disorder. GAD is often diagnosed between the ages of 18-29 (Terlizzi &
TREATMENT OF GAD USING CBT 6

Villarroel, 2020). However, Ruscio et al. (2017) argue GAD symptoms typically begin to

manifest much earlier. The frequency and duration of worry and uncertainty intolerance peak

during adolescence (Cowie et al., 2015), adding an additional layer of stress to a critical period

of growth and personal transformation – a time filled with social, emotional, mental, biological,

and physical change.

The present case study followed the treatment progress for Jenny as she attended eight

therapy sessions over the course of three months at a community mental health center. Six of the

eight sessions were conducted via telehealth due to concerns related to COVID-19. Two co-

therapists were present for each session. One therapist, who is the author of this document, was a

clinical psychology master’s student on internship, and the other therapist was a licensed clinical

psychotherapist (LCP) who supervised the student therapist. Sessions were collaborative, and

primarily led by the student therapist. The therapists utilized cognitive behavioral therapy (CBT)

techniques to assist Jenny in reducing and managing her anxiety symptoms associated with a

primary diagnosis of GAD. Extensive literature supports CBT as an effective treatment for

anxiety disorders in children and adolescents (Kessler et al., 2005).

Theoretical Foundation of Generalized Anxiety Disorder

Triple Vulnerability Theory (Etiology of Anxiety and Related Disorders)

The triple vulnerability theory (TVT) proposes that three vulnerabilities contribute to the

etiology of anxiety disorders: (1) general biological vulnerability, (2) general psychological

vulnerability, and (3) specific psychological vulnerability (Barlow, 2002). The presence of a

single vulnerability would likely not contribute to the development of GAD, but the combination

of two or more vulnerabilities (e.g., generalized biological and psychological) would increase the

likelihood, especially in the context of external stressors (Barlow, 2002).

TREATMENT OF GAD USING CBT 7

According to the model, a generalized biological vulnerability is a genetic predisposition

to be emotionally reactive to environmental changes (Barlow, 2002). An individual is not

guaranteed to develop an anxiety disorder even if both parents are diagnosed with one because

anxiety disorders are not directly inherited. Sex, race, and eye color are traits that are directly

inherited; the environment plays no role in the determination of such traits. In contrast, the

development of an anxiety disorder is influenced by genetic and environmental factors. An

individual is not born with generalized anxiety disorder; however, they can inherit a higher stress

baseline, hypersensitivity to stress and environmental changes, and an exaggerated physiological

stress response. These environmental responses may increase the likelihood of developing GAD

(Barlow, 2002). The generalized biological vulnerability encompasses research on inherited

temperament with varying labels such as neuroticism, negative affect, behavioral inhibition, and

trait anxiety (Barlow, 2002). The biological vulnerability may or may not result in the

development of an anxiety disorder, as additional environmental factors must be present (e.g.,

unpredictable and/or uncontrollable environment or specific external or social stressors).

The TVT asserts biological vulnerabilities are expressed when general psychological

vulnerabilities are also present. Generalized psychological vulnerabilities are defined as early life

experiences that are perceived as negative, turbulent, unpredictable, or uncontrollable (Barlow,

2002). Adverse childhood experiences such as abuse, neglect, trauma, and lack of access to

consistent care/nurturing from caregivers can foster a diminished sense of control. Generalized

psychological vulnerabilities can contribute to the development of a pessimistic attributional

style – meaning that an individual may attribute negative events to internal, global, and stable

causes and positive events to external, unstable, and specific causes (Abramson et al., 1978).

Parenting styles and family dynamics have also been linked to the development of a child’s sense
TREATMENT OF GAD USING CBT 8

of control (Schneewind, 1995). Parenting styles that facilitate the development of a child’s sense

of control include warmth, sensitivity, consistency, as well as encouragement of autonomy and

absence of intrusion or an over-controlling style (Chorpita et al., 1998).

According to the TVT, the generalized biological and generalized psychological

vulnerabilities set the stage for developing clinically significant anxiety, but not specific

disorders in those spectrums (e.g., social phobia, obsessive-compulsive disorder). The disorder

that arises from these vulnerabilities depends upon environmental factors. Barlow (2002) defines

specific psychological vulnerabilities as certain learning experiences that focus anxiety on

specific situations, sensations, features, etc. that are deemed dangerous through direct or indirect

experience. For example, an individual with generalized biological and psychological

vulnerabilities is more likely to develop a specific psychological vulnerability. Barlow (2002)

considers GAD the basic anxiety disorder because it is not associated with a specific

psychological vulnerability.

Cognitive Model

Aaron Beck originally developed the cognitive model in 1967. This model is central to

cognitive behavioral therapy and helps conceptualize many emotional disorders, including GAD.

Within the cognitive model, Beck proposed thoughts and perceptions of a situation influence the

way a person thinks, feels, and behaves (Beck, 1979). During an anxiety provoking situation,

perceptions may become distorted and result in negative emotions and problematic behaviors

like avoidance. A single situation does not determine how a person thinks, feels, and responds –

rather it is the interpretation of the situation that fuels these responses (Beck, 2011). For

example, two people are about to take a written exam. Despite facing the same situation, their

emotional and behavioral responses may be vastly different based on what type of thoughts they
TREATMENT OF GAD USING CBT 9

are having. The thought that “I am going to fail” (a negative automatic thought) versus “I

engaged in adequate preparation and am just going to try my best” (rational thought) will lead to

different emotional reactions (high anxiety versus low anxiety) and different levels of

engagement with the test (distraction versus focus on the test).

As Beck’s (1979) theory evolved, he conceptualized cognitions into three levels: 1) core

beliefs, 2) dysfunctional assumptions, and 3) automatic thoughts. Throughout cognitive

treatment, clients are encouraged to engage in therapeutic tasks outside of session and complete

homework assignments to promote the reappraisal of these key cognitions (Okamoto et al.,

2019). Aaron Beck and Albert Ellis were among the first therapists to apply the cognitive model

within their implementation of cognitive behavioral therapy techniques, laying the foundation for

one of the most popular and efficacious therapies to date (Beck, 2011).

The first level of cognitions as defined by Beck (2011) are core beliefs/schemas. An

example of a core belief about oneself is “I’m unlovable.” These beliefs are often formed during

childhood and are influenced by early life experiences. They are typically rigid, concrete, and

overgeneralized to oneself, others, or the world. They are viewed as absolute truths and “just the

way things are” (Beck, 1979). Individuals are likely unaware of their core beliefs, though they

are inclined to focus on information that confirms their core belief (e.g., their recent breakup) or

discredits information that disconfirms their core belief, (e.g., “they only said yes to going on a

date with me because they felt bad”). They are also likely to behave in a manner consistent with

their core beliefs even if the belief itself remains beneath their conscious awareness.

The second level of cognitions, dysfunctional assumptions, are defined as an intermediate

class of beliefs, which often include rigid rules, attitudes, and postulations (Beck, 2011).

Dysfunctional assumptions combine aspects of automatic thoughts and core beliefs, which often
TREATMENT OF GAD USING CBT 10

result in unarticulated “if/then” mental rules. For example, “if I make a mistake, then my teacher

will be disappointed,” and “if I avoid taking hard classes, I’ll be successful.” Rosen (1988)

proposed that core beliefs and dysfunctional assumptions arise due to attempts to make sense of

the self and the world at large.

The third level of cognitions that Beck proposed are categorized as automatic thoughts.

Automatic thoughts occur quickly and spontaneously in the moment and are not the result of

deliberation or logical reasoning (Beck, 2011). An example of an automatic thought is “I won’t

know the answer; I’ll look dumb.” These thoughts are often spontaneous, negatively framed, and

are more superficial than the other two levels of cognitions (Beck, 2011). These thoughts often

occur suddenly and for such a brief amount of time that they may go unnoticed by the individual.

A person is more likely to notice the emotion(s) or behavior(s) that follow the automatic thought

(Beck, 2011).

The cognitive model emphasizes cognitions because once an individual can recognize

their automatic thoughts, they can question and challenge them. This model suggests cognitions

are the driving force behind dysfunctional emotional, physiological, and behavioral reactions.

Among these experiences, cognitions are the most amenable to intentional modification because

they can be easily identified and articulated, critically and objectively examined, and subjected to

challenges and modifications that culminate in maladaptive cognitions being replaced by more

adaptive cognitions (Beck, 1979). A visual example that illustrates the role of automatic thoughts

in Beck’s cognitive model can be seen in Figure 1.

The cognitive model asserts that cognitive changes will be required to decrease

problematic anxiety. As an initial step in the process of cognitive change, clients receive

psychoeducation on common cognitive distortions relevant to automatic thoughts and core

TREATMENT OF GAD USING CBT 11

beliefs (see Appendix A for a list of common cognitive distortions). Initially with assistance

from the therapist, and later independently, the client initially develops the ability to identify

their most common cognitive distortion(s) and recognize how those unhelpful thinking patterns

contribute to and perpetuate their anxiety (Beck, 1995). Once cognitive distortions are correctly

identified, disputing questions are introduced to the client. Some examples of disputing questions

are, “Do I know for certain that ___?”; “Am I 100% sure of _____?”; “How much do I trust and

respect the source of ____?”; “Is it logical and reasonable to believe that ____ is true?”; and

“What would I tell a friend who is having this thought?”. While many cognitive distortions can

be successfully challenged through logical disputation, evidence-based refutation, or reframed in

a more adaptive manner – the ultimate challenge lies in how “helpful” a cognition is in

promoting moving the client in a psychologically healthy direction. The purpose of disputing

questions is to challenge the client’s problematic thoughts and aid in the development of rational

responses (Craske & Barlow, 2006).

Automatic thoughts, intermediate beliefs, and core beliefs can be challenged through

cognitive restructuring and behavioral experiments. That said, many therapists target the client’s

automatic thoughts first because they are often the easiest of the three cognitive levels to identify
TREATMENT OF GAD USING CBT 12

and challenge (Barlow, 2004). While implementing the cognitive model, cognitions are

challenged by the therapist via Socratic questioning to reach a deeper understanding of a client’s

goals, core values, and barriers to change (Braun et al., 2015). An example of a Socratic question

is, “You say people will only like you if you are perfect. Is there another perspective? Is it

possible that our flaws humanize us and make us more relatable?”

In addition to focusing on cognitions, the impact of CBT can be enhanced by utilizing the

inherent connection between cognitions and behaviors. If therapists can design interventions that

require the client to behave in new ways, those new behaviors can be used to challenge the pre-

existing cognitions. These interventions are called behavioral experiments. A behavioral

experiment for an adolescent who believes people will only like her if she is perfect would be to

have her make a few, purposeful mistakes outside of session and to observe how people respond.

The cognitive model provides the foundation for cognitive behavioral therapy, and

homework plays a critical role in treatment outcome (Barlow, 2011). Homework provides the

client an opportunity to take what they have learned in-session and apply it in real-life situations

outside the session. Cognitive homework is shown to help with information retention, cognitive

reappraisal, and strengthening the client’s sense of self-efficacy (Okamoto et al., 2019).

Homework designed as behavioral experiments encourages clients to engage in behaviors that

directly counteract their maladaptive thoughts. These out-of-session assignments provide

evidence the feared outcome does not always occur, as well as demonstrating the client can act in

new ways, thereby promoting an internal locus of control and self-efficacy.

Homework should be developed in a collaborative manner, meaning the therapist and client

determine together what the homework will be, as it should be appropriate for the client based on

skill level, understanding, and current progress in treatment (Beck, 2011). Well-designed
TREATMENT OF GAD USING CBT 13

homework anticipates and accounts for potential obstacles, while also designating the specific time

and place when the homework will be completed. Successful completion of homework encourages

the realization the client can manage and survive their anxiety without the assistance of the

therapist (Craske & Barlow, 2006).

Empirical Support for Treatment

Three meta-analytic reviews found CBT significantly superior at post treatment and

follow-up compared to behavior therapy alone (relaxation techniques or anxiety management

training) or cognitive therapy alone (cognitive challenging interventions). CBT combines both

cognitive and behavioral elements, which was found more efficacious at post-treatment and

follow-up (Chambless & Gillis, 1993; Covin et al., 2008; Mitte, 2005). CBT results in the largest

effect sizes overall when looking at improvement on measures of anxiety and depression at post

treatment and at follow-up (Seligman & Ollendick, 2011) An analysis of within-group effects for

follow-up shows gains from treatment are maintained for up to a year (Chambless & Gillis,

1993; Covin et al., 2008).

Two very recent studies provide evidence for the effectiveness of CBT when working

with adolescent clients. First, a quasi-experimental study conducted by Walczak et al. (2019)

examined whether CBT and Metacognitive Therapy (MCT-c) showed differential effects in 63

adolescents with a primary diagnosis of GAD based on baseline characteristics. To investigate

which treatment was most beneficial for whom, three potential moderators (age, symptom

severity, and comorbid social anxiety) were examined. With pre- and post-treatment assessments

completed, CBT and MCT-C were both found highly effective, with no moderating impacts,

though the CBT participants reported less impairing anxiety symptoms than the MCT-C group

six months post experiment (Walkzac et al., 2019).

TREATMENT OF GAD USING CBT 14

Second, Perrin et al. (2019) examined whether anxiety symptoms remained low three

months after participating in ten weeks of CBT using a sample of adolescent clients. Participants

in this study were diagnosed with GAD and were between 10 to 18 years of age. The participants

were randomly assigned to either ten weeks of individual CBT or placed on a supported waitlist.

Wait-listed participants who still required treatment at the end of the 10-week period were

provided immediate treatment in the clinic, either the GAD-specific CBT tested in this trial or

another appropriate treatment. Participants in both groups completed primary and secondary

outcome measures at pre- and post-treatment. The primary outcome was assessed blindly at post-

treatment for both groups, and at a 3-month follow-up for the CBT treated participants. Large

between-group differences in favor of CBT over the supported waitlist were observed.

Remission from GAD symptoms was 80% for the CBT treated group and 0% for the supported

waitlist group. Further, reduction of symptoms associated with a comorbid disorder was 83% for

the CBT treated group and 0% for the supported waitlist group. All gains were maintained at 3-

month follow-up in the CBT group, thus showing that CBT is an efficacious and valid treatment

option for children and adolescents with a diagnosis of GAD.

Standpoint Statement

Anxiety symptoms during childhood or adolescence are often invalidated by caregivers

or peers who have not experienced those feelings. My education and clinical training experiences

have served to strengthen my belief that environmental factors heavily influence the

development of anxiety disorders, especially parent/child relational stress and trauma. When I

began providing mental health services in a public-school setting, I realized the significant

influence the “nurture” component has within the nature vs. nurture debate. Families where

parents were relatively affluent, psychologically well-adjusted, and aware of and willing to
TREATMENT OF GAD USING CBT 15

access mental health services generally had children who had not experienced trauma, abuse, and

neglect--and those children showed age-appropriate emotional, psychological, social and

academic adjustment. In contrast, many children who struggled with symptoms of anxiety were

of low socioeconomic status and could not access mental health resources. Many of these same

children had parents who were struggling with their own mental health difficulties. The town

where I grew up did not prioritize or openly talk about mental health. Had mental health been

more of an acknowledged subject, perhaps I would not have struggled with my own anxiety

symptoms for so long, hoping that it would just “go away.” As a therapist in training, I actively

work to provide psychoeducation and facilitate an open line of communication with my clients

and their families regarding mental health treatment.

I strongly believe therapy can benefit everyone regardless of their circumstances.

Therapy can be especially helpful for children and adolescents because research has shown that

if mental health concerns are diagnosed and treated early, there is a better chance of improved

functioning and reduction of symptoms through adulthood (Ruscio et al., 2017). Childhood and

adolescence are a time of change, self-discovery, and trial-by-error learning. An adolescent

experiencing anxiety may miss out on important life experiences that promote the intrapersonal

and coping skills that instill self-confidence because of preoccupation with troublesome

thoughts.

As I am a logical and concrete thinker, CBT fits well with my personality and approach

to therapeutic treatment. CBT is an empirically based approach to treating GAD and is more

structured than many other forms of therapy. I have been thoroughly trained on CBT through the

Clinical Psychology Master’s Program at Washburn University and am confident in my ability to

utilize what I have learned to help improve the lives of children and adolescents with anxiety.
TREATMENT OF GAD USING CBT 16

Presenting Problem and Relevant History

Presenting Problem

Jenny was accompanied and encouraged to attend therapy by her mother who had

witnessed increased anxiety, irritability, and occasional emotional outbursts in her daughter.

When asked for a brief synopsis of the presenting problem, both Jenny and her mother agreed

anxiety was the main concern, followed by Jenny’s mood swings, overthinking, and increased

irritability. Jenny’s “overthinking” manifested as worry about the future, making mistakes,

sudden/unexpected changes, and how others perceive her. Jenny explained that she felt her mood

swings and irritability stem from her anxiety because when she feels anxious, she becomes

overstimulated and “on-edge,” especially if her younger brother is antagonizing her. Jenny’s

mother reported the family often feels as if they must “walk on eggshells” around Jenny "to keep

her steady." Following careful exploration by the therapist, it became apparent that Jenny’s

irritability and emotional outbursts are restricted to the family environment. The final issue that

Jenny’s mother introduced was that Jenny tends to “take on the feelings of others” and is overly

empathic. When asked to elaborate on this, Jenny’s mother explained that if she (the mother) is

sick, Jenny also becomes sick with similar symptoms (e.g., malaise, fatigue, sore throat). If

someone in the family is stressed, Jenny becomes stressed. The family feels as if they all must

remain calm to keep Jenny’s anxiety at bay.

Demographics

Jenny is a 17-year-old, Asian American cisgender female residing in a midsize city in the

Midwest United States of America. She was adopted by her current family when she was six

months old. The family unit is comprised of Jenny, her father and mother, and two younger

brothers. Both brothers were also adopted into the family. Jenny reported living with her
TREATMENT OF GAD USING CBT 17

adoptive parents and adoptive younger brothers. The family moved from a neighboring state to

their current Midwest home approximately one year ago. The family has moved frequently over

the years, spanning over six different states since Jenny was adopted. Jenny’s parents work in the

finance industry and, due to the coronavirus pandemic, Jenny’s mother often works from home.

The family identifies as upper socioeconomic status and devout Southern Baptists. Jenny’s

parents are Caucasian, and both of her adoptive younger brothers are African American. By

physical appearance alone, others would likely not be able to identify Jenny as being racially

“different” from her parents.

Medical History

Jenny was born at 25 weeks' gestation. Her birth mother went into labor in a hotel room

located in the southernmost part of the United States, and there was a possibility of drug

exposure in utero. Jenny was placed on a ventilator and was not expected to survive. Jenny’s

mother reported that Jenny spent nearly six months in the NICU due to various health

complications including having a hole in her heart. Shortly after birth, Jenny’s birth mother

abandoned Jenny, and her adoptive family took custody when Jenny was approximately six

months old. Jenny was on oxygen until six weeks before her first birthday. She experienced great

difficulty eating and needed feeding therapy until she was a year old. Jenny’s mother reported

Jenny was diagnosed as “failure to thrive.”

Goh et al. (2011) defines “failure to thrive” as inadequate growth or inability to maintain

growth, usually due to malnutrition in utero. Individuals who have experienced medical

challenges from an early age are more at risk of being diagnosed with a mental disorder (Goh et

al., 2011). Family conditions and quality of parenting have a significant impact on risk of mental

and physical health (Hudson & Rapee, 2008). The Institute of Health Equity found “lack of
TREATMENT OF GAD USING CBT 18

secure attachment, neglect, lack of quality stimulation, and conflict” negatively impact future

social behavior, educational outcomes, employment status, and mental and physical health

(Colizzi et al., 2020).

Jenny has had multiple surgeries and faced many health issues. She had surgery at nine

months of age for a hernia near her ovaries. At two and a half years of age, she had pneumonitis

and was in the hospital for nine days. Jenny had a tonsillectomy and adenoidectomy at six years

of age due to frequent fevers and infected adenoids. At 10 years of age, she had an operation for

a Meckel diverticulum. Jenny had breast reduction surgery in September of 2019 due to back

pain and no relief from chiropractic treatments and occupational therapy. She also received

massage and pressure therapy to reduce pain associated with her short stature and stunted

growth, both a result of “failure to thrive.” Goh et al. (2011) found children diagnosed with

“failure to thrive” are likely to express feelings of guilt, inadequacy, and anger when faced with

psychological or social difficulties.

Jenny is allergic to morphine with no other known drug allergies reported. Her mother

reported Jenny’s immunizations are up to date but did not allow Jenny to receive the optional

COVID-19 vaccines due to safety concerns. Jenny has severe asthma and takes Spiriva and

Arnuity to treat it. No history of head traumas, loss of consciousness, or seizures were reported.

Jenny’s mother reported Jenny was delayed in all developmental milestones due to her prolonged

post-natal hospitalization. Jenny currently takes 10 mg of Prozac for anxiety and finds it helpful.

Psychological History

Jenny was first seen for psychological treatment at age seven due to inattentive behaviors,

anxiety, and occasional tantrums. She was diagnosed with Attention-Deficit/Hyperactivity

Disorder, Predominantly Inattentive Presentation (ADHD) at age seven and did not receive
TREATMENT OF GAD USING CBT 19

treatment until she began interactive metronome therapy at age 13 in effort to improve Jenny’s

working memory and ability to focus. During interactive metronome therapy the individual

synchronizes a range of hand and foot exercises to a precise computer-generated reference tone

heard through headphones (Park & Choi, 2017). Jenny’s mother reported Jenny’s ADHD

symptoms were less noticeable for the first few weeks of metronome therapy, though the

symptoms soon returned which prompted the cessation of metronome therapy. Since Jenny’s

family moved so frequently, Jenny received psychological treatment from many different

providers throughout her childhood and adolescence.

In February of 2020, Jenny and her mother sought treatment from a child psychiatrist for

Jenny’s anxiety, mood swings, and inability to focus on school assignments. Jenny was

prescribed Vyvanse, which was well tolerated and effective for the first 11 months. Jenny

stopped taking the Vyvanse in May of 2021 after she experienced symptoms similar to what she

had endorsed prior to starting the medication, but this time with more extreme anxiety. During a

follow-up appointment with the child psychiatrist, Jenny’s mother expressed concern about

Jenny’s increased anxiety, unstable mood, and inability to focus. The child psychiatrist advised

Jenny to resume the Vyvanse and begin taking Cymbalta, which was reportedly prescribed to

help stabilize Jenny’s mood.

Jenny’s mother reported little was done during Jenny’s psychiatric appointments besides

being “thrown another pill.” Jenny’s mother questioned the child psychiatrist as to whether Jenny

may have mood dysregulation in addition to anxiety and was reportedly told by the psychiatrist

that he “does not endorse labels but treats symptoms.” While taking Cymbalta, Jenny

experienced nausea, shaking, and a racing heart. Her mother questioned the combination of

Vyvanse and Cymbalta and decided to have Jenny stop taking the Vyvanse, a decision that the
TREATMENT OF GAD USING CBT 20

psychiatrist reportedly disagreed with. A week later, against medical direction, Jenny’s mother

also instructed her to stop taking Cymbalta. After being instructed by the psychiatrist to resume

taking Cymbalta, Jenny again experienced the same adverse effects. Jenny’s mother explained

that she was told by the child psychiatrist that "anxiety is not hereditary, it is learned, and she has

learned it from you." Jenny’s mother did not like that statement, which solidified her decision to

find a different provider.

Family History

There is minimal information regarding Jenny’s biological family history as her

biological mother abandoned her shortly after birth. Jenny has two younger brothers, ages eight

and 13, both of whom were also adopted at birth within the United States. None of the children

are biologically related but are all chronically ill in some way. The therapist asked Jenny if

learning more about her biological parents or Asian-American culture was of interest and she

reported that her adoptive parents spoke negatively about her biological parents due to the

suspected drug use and abandonment, so she was not interested in learning anything more about

them. Nothing is known about the biological father. Jenny also did not express any interest in

learning about Asian-American culture and appeared uncomfortable when asked if that was her

decision or her parents’ decision as she quickly changed the topic.

During treatment, Jenny’s adoptive father never presented to session and rarely came up

in conversation unless the therapist asked a question specifically related to him. Jenny shared she

and her father have a positive relationship and occasionally go on “daddy-daughter dates,”

though due to his demanding work schedule, they have not spent much time together or gone on

such an outing in approximately six months. Jenny described her father as hardworking and

“hardly ever home.” Jenny clarified she loves her dad but dislikes how he is unhappy, negative,
TREATMENT OF GAD USING CBT 21

always working, and ungrateful for the blessings in his life – a direct result of “not following

Jesus’ path.” Jenny reported feeling much closer to her mother and that she considers her mother

to be her best friend. Jenny reported her parents argue but would not elaborate on frequency or

other details. Research has shown interparental conflict and familial stress lead to increased

anxiety symptoms and feelings of self-blame in children (Hudson & Rapee, 2008). Jenny

reported a positive relationship with her younger brothers.

Educational/Social History

Jenny attended a private school until the age of 13, switching to being homeschooled

until the age of 17. Jenny reportedly struggled with many subjects, particularly math, though she

was still able to maintain good grades (A’s and B’s). At the time of treatment, Jenny was in the

11th grade at a public high school and planned to switch back to homeschooling for her senior

year. Jenny engaged in a program through her high school that allowed her to attend a nearby

technical college part-time, during the school day, to work toward a trade school degree in

cosmetology. Jenny reported she enjoyed the technical program more than regular school but

dropped out before the semester ended after receiving negative feedback from her teacher on one

assignment. When asked whose decision it was to drop out of the cosmetology program and

switch back to homeschooling, Jenny reported it was her idea.

Jenny reported she has the same number of friends as most kids her age and felt content

with her current number of friends. Jenny endorsed having anxious thoughts about how her peers

may view her. Jenny indicated her best friend, besides her mother, was a girl she met recently at

church. Jenny denied having trouble making or keeping friends but explained how she preferred

to be friends with people who go to her church and share similar values. Jenny reported being

unable to connect with most kids at her high school because of their immaturity, reckless
TREATMENT OF GAD USING CBT 22

behavior, and underage drinking. Murphy (2014) found that homeschooling reduced

opportunities to recognize the variety of people in a variety of different situations. This

introduction is necessary as the process of understanding other people, finding a solution of the

divergence, and the creation of friendships that can serve as a source of social support (Murphy,

2014). The therapist did not perceive Jenny’s report of satisfaction with current friendships to be

accurate based upon her endorsement of feeling unable to connect with peers that hold different

values. Jenny described participating in a Bible study group twice a week through her church.

Jenny reported she was not allowed to spend the night at a friend’s house, nor was she allowed to

host a sleepover at her house.

Jenny’s mother also reported Jenny was not allowed to date, but courtship was allowed.

Jenny’s mother described courtship as “dating with a purpose,” with that purpose being marriage

and keeping Christ at the center of the relationship. The mother’s viewpoint was that the man

must ask the father of the woman permission to court and, if granted, the couple spends several

highly supervised months together before deciding whether they are ready for marriage.

Assessment Measures

The Anxiety Disorders Interview Schedule for DSM-V for Children- Child and Parent

Version (ADIS for DSM-IV: C; Silverman & Albano, 1996) and The Screen for Anxiety Related

Disorders-Revised (SCARED-R; Muris et al., 2004) were administered for diagnostic purposes.

Jenny and her mother completed the ADIS-IV-C/P and SCARED-R during the first therapy

session. The ADIS-IV-C/P and SCARED-R facilitate differential diagnosis by including items

consistent with panic/somatic disorders, specific phobia, social phobia, separation anxiety,

obsessive-compulsive disorder, and persistent depressive disorder. Jenny was also administered
TREATMENT OF GAD USING CBT 23

the Generalized Anxiety Disorder – Seven (GAD-7; Spitzer et al., 2006) bi-weekly to monitor

Jenny’s treatment progress.

Diagnostic Measures

The Anxiety Disorders Interview Schedule for DSM-V for Children- Child and Parent

Versions (ADIS-IV-C/P)

The ADIS-IV-C/P is a semi-structured clinical interview that takes approximately two

hours to administer by a trained clinician. The ADIS-IV-C/P includes questions regarding

anxiety symptoms and associated distress and functional impairment (Evans et al., 2017). The

clinician assigns a Clinical Severity Ratings (CSR) for each anxiety disorder on a scale of 0

(‘complete absence of psychopathology’) to 8 (‘severe psychopathology’). The ADIS-IV-C/P

clinician manual (Albano & Silverman, 1996) dictates that children are assigned a particular

diagnosis with a CSR of 4 (‘moderate psychopathology’) or greater, based on either child or

parent report, with the higher of the two used as the primary score (Evans et al., 2017). The

anxiety disorder with the highest CSR after administration is then assigned as the primary

diagnosis.

The ADIS-IV-C/P is considered the “gold-standard” assessment tool for the diagnosis of

anxiety disorders in children (Evans et al., 2017). Both interrater and test-retest reliability of

anxiety diagnoses and specific symptoms using the ADIS-IV-C/P have demonstrated satisfactory

to excellent levels of reliability. Interrater reliability has been established at k = .94–.99 (Evans et

al., 2017). The test-retest reliability of the “symptom summary scores” (e.g., total “yes”

responses to the symptoms that compose each diagnostic subcategory) was examined and found

to be satisfactory r = .71 (Evans et al., 2017). See Appendix B for more information.
TREATMENT OF GAD USING CBT 24

The Screen for Child Anxiety Related Emotional Disorders - Revised (SCARED-R)

The SCARED-R is a reliable, valid, and sensitive measure to screen for anxiety disorders

in children (Behrens et al., 2019). The SCARED-R is a 69-item, self-report measure that is filled

out by the child. The SCARED-R includes questions to assess avoidance behaviors and anxiety-

related symptoms (Muris et al., 2001). The items are worded to assess pathological worry, with

higher scores indicating more worry. Items are scored on a three-point scale: 0 = ‘Never or

almost never’, 1 = ‘Sometimes’, and 2 = ‘Often.’ Total score and subscale scores can be obtained

by summing across relevant items. A total score of 46 or higher may indicate the presence of an

anxiety disorder. Scores higher than 56 may indicate a specific anxiety disorder, thus helping the

clinician with differential diagnosis. See Figure 2 for scoring instructions and item summation

per disorder assessed by the SCARED-R.

Clinical findings from a study of 1,092 anxious and healthy parent-child pairs found that

the SCARED-R had good internal and convergent validity, strong test-retest reliability, with

adequate support for external validity when compared to a clinician-rated anxiety measure

(Behrens et al., 2019). Internal validity indicates that the SCARED-R is a reliable and valid

measure to accurately assess and measure anxiety symptoms in children and adolescents. Strong

test-retest reliability of r = .78 was reported by Muris et al. (2004). The SCARED-R

demonstrates high internal consistency with Cronbach’s alphas ranging between .64 and .94

(Muris, et al., 2004; Muris et al., 1999). Evidence of strong convergent and divergent validity is

provided by a comparison between the SCARED-R and Child Behavior Checklist (CBCL). As

anxiety is conceptualized as an internalizing disorder, support is obtained through the correlation

of r = .26, p < .05 with the internalizing factor from the CBCL, along with a non-significant

correlation of r = -.07 with the externalizing factors of the CBCL (Muris et al., 2004). In
TREATMENT OF GAD USING CBT 25

conclusion, the SCARED-R appears to be a valid and reliable assessment for children and

adolescents who present with more internal/cognitive based anxiety. See Appendix D for

information on Jenny’s SCARED-R scores and diagnostic cut-off scores for the range of anxiety-

related disorders assessed by the SCARED-R. See Appendix C for the full measure.

Measures of Treatment Progress

The Generalized Anxiety Disorder – 7 (GAD-7)

Developed for use in primary care settings, the 7-item Generalized Anxiety Disorders

Scale (GAD-7; Spitzer et al., 2006) was administered to monitor client progress. Recognized for

good reliability and construct validity, the GAD-7 is increasingly used as a measure for

generalized anxiety disorder, but it can also be used to accurately monitor progress for other

anxiety disorders (Johnson et al., 2019). Consisting of seven items that measure worry and

anxiety symptoms, each item on the GAD-7 (Spitzer et al., 2006) is scored on a four-point Likert

scale (0 = not at all; 3 = nearly every day). Total scale scores can range from zero to 21 with

higher scores reflecting greater anxiety severity. Scores above the cut-off score of 10 are

considered to be in the clinical range (Spitzer et al., 2006). While Spitzer et al. (2006) advocated

the use of specific cut-off scores for mild (5-9), moderate (10-14) and severe anxiety (14-21) in

the original development of the GAD-7, more recent research advises cut-off scores for the

GAD-7 should vary depending on the research and participant sample due to issues of specificity

and sensitivity (Johnson et al., 2019). Rutter and Brown (2017) found the most balanced

psychometrics for the GAD-7 are seen at a cut-off score of 13 (64.5% sensitivity, and 65.5%

specificity).

The internal consistency of the GAD-7 has been established at Cronbach's alpha = .89). It

has also demonstrated strong test-retest reliability (r = .83) across a period of two weeks (Spitzer
TREATMENT OF GAD USING CBT 26

et al., 2006). Convergent validity for the GAD-7 is demonstrated via moderately strong and

positive correlations with the Penn State Worry Questionnaire (r = .66) and with other scales of

anxiety ranging from r = .72 to .74 (Spitzer et al., 2006). The GAD-7 is well suited for use as a

measure of treatment progress as research suggests the GAD-7 is best utilized as a dimensional

measure assessing GAD severity in already diagnosed clients, rather than as a screening tool

evaluating the presence or absence of diagnostic criteria (Rutter & Brown, 2017; Stein & Sareen,

2015). See Appendix E for the full measure.

Diagnostic Assessment Results and Objective Interpretation

The therapist administered the Separation Anxiety Disorder, Social Phobia, Specific

Phobia, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, and Interpersonal

Relationships sections of the ADIS-C/P to obtain information relevant to making an accurate

anxiety diagnosis. The SCARED-R was used to gather additional diagnostic information and to

help rule out differential diagnoses. The GAD-7 was used to assess treatment progress.

ADIS-C/P

Jenny endorsed symptoms consistent with Generalized Anxiety Disorder (GAD) and met

the required criteria for the diagnosis. Jenny endorsed significant, excessive, uncontrollable, and

persistent anxiety and worry about a variety of topics, events, and situations. Jenny endorsed

excessive worry about school, specifically about tests and grades. A Clinical Severity Rating

(CSR) of four was assigned to the ‘School’ worry area. Jenny also endorsed excessive worry

about making mistakes and being late to school. Jenny reported that she would get to school an

hour early each day to ensure she would not be late. A CSR of four was assigned to the

‘Perfectionism’ worry area. Since one or more worry areas were assigned a CSR of four, Jenny

met the first criteria for a diagnosis of GAD.

TREATMENT OF GAD USING CBT 27

Jenny reported she felt it was difficult to stop worrying about school, being on time, and

making mistakes, thus meeting the second criteria for a GAD diagnosis. Jenny reported she

worries nearly every day and has for at least six months, fulfilling an additional two timeframe

criterion for GAD. In addition to the worry symptoms, Jenny reported experiencing several

physical symptoms such as: difficulty relaxing, feeling tired most of the time, difficulty paying

attention, becoming easily upset, and difficulty falling and staying asleep. Jenny endorsed an

interference rating of four, thus meeting the last diagnostic criterion for a diagnosis of GAD.

Jenny experienced impairment due to her anxiety in the home setting, specifically a strained

relationship with her younger brother due to increased irritability because of her anxiety and poor

sleep. Jenny also experienced impairment at school due to her fear of making mistakes and being

judged negatively by teachers. Jenny’s anxiety symptoms are not because of a substance or

medication as her symptoms pre-dated her use of prescription medication, and she currently

denied using any other substances at this time. While Jenny has received treatment for several

medical conditions during her life, her physical health was not identified as an important focus of

her worry, therefore, GAD is not better explained by another medical condition.

Other rule-outs for GAD specified within the DSM-V were clarified as Jenny and her

mother denied fears, worries, feelings, or behaviors related to Separation Anxiety Disorder,

Social Phobia, Specific Phobia, Agoraphobia, Major Depressive Disorder, and Persistent

Depressive Disorder. Based on the preceding review of diagnostic information, all diagnostic

criteria were met for GAD.

SCARED-R

The SCARED-R was completed by Jenny at the start of treatment. Due to stopping

treatment before the 90-day mark, the therapist was unable to re-administer the measure to assess
TREATMENT OF GAD USING CBT 28

treatment outcomes. Questions related to generalized anxiety were most endorsed by Jenny.

Refer to Figure 2 for items specific to each diagnostic category. Within the GAD factor, a score

of 11 or more may indicate GAD and Jenny reported a score of 16. Jenny’s total score was 45

which supports the presence of an anxiety disorder, but likely not a specific anxiety disorder such

as panic disorder, social phobia, etc. See Appendix D for more information on Jenny’s scores

and diagnostic cut-off scores.

DSM-5 Diagnoses

The following diagnoses were determined based upon criteria listed in the American Psychiatric

Association Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American

Psychiatric Association, 2013). The diagnosis of 300.02 Generalized Anxiety Disorder was

assigned by the student therapist and is the primary focus of this case study. The additional

diagnoses were assigned to Jenny’s by previous treatment providers and appeared relevant upon

review of client’s records.

F41.1, Generalized Anxiety Disorder (principal diagnosis).

F90.0, Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation.

Z62.891, Sibling Relational Problem.

TREATMENT OF GAD USING CBT 29

FA1.0, Specific Learning Disorder, with Impairment in Reading.

FA1.2, Specific Learning Disorder with Impairment in Mathematics.

Differential Diagnosis:

300.3 (F42) Obsessive-Compulsive Disorder DSM-5

During the clinical interview, Jenny endorsed the presence of intrusive thoughts that were at

times aggressive or nonsensical. The aggressive obsessions were only directed towards her

younger brother when he had intentionally antagonized her. Jenny explained that she would think

about throwing a rock at him until he stopped bothering her. Jenny also endorsed nonsensical

thoughts that related to getting TikTok songs stuck in her head for several hours. Jenny

frequently engaged in reassurance seeking behavior due to excessive doubting. Jenny’s mother

reported Jenny would check to see if she turned her hair straightener off multiple times before

leaving the house. Jenny also endorsed having obsessive thoughts about her hygiene. For

example, Jenny would ask her mother several times if she smelled before leaving for school.

Jenny would reportedly apply multiple layers of deodorant and change her underwear more than

four times a day to make sure she did not smell. After a thorough diagnostic interview and

consultation with a supervisor, the therapist felt that Jenny’s symptoms were best conceptualized

as worries consistent with GAD. Jenny was not distressed by her obsessive thoughts and reported

no compulsions. Jenny’s obsessive thoughts were more consistent with her anxiety of how others

perceive her, e.g., not wanting to smell. Intrusive thoughts are also commonly seen with GAD

(Payne et al., 2011).

TREATMENT OF GAD USING CBT 30

Case Conceptualization

Etiology

As previously described, Barlow (2002) suggests there are three main vulnerabilities that

increase an individual’s odds of developing an anxiety disorder: 1) general biological

vulnerability, 2) general psychological vulnerability, and 3) specific psychological

vulnerability. One vulnerability in isolation is not sufficient to produce an anxiety disorder, but

rather the combination of factors between at least two of the vulnerabilities may increase an

individual’s risk of developing one, as can be seen with Jenny’s experiences (Barlow, 2002).

In Jenny’s case, not much is known about her biological predisposition since she was

adopted shortly after birth and has had no contact with her biological parents. However, Jenny

did report general psychological vulnerabilities that emerged from her early childhood

experiences that are characterized by a stressful, unpredictable environment. Jenny dealt with

abandonment, adoption, poor health, extensive hospital stays, multiple surgeries, and was

diagnosed with failure to thrive. Jenny’s family moved frequently to accommodate her father’s

job, which did not allow for Jenny to find consistency or stability at school or to connect with

peers to form meaningful friendships. Jenny’s early life experiences led to a general sense of

unpredictability and uncontrollability over her life, contributing to the etiology of her anxiety

(Barlow, 2002).

Chorpita et al. (1998) hypothesized that overcontrolling family environments foster a lack

of personal control and may produce a sense of uncontrollability within one’s own life, which

fosters an external locus of control, like Barlow’s theory of generalized psychological

vulnerability. Jenny’s mother identified she often depended on Jenny to help manage her own

anxiety through reassurance and distraction techniques. Jenny’s mother reported attending
TREATMENT OF GAD USING CBT 31

therapy for her anxiety approximately five years ago but did not find it beneficial and stopped

going after three sessions. Jenny’s mother shared that she was aware of her own tendency to be

highly reactive and perfectionistic, often holding high expectations of Jenny and enforcing strict

rules in compliance with their Baptist faith. The restrictive guidelines for dating previously

described are one example. Jenny learned that she would constantly need to strive to be the “best

version” of herself which put her in a perpetual state of inadequacy as she strove for the

impossible standard of perfection offered by her mother

Consistent with Beck’s cognitive model, Jenny’s anxiety often manifested first in

automatic thoughts, which then led to uncomfortable emotions, (e.g., shame, sadness,

annoyance), and uncomfortable physiological sensations (e.g., heart palpitations, chills,

headaches, upset stomach). Examples of Jenny’s automatic thoughts can be seen below in Table

2. Jenny noted that these automatic thoughts occurred after she realized she wanted to be alone

rather than eating a meal with her family at a restaurant. Once aware of her initial cognition, the

following automatic thoughts occurred and led to feelings of anxiety, shame, and guilt. Jenny

reported not actively engaging in conversation and being on her phone to distract from her

anxiety. During session, the therapist and Jenny explored themes across her automatic thoughts

which included being overly self-critical and that her anxiety stemmed from the idea that

something must be inherently wrong with her. After further examination of automatic thoughts

and recurring themes, the therapist was able to help Jenny identify her dysfunctional assumption,

“if I’m anxious, no one will like me.” In subsequent sessions, Jenny’s core belief of “I am

broken” was identified.

TREATMENT OF GAD USING CBT 32

Maintenance

Jenny’s anxiety is maintained by several factors, consistent with Beck’s cognitive model.

Jenny’s automatic thoughts (e.g., “I don’t fit in”) justifying her plan to switch back to

homeschooling influenced how she felt (e.g., isolated/lonely), which influenced her behavior

(e.g., lying in bed, neglecting self-care). Allowing Jenny to revert to homeschooling for her

senior year will maintain her anxiety through avoidance of anxiety provoking situations (e.g.,

crowded hallways, hygiene concerns, disappointing teachers, and making mistakes), thereby

preventing opportunities for inhibitory learning to occur. Prior to seeking treatment, this cycle of

anxiety was maintained due to Jenny’s inability to cope with her own anxiety and ultimately led

to avoidant and reassurance-seeking behaviors in response to her negative thoughts and feelings.

While Jenny has learned coping skills and cognitive restructuring techniques during treatment,

there is still a strong chance that her anxiety is being maintained through avoidance and safety

behaviors.
TREATMENT OF GAD USING CBT 33

Behaviors such as avoidance and reassurance seeking are common in individuals with

anxiety (Turk et al., 2004). In Jenny’s case, she often sought reassurance from her mother, which

prevented her from learning that she can survive her anxiety/discomfort without assistance.

Rather than utilizing a mindfulness technique when anxious, Jenny would use her phone as a

distraction and avoidance technique to reduce her distress, which caused her symptoms to persist

over time. Jenny’s mother commented throughout treatment that something else had to be wrong

with Jenny because her behaviors were not justified by anxiety alone. Comments of this nature

further reinforced Jenny’s core belief she is broken and needs her mother to advocate and care

for her.

To understand how Jenny's anxiety is maintained, Barlow (2002) suggests both familial

and social environments, as well as child/parent interaction, should be examined. Hudson and

Rapee (2008) examined the link between parenting style and anxious avoidance in children and

found that parents of anxious children were more likely to support avoidant behavior, especially

if the parent had an anxiety disorder. For example, the therapist perceived Jenny’s decision to

resume homeschooling as avoidant behavior, while Jenny’s mother verbalized full support for

the switch because she could ensure Jenny was getting the best education possible. This example

supports the maintenance of Jenny’s anxiety by highlighting the overprotective and over

controlling nature of Jenny’s mother, as well as the role avoidant behaviors play in maintaining

anxiety. Research indicates a significant and positive relationship between over controlling and

overprotective parenting and the development and maintenance of anxiety disorders (Chorpita et

al., 1998).

The negative experience Jenny’s mother had during her own brief therapy experience

carried over into Jenny’s treatment as the mother was critical, skeptical, and overinvolved,
TREATMENT OF GAD USING CBT 34

including openly disagreeing with Jenny’s diagnosis. Jenny’s mother questioned the therapist

and medication provider multiple times through email about Jenny’s diagnosis. The mother’s

over-involvement in Jenny’s treatment was not only observed through email, but also during

Jenny’s televideo therapy sessions that were intended to be private and confidential individual

sessions between only Jenny and the therapist. In meetings with Jenny’s mother, the therapist

provided psychoeducation on maladaptive behaviors that maintain Jenny’s anxiety and

encouraged the mother to stop reassuring Jenny when she is anxious. Psychoeducation regarding

parental modeling was also provided since Jenny’s mother endorsed her own struggles with

anxiety and reliance on Jenny for support. The therapist emphasized the importance of managing

one’s own anxiety but did not explicitly recommend that Jenny’s mother seek therapy services

because the therapist was unsure how the mother would react and did not want to damage the

therapeutic relationship with Jenny.

Treatment Goals and Plan

Assessment

• Diagnostic Evaluation using the ADIS-IV-C/P and SCARED-R

• Monitor symptoms bi-weekly using the GAD-7

Psychoeducation

• Develop an understanding of GAD and anxiety treatment

Treatment

• Identify automatic thoughts and corresponding cognitive distortion

• Effectively challenge automatic thoughts using disputing questions

• Create meaningful and logical rational responses

• Provide psychoeducation on etiology of anxiety

TREATMENT OF GAD USING CBT 35

• Engage in behavioral experiments to challenge anxiety

• Emotional awareness training (mindfulness)

• Countering unhelpful behaviors (avoidance, safety behaviors)

• Explore recurring themes (religion, perfectionism, mother) to identify core beliefs

• Engage in relaxation exercises like deep breathing and progressive muscle relaxation

• Explore goals, values, perceived sense of self

• Discuss barriers to treatment, e.g., contributing factors that maintain anxiety

• Troubleshoot barriers and maintenance factors

• Explore future plans and provide psychoeducation on goal setting

• Develop a plan to help Jenny maintain gains independently, outside of session

Overall Goals for Jenny

• Decrease symptoms of anxiety

• Identify specific triggers and use coping mechanisms at least three out of five times

• Become more autonomous

• Identify and use specific strategies such as deep breathing or mindfulness when anxious,

rather than using cell phone as a distraction

Overview of Treatment

Jenny completed eight sessions in total, one of which included the initial intake and

administration of the ADIS-IV-C/P and SCARED-R. Jenny did not miss any sessions and was

adherent to homework and consistent with participation during sessions. Research has shown

adherence to treatment protocol, consistent attendance, and completion of homework throughout

CBT treatment is one of the most predictive factors of client success and remission of anxiety

symptoms (Lee et al., 2019). Consistent with CBT for GAD and the requirements of this EST
TREATMENT OF GAD USING CBT 36

Case Study, treatment included a diagnostic interview, objective assessments, a progress

measure, and psychoeducation on the etiology and maintenance of anxiety. Her sessions also

included psychoeducation about methods used to treat anxiety, including cognitive restructuring,

self-monitoring, and relaxation training.

Ultimately, Jenny discontinued treatment due to multiple scheduling conflicts and not

wanting to miss school. Jenny reported the decision to discontinue treatment was her mother’s

idea and would not elaborate on other reasons for the abrupt termination. Missing school had

never been an issue up until this point in treatment and both Jenny and her mother appeared

confident that it was the right decision to cease treatment and resume when “things settle down.”

Termination of treatment precluded implementation of more advanced interventions such as

imagery exposures or in-vivo exposures during treatment. Anxiety started as the primary reason

for seeking treatment but shifted towards transitional goal setting for the latter part of treatment.

Jenny expressed interest in learning life skills and setting goals that would help her become more

independent. Jenny would occasionally endorse symptoms consistent with OCD but after further

questioning, it was clear that her obsessional thinking was due to her anxiety of negative

evaluation. No other diagnosis emerged during treatment.

Course of Treatment

The therapist and Jenny discussed informed consent, limits of confidentiality,

agreeableness to being audio/videotaped, and willingness to be a voluntary participant in a case

study. Jenny and her mother agreed to these terms of treatment and consented to the case study.

A diagnostic, semi-structured interview was completed during the first session, as well as a

secondary screening measure to help rule out secondary diagnoses such as social anxiety

disorder, panic disorder, specific phobia, and obsessive-compulsive disorder. The therapist
TREATMENT OF GAD USING CBT 37

administered a brief, self-report measure at the start of each session to monitor Jenny’s anxiety

and to track treatment progress. The therapist informed Jenny that the primary goal of her

treatment would be to help her gain insight into her anxiety disorder and develop adaptive coping

skills to appropriately manage and reduce her anxiety symptoms.

At the start of treatment, Jenny reported feeling worried about doing poorly in school,

messing up at work, and receiving negative evaluation from others. Jenny felt most anxious

when she felt she was not in control of a situation, felt rushed, or if plans changed suddenly. The

therapist collaboratively worked with Jenny on topics such as automatic thoughts, cognitive

distortions, disputing questions, rational responses, core beliefs, avoidance, and homework. The

therapist worked to build and maintain a therapeutic alliance throughout treatment and

collaborated with Jenny and her mother on most aspects of treatment to increase the likelihood of

consistent session attendance, treatment adherence, homework compliance, and to ensure the

best possible treatment outcome. Periodic consultations with Jenny’s mother occurred during the

first five minutes of Jenny’s individual telehealth sessions and during both in-person, family

therapy sessions. Jenny’s mother often used this time to discredit Jenny’s progress and share

mostly negative examples of Jenny’s behavior. Jenny’s mother emailed the therapist three times

throughout Jenny’s treatment to update the therapist on new, negative behaviors she observed

and to question the accuracy of Jenny’s GAD diagnosis because she did not believe Jenny’s

symptoms were best explained by GAD.

Session structure and therapy techniques were consistent with CBT due to its strong

theoretical backing and extensive support within the literature regarding the treatment of GAD in

adolescents. The interventions included psychoeducation about anxiety, the CBT triangle,

cognitive distortions, cognitive restructuring, rational responses, and helping Jenny see how her
TREATMENT OF GAD USING CBT 38

anxiety was reinforcing her core belief of being broken/flawed. The therapist also facilitated

discussions about how Jenny’s anxiety was being maintained and reinforced at home, which

could stop her from living the independent life that she desired.

The therapist primarily used the Mastery of Your Anxiety and Worry Workbook (2nd ed.).

(Craske & Barlow, 2006) as a guide for GAD treatment, while also incorporating other CBT

materials from the community mental health care center. Jenny received psychoeducation about

the three components of anxiety: thoughts, emotions, and behaviors, as well as the cyclical and

interrelated connection between them. The therapist explained how each component could either

positively or negatively impact the others and that anxiety is commonly a result of that negative

interaction. Further, the therapist explained how each component contributes to increased

anxious thinking and behaviors. The therapist also educated Jenny about the concept of

behavioral avoidance. Specifically, how if avoidance perpetuated, Jenny would not learn how to

survive through the anxiety-provoking situation or develop new ways to respond to it. The

therapist explained that with repeated, prolonged exposure, the brain begins to learn that the

original, feared stimulus, poses no threat or real danger. Consistent exposure to various feared

stimuli would reduce associated anxiety and distress symptoms over time.

The next step in treatment involved educating Jenny about the cognitive triad to help her

start to recognize her thinking and behavior patterns, as well as identifying her thinking errors or

cognitive distortions (Craske & Barlow, 2006). The thinking errors she endorsed the most

included mind reading, fortune telling, and catastrophizing, which were closely tied to her more

frequent automatic thoughts and her core belief of being broken/flawed. The therapist assisted

Jenny to develop rational responses in the session that could be used to combat cognitive

distortions whenever they arose in-session or outside of the session. An example of a rational
TREATMENT OF GAD USING CBT 39

response that Jenny provided was “it is okay if I make a mistake because everyone does at some

point.”

It was evident that Jenny understood the core psychoeducational components of anxiety

and could apply them to her own life as evidenced by homework completion that was consistent,

thorough, and accurate. The therapist explained to Jenny that worry associated with GAD often

encompass a wide range of situations, experiences, and topics. The therapist provided guidance

as Jenny brainstormed anxiety-provoking situations to create a fear hierarchy (refer to Table 1

below), a tool used to rank and organize situations that elicit anxiety to aide in the determination

of clinically appropriate exposures. Jenny assigned a Subjective Unit of Discomfort (SUDS) to

each situation. SUDS can range from zero, no anxiety – to ten, the most/worst anxiety ever

experienced.
TREATMENT OF GAD USING CBT 40

Evaluation of Treatment Outcomes and Disposition

Jenny attended eight sessions and was adherent to completing session homework

approximately 90% of the time. Jenny willingly engaged in discussions that challenged her

anxious thoughts. After the sixth and seventh session, Jenny was able to accurately identify her

cognitive distortions and reported doing so independently, outside of session. She had made

significant progress on her treatment goal of decreasing anxiety related symptoms. More work

could have been done in terms of exposures but, due to Jenny’s sudden shift in wanting to work

more on transitional life skills and goal setting, this exposure work did not occur.

Treatment outcomes were positive in terms of GAD-7 score reduction, though Jenny

admitted to downplaying her anxiety symptoms after the therapist pointed out the discrepancy

between her verbal report and GAD-7 scores. As such, it is unknown if these scores were an

accurate representation of Jenny’s anxiety or if they were what Jenny knew the therapist was

hoping to hear. The following graph indicates Jenny’s GAD-7 scores throughout treatment.

16
Sym tom Se erity atin reflects
14
14 1
distress caused by GAD symptoms
1
(score summation of items 1 -7)
12 0-4: minimal anxiety
10 5-9: mild anxiety
10 10-14: moderate anxiety
15-21: severe anxiety
Score

6 5 5

4
ife nterferen e atin reflects
2 2 2
2 1 1 1 1
home, work, lifestyle, or social
0 difficulty caused by anxiety
0 symptoms depicted in items 1-7
0 no difficulty
1 some difficulty
Session Dates 2 very difficult
extremely difficult
Symptom Severity Rating ife Interference Rating
TREATMENT OF GAD USING CBT 41

Transcript: Self-Evaluation

This case study includes a transcription of session seven with additional comments (bold

and italicized) that highlight areas of therapeutic technique, clinical strength, areas to

improve/what else could have been said and relating concepts from the session back to the

theory. Due to COVID-19 precautions, the transcribed session was conducted via televideo. A

Licensed Clinical Psychotherapist, who helped supervise the case, observed each session in real

time. During this session, the supervisor was present via televideo but had her video off and was

muted unless I requested assistance. In the transcript, “T” refers to the therapist, and “C” refers

to Jenny, the client. Refer to Appendix F for a copy of the transcribed session with the addition

of comments.

Areas for Growth

To be a good therapist, it is important to reflect on areas for improvement. Reviewing the

transcribed session allowed me the opportunity to reflect on aspects of the session in which I

could have taken a different approach. Looking over the transcript, I wish I had advocated more

for in-person sessions rather than televideo. There were several times throughout treatment that I

observed Jenny’s mother in the background of the televideo session or heard her voice off

screen, even though the session was only meant to be with Jenny. I wonder if this lack of privacy

impacted Jenny’s ability to be candid during session. If sessions had been in-person, Jenny

would have been in my office while her mother waited in the lobby of the community mental

health center. This would have provided Jenny the space to speak openly because her mother

was not listening in. In-person sessions also would have allowed more opportunities for in-

session exposures, greater rapport building, and provided greater insight into Jenny’s

presentation and body language. Within the context of in-person therapy, Jenny may have felt
TREATMENT OF GAD USING CBT 42

comfortable enough to be honest about her anxiety and explore her own identity, values, goals,

and desires without the risk of upsetting anyone in her family.

Upon further reflection, I could have been more consistent with session structure,

assigning homework, and reviewing homework at the start of the next session. I could have also

implemented more in-session relaxation technique practice. At times, Jenny spoke so quickly

that I missed important parts of the discussion that warranted clarification or a follow-up

question. I would have also liked to do more family therapy sessions so I could have had the

opportunity to better understand how Jenny’s mother influenced Jenny’s self-esteem, self-

identity, and autonomy. Family therapy could have explored the role that Jenny’s mother played

perpetuating the stereotype of her child being ill. Several potential difficulties may arise for the

family, including overprotection of the ill child, the development of a split in the marriage as one

parent cares exclusively for the ill child, and disruption of the remainder of family life (Sargent,

1983). Family therapy sessions could have also illuminated patterns in the parental and sibling

relationships that could have been integrated into the individual work.

I wish I had assisted Jenny in learning more ways to assert herself, express her emotion,

and become more accepting of herself. Societal expectations placed upon Asian-Americans

typically emphasize academic success and strict adherence to rules. Asian-American culture

traditionally assigns each member of the family a clearly defined role and position within the

family unit. Each person is expected to function within that role, submitting to the larger needs of

the family (Kramer et al., 2012). It is interesting that although Jenny’s parents were not of Asian

descent, their adherence to conservative religious values and beliefs created expectations of their

daughter that paralleled traditional Asian values, including respectful obedience to parental

authority, formal speech patterns that avoid open discussion of emotions, how one’s own
TREATMENT OF GAD USING CBT 43

behavior reflects upon and impacts the family’s social status and “honor,” and clearly articulated

gender roles in courtship (Kramer et al., 2012).

Jenny’s strict adherence to her faith likely impacted her anxiety more than I realized,

especially regarding her desire to be perfect and positively perceived by others. Rosmarin et al.

(2019) discuss a clinical protocol for delivering a flexible, spiritually integrated cognitive-

behavioral therapy approach to help clients begin to explore and make connections between their

mental health and their religious beliefs. This spiritually integrated CBT approach is entitled

spiritual psychotherapy for inpatient, residential, and intensive treatment (SPIRIT). If I had

utilized SPIRIT during Jenny’s treatment, I would have asked her how she thought her

spirituality was relevant to her mental health and treatment. That question guides the first part of

a SPIRIT session by prompting clients to think about how their spirituality or religion relates to

their symptoms (in both positive and negative ways) and it provides an opportunity for clients to

think about how their religion applies to their treatment (Rosmarin et al., 2019).

After getting to know Jenny over the course of treatment, I presume she would have

initially associated her Southern Baptist faith and anxiety in a positive way, as she often

expressed how her relationship with God brought her comfort and that her church friends helped

her feel connected and grounded. Jenny may not have been ready to examine the relationship

between her faith and her core belief of being flawed, her desire to be perfect, and fear of

negative evaluation. Jenny reported feeling shame, guilt, and sadness when she made mistakes or

felt as if she disappointed her family or God. Consistent with SPIRIT, I would have provided

Jenny psychoeducation on how religion can serve as a positive resource to cope with

psychological distress and how it can also exacerbate or contribute to psychological distress for

people (Rosmarin et al., 2019).

TREATMENT OF GAD USING CBT 44

The second half of SPIRIT addresses spirituality in treatment and provides

psychoeducation topics that include Spiritual/Religious Beliefs and Reframes (cognitive),

Spiritual/Religious Coping in Treatment (behavioral), Meditating on the Psalms

(cognitive/behavioral), Sacred Verses (cognitive/behavioral), The Power of Prayer

(cognitive/behavioral), Spiritual/Religious Struggles (behavioral), and Forgiveness (Rosmarin et

al., 2019). Overall, I believe that many aspects of SPIRIT would have resonated with Jenny,

particularly the cognitive reframing in a religious context and utilizing sacred verses or prayers

as coping skills. Moving forward, I will be more mindful of the role religion may play in a

client’s life and tailor my treatment approach in response.

Therapist Successes

Looking at the transcribed session, I was able to reflect on aspects of the session that I

feel went well and pinpoint specific parts of the session where I demonstrated effective therapy

skills. As I was talking with Jenny, I recall that it felt natural, and the conversation flowed easily.

I feel like I successfully created a comfortable, safe space for therapy, despite the unique

challenges that televideo therapy presents. As Jenny and I were talking, I actively tried to be as

collaborative as possible, e.g., asking Jenny what she would like to add to the agenda. I believe

that this collaborative approach helped Jenny feel comfortable enough to expand on her thoughts

without needing prompting. I incorporated pieces of psychoeducation that we had covered in

previous sessions and asked Jenny to recall what she remembered about the concept, which

provided a sense of continuity across the sessions as well as the opportunity for Jenny to pull

from the skills and knowledge she had developed during her time in therapy with me.

Consistent with Jenny’s diagnosis of GAD, she often worried about how others perceived

her; when she answered a question that I posed, expanded on a topic without prompting, or
TREATMENT OF GAD USING CBT 45

accurately explained a concept, I made sure to praise her and thank her for her hard work. An

additional strength throughout the session was that I provided opportunities for Jenny to ask

questions and elaborate more on a topic by utilizing open-ended and cyclical questioning. I am

particularly proud that I respectfully challenged Jenny’s desire to return to homeschooling, as I

viewed that as a form of avoidance.

In terms of assessments, I was able to correctly diagnose Jenny and rule out differential

diagnosis by providing a thorough pre-assessment with standardized measures to support the

theory and conduct an empirically supported treatment. A final strength would be my

consistency with administering the GAD-7 at the start of each session. Over the course of

treatment, Jenny’s GAD-7 scores consistently decreased, meaning that her anxiety symptoms

and associated impairment were becoming less bothersome, and that treatment progress was

being made.

Overall, I did not push an agenda and was always willing to work with whatever Jenny

brought up during session. I was flexible, empathetic, curious, and motivated to help Jenny

improve in all aspects of her life, not just the reduction of her anxiety symptoms. Being able to

“go with the flow” is perhaps the greatest skill that I have acquired since I began my internship.

Clients deserve unconditional positive regard and for their therapist to meet them where they are,

therapeutically, which I feel as though I did.

TREATMENT OF GAD USING CBT 46

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TREATMENT OF GAD USING CBT 53

Appendix A

Common Cognitive Distortions

TREATMENT OF GAD USING CBT 54

Appendix B

The Anxiety Disorders Interview Schedule for DSM-IV – Child and Parent Version

The Anxiety Disorders Interview Schedule for DSM-IV – Child and Parent Versions is a

copyrighted measure that cannot be reproduced. A detailed description of the measure, including

information for obtaining copies of the specific items, can be accessed using the information

provided below.

Silverman W. K. & Albano A. M. (1996). The Anxiety Disorders Interview Schedule for DSM–

IV—Child and parent versions. San Antonio, TX: Psychological Corporation.

TREATMENT OF GAD USING CBT 55

Appendix C

Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R) – Child Version
TREATMENT OF GAD USING CBT 56
TREATMENT OF GAD USING CBT 57

Appendix D

SCARED-R cut-off scores for individual diagnoses

 TREATMENT OF GAD USING CBT 58

Appendix E

The Generalized Anxiety Disorder – 7 (GAD-7)

GAD-7 Anxiety
Over the last two weeks, how often have you Not Several More Nearly
been bothered by the following problems? at all days than half every
the days day
1. Feeling nervous, anxious, or on edge
0 1 2 3
Not being able to stop or control
2. worrying
0 1 2 3
Worrying too much about different
3. things
0 1 2 3
4. Trouble relaxing
0 1 2 3
Being so restless that it is hard to sit
5. still
0 1 2 3
6. Becoming easily annoyed or irritable
0 1 2 3
7. Feeling afraid, as if something awful
might happen 0 1 2 3

Column totals _____ + _____ + _____ + = _____

Total
score _______

If you checked any problems, how difficult have they made it for you to do your
work, take care of things at home, or get along with other people?
Not difficult at all Somewhat difficult Very Extremely difficult
difficult

□ □ □
Treatment of GAD 59

Appendix F

Session Seven Transcript

Master’s level intern and LCP were both present for this televideo session. Master’s level intern

led the session as the LCP observed with their video off and muted

T: Happy New Year. It is 2022! How do you feel about that?

C: It's crazy. It's weird. I wrote 21 yesterday on my paper at school when I was like, oh, wait, no,
it’s not 2021 anymore.

T: Yep, I did the same thing the past two days so you're not alone. Did you make any new year's
resolutions? *Trying to gain insight into client’s goals/hopes

C: No, no, I stopped doing those after I worked out the first day like a couple years ago. I'm like,
no, no, not doing that again.

T: Understandable. But here's to good things happening in 2022. *Instilling hope

C: Yeah, we can hope. Fingers crossed. Yeah.

T: So, before we go ahead and get started, I am going to run through the tracking measure we’ve
been using called the GAD-7. I’ll ask you those questions and you’ll pick a rating for me. Over
the last two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Remember, this is on that zero to three scale with zero being ‘not at all’ and three is ‘nearly
every day.’ *A standard part of CBT is ongoing objective assessment of progress –
administering it verbally due to the session being over televideo

C: Zero.

T: How often over the past two weeks have you not been able to stop or control worrying?

C: One.

T: What about worrying too much about different things?

C: One.

T: Trouble relaxing?

C: Zero.

T: Being so restless that it was hard to sit still?

C: Zero.
Treatment of GAD 60

T: Becoming easily annoyed or irritable?

C: Three.

T: So nearly every day?

C: Yep.

T: Okay, and then the last question. Over the past two weeks how often have you felt afraid as if
something awful might happen?

C: Zero.

T: All right, thanks for doing that with me. So, you endorsed ‘becoming easily annoyed and
irritable’ for nearly every day over the past two weeks and ‘worrying about different things’ for
several days. How difficult have those feelings made it for you to do work, school, enjoy
Christmas break, etc.? The options are ‘not difficult at all, somewhat difficult, very difficult, and
extremely difficult.’ *In addition to symptoms, the GAD-7 also assesses for impairment caused
by the previously mentioned symptoms

C: Somewhat difficult.

T: Okay. So, I would like to talk a little bit about you feeling annoyed and irritable since you
rated that as ‘nearly every day.’ Tell me more about what was going on? *Open ended
questioning

C: Um, that was partly because I was about to start my period this week. Um, but overall,
probably just being with [younger brother] like, for two weeks, and coming home was really
stressful. Anyway, um, he was just kind of annoying, but I guess just like, even now, especially
like, on vacation and like, on the way back. He was just annoying. And I had to sit by him on the
car ride home so like, that didn't help.

T: Those younger siblings know how to get on your nerves, huh? *Humorous reflection, though
I could have asked how the brother was being annoying

C: Yes, he does not he does not think about other people's space. Especially in the car. And so, I
was constantly telling him like, no, you need to back off my space. So, yeah, that was probably
the most annoying.

T: Is he receptive when you kind of tell him those things? *I could have framed this to be open-
ended, e.g., how does he respond when you tell him to give you space?

C: Yes. Yes. He knows how to do it but won’t until we get mad at him.

T: How does that make you feel? *Trying to elicit emotion identification
Treatment of GAD 61

C: Annoyed and angry. I just tell my mom and she handles it. He likes to not listen and push
buttons, especially on road trips where we’re all tired and done and we've been in the car
together for you know, eight plus hours already and we're done.

T: Eight hours is a long time to be in a car with anyone. Where did where did your family go
again?

C: We went to Mississippi. North Mississippi.

T: What is in north Mississippi?

C: Some friends and family.

T: Okay, so you went for the holidays?

C: Well, yeah, I mean, holidays kind of, well, more New Years.

T: How was your anxiety being away from home?

C: Really not bad. I had a fun time.

T: That’s really great to hear. Sounds like you had a pretty good holiday besides the road trip
stuff, which you handled as well as you could. It seems like your anxiety has been low as far as
the measure that we just took. You scored the same as the last time we met. So really, no changes
there. So, for today's session, I was just hoping that we could talk about how we feel last session
with mom went and where treatment is heading. I’d also like to talk about anxiety and our
tendency to avoid what is uncomfortable. How does that sound? *Reflection to show active
listening and setting an agenda, per typical CBT approach

C: Good.

T: Awesome. Then we can finish up and touch base on anything we might have missed.
Anything else you'd like to add to the agenda? *Collaborating with client on agenda items,
collaboration is a key component of CBT

C: I think that sounds good. Okay. I’m freezing!

T: Yeah, it's also cold in my house hence why I'm wearing this hat! Are you a fan of the cold
weather or are you more of a summer person? *Building rapport by asking a get-to-know-you
question

C: I say I like cold weather only because I like to wear my fur coats but my favorite time of all,
weather wise, it's definitely summer. I like snow but when you have to drive to school every day,
it's really not that fun.

T: Agreed. Snow is pretty, but I only really want it to snow on Christmas.

Treatment of GAD 62

C: Hopefully next year. I really like for it to snow on Christmas because I think I've only had two
white Christmases like, as long as I've been born. In Mississippi It doesn't really snow and when
it does, everything melts down. So, I was hoping for snow but no, it didn't snow. We tried to rush
back Friday to get home before the snow Saturday.

T: How did that impact your anxiety? *Pulling for automatic thoughts

C: Not so much, just sucked because we had to leave a day early to beat the snow.

T: That is a bummer, but at least you got home safe. et’s talk about last session, the one with
mom. How do you feel that went, Jenny? *Positive reframe *The prior session was a family
therapy session with Jenny and Jenny’s mom, no homework assignment was given – though
that is something I could have done. This would be an appropriate time to review homework if
it had been assigned.

C: I think it went really well. I enjoyed my mom being there. Um, having her hear what we have
done so far and talking about the triangle, the one with the thoughts and emotions.

T: The CBT triangle? *The CBT triangle is a visual representation of the cyclical nature
between our thoughts, emotions, and behaviors – a core component of CBT

C: Yeah! My mom is a very anxious person, like a big worrier, so it was cool to talk with her
because maybe it can help her too.

T: I’m glad to hear that! CBT gives us many ‘tools’ that we can use to help ourselves and others
less anxious. You and your mom seem very close. *Was curious to see what client would say

C: Yes.

T: I’m wondering, since you just said that your mom also has anxiety, how does that play into
your own anxiety? *Trying to elicit reflection by asking an open-ended question

C: Well, I think I got some of it from her, but I don’t know, we just are very alike. When she is
worried, I worry. Like we feel the same things sometimes.

T: Your mom mentioned that we could work on some transitional life skills in addition to your
anxiety, how do you feel about that? *Encouraging self-efficacy by checking to see if Jenny’s
treatment goals aligned with her moms

C: Yeah, I think that would be good.

T: Last session we talked with your mom about co-dependency, what do you remember about
that conversation? *Engaging client’s memory from last session to see if she was engaged

C: Um, yeah, I would agree with what my mom said. We do depend a lot on each other but when
I was so sick as a kid, she was my rock, you know? And I love her so much.
Treatment of GAD 63

T: How might that co-dependency impact your transition into adulthood? *Was curious if the
client would be able or willing to share a pitfall or negative aspect of co-dependency with mom

C: I think that it’s good to have that foundation, but I am kinda lazy, like with motivation to
clean and stuff. I think that’s why mom wants us to talk about stuff that I need to be doing
without her help. I guess I hadn’t really thought about it but like, yeah, maybe we do depend on
each other too much.

T: Transitions can be tough, but it’s good that you are able to reflect on potential challenges, as
well as things that may help you. I appreciate you being so open and honest during our sessions.
What are your thoughts about how your anxiety has been lately? *Reflecting and praising client
on her honesty to lighten the mood and encourage her to continue being honest and open

C: Um, anxiety has been pretty good, and I’ve been doing okay. I've been doing okay with
chores. I normally just get one load of laundry done and put them in the dryer, but like, the other
day they kind of just started piling on my floor.

T: Why do you think that is?

C: Probably because I was tired, but you know, I still should’ve probably got up to put them
away. I knew that mom would do it for me. The next day I did, you know, kind of clean up my
room and, you know, that made me feel better and going into you know, the new semester.

T: Your last semester, right? *I could have asked Jenny why she thought she felt better after
cleaning her room

C: No, no, I am a junior. I’m supposed to be a senior but got held back in pre-K. You know, it’s
okay. Some grief, but it’s fine. I saw a sign about graduation and was like, dang, that could be
me. But I’m not graduating. It’s sad because I want to be out. But it’ll make my graduation day
next year like that much more memorable and special, you know?

T: You’re really looking forward to it. It’ll be here before you know it. What are your plans after
graduation? *Hoping client will verbalize her plans (they have changed frequently – first she
wanted to move to NYC, then another big city in the Midwest, now she plans to stay at home
with her mom)

C: I probably will still live here for a while. Um, depending on what I want to do. Next school
year I plan on homeschooling for senior year instead of going back to public school and going to
[trade school] to do early child development, because there is a daycare thing that my mom
found at a church, and you can be a preschool teacher or just help out. It's kind of like a daycare,
almost, but there's like a little preschool teacher thing that I might do. I'm interested in that. Um,
yeah, it's basically just like a big daycare, basically.

T: That’s exciting! Quite a big change from cosmetology and your original plan of moving to
New York city. *I wondered if client would express her rationale for the drastic change of
plans or if she’d express how she was feeling – as she has expressed, she doesn’t like change

C: I'm excited, yep. So, yeah, I like kids.

Treatment of GAD 64

T: Sounds like it'll be meaningful work.

C: Yes, yeah.

T: So just so I'm clear - this is going to be your last semester of in-person schooling and all
senior year you're going to homeschool? *Clarifying question before exploring Jenny’s
reasoning for wanting to switch to homeschooling

C: Yes, yes. That is what we're thinking.

T: Who is ‘we?’

C: Mom and me.

T: Oh okay. And so, you’ll attend [trade school] in addition to homeschool? Is that right?

C: Yep. Well, I was supposed to finish [trade school] program this semester for cosmetology,
you know? But then I dropped out because of the mean teacher. I just feel like I learn better at
home.

T: When you say that you learn better at home. What are some potential reasons why that might
be? *Pulling for automatic thoughts or if client could recognize that this is part of anxiety -
avoidance

C: Um, the kids are not there. The other students at school annoy the crap out of me. Um, I just
don't feel like I relate to them. They're just not mature enough. They don't think smartly. And so,
it's like sometimes the teachers are constantly having to like, you know, reinforce rules and it's
just it's so much hassle because they don't know how to really properly act. And that just kind of
gets on my nerves because I'm just like, why haven't you been taught any better to you know, sit
down, do your work, but all they want to do is you know, sit on their phones and there are some
kids who you know, sit down and do their work, but I'm just wanting to focus better not be in
that environment as much. And I just don't like the aspect of public school. I just really like
home school. I can work I feel like at my own pace. I mean, at school, I can work at my own
pace to an extent, but at home school, I really can. And I don't like changing classes and the loud
hallways. It's just, there's a lot that goes into one day that just it's kind of stressful.

T: I’m noticing that there seems to be a pattern of being annoyed by people or and not liking to
be rushed. What do you think? *I could have been more explicit about the anxious statements
that client made, e.g., changing classes, loud hallways, annoyance w/ other students

C: Yeah, I like to work at my own pace.

T: Why do you think that is? *Encouraging client to self-reflect

C: I don’t really know. I like my work to be done right.

T: What does ‘done right’ mean? *Clarifying question to get at client’s intermediate or core
belief
Treatment of GAD 65

C: Perfect, you know? No mistakes.

T: What bothers you about mistakes? *Trying to get client to recognize her own anxiety and
desire to be perfect

C: I think that the teacher thinks I’m dumb and didn’t try.

T: et’s think about to those thinking errors we talked about a couple sessions ago. When you
think that the teacher will think you are dumb if you make a mistake on an assignment, what
thinking error would that be? *Tying in psychoeducation from previous sessions to reinforce
client’s comprehension and check for understanding. Being able to accurately assign thinking
errors, also known as cognitive distortions, to automatic thoughts is a crucial first step in
cognitive restructuring

C: Um, probably like mind reading or fortune telling.

T: Very nice job remembering those. Do you know for certain that the teacher would think that?
*Offering praise and asking a disputing question. I could have asked client to come up with
her own disputing question rather than me saying one.

C: No, guess not.

T: What would you tell a friend if they had that same thought that we just challenged?

C: Mistakes don’t define you; everyone makes mistakes. Just try your best.

T: Excellent. Why don’t you let yourself feel that way? *Checking for emotional insight and
client’s perceived value in herself and her wellbeing

C: I just don’t want to disappoint anyone, you know? I like to make my mom proud and my
teachers. Especially God.

T: You worry you’re not good enough. *Amplified reflection

C: Yeah, sometimes. I try to think positive though.

T: That’s good. How often do you try and identify those thinking errors? *Assessing how often
client utilizes cognitive restructuring skills outside-of-session

C: A lot actually, I really seem to fortune tell and mind read.

T: I’m glad you have found that helpful. What kind of thoughts do you have about homeschool
next year? *Pulling for automatic thoughts or if client has any hesitation with the transition to
homeschool

C: Well, I started homeschooling in second grade when my teacher really wasn't teaching, and
she looked at me different because of my learning disabilities. She said that she couldn’t answer
any more of my questions because I wasn't learning. I was getting really behind, and my mom
Treatment of GAD 66

was getting frustrated. She thought I was being dramatic, so she came to visit my class and
noticed is that my teacher wasn't teaching. She would sit on her phone or read a book. And we
would just be expected to do our work. So, I was really falling behind. But I was like, okay, for
English, and math she had a para pull me out but then I missed other stuff in class. Well, long
story short, mom got more annoyed. She was kind of done with, you know, just all of that. And
so, we thought why not homeschool? We just homeschool and catch me up because I was like,
behind, like I was so behind we had to start at like, first grade work? I think even some
kindergarten stuff because I was so far behind because no one would help me in that class. So,
we decided to do homeschool and I finally caught up and it was great. I worked really well, like
focus. I got really good grades, you know, just academically it was really good for me. And then
we decided to try public school the year we moved here. I love the teachers and that aspect, I
just, I don't like the lunchroom. It's too loud. And it's crazy and all that. I don't like the hallways.
It's just too many people. I mean, you're just, it's sometimes survival of the fittest because people
are moving so fast. So, I try and stay on the outside because I'm small and get squished if I don’t
watch out. I don’t know, like, I just don’t really enjoy that environment. But I am really excited
to be homeschooled again. Um, I just really enjoy it.

T: I'm not super familiar with how, like homeschooling works. Is the curriculum the same as,
like a public school, except who is the teacher? *I genuinely didn’t know how homeschooling
worked, so I asked a clarifying question – though I could have asked Jenny to elaborate on
why homeschooling worked so much better for her

C: So, since it'll be senior year, I will mostly do the schoolwork myself because my mom’s main
priority right now is helping [brother] with his medical problems right now. Um, lots of doctor
visits. So, she's just trying to focus on him so I would be in charge of myself. She creates lesson
plans on Excel. So, she would probably just do those when she does my brothers and then I
would follow that and know exactly what I would need to do each day. I would read it and I
would do the work. I would have the chance to check myself, fix my mistakes, and just kind of
do that with every subject. So basically, I would be self-teaching myself senior year and kind of
doing that and I'm okay with that. Because I know mom has priorities right now. It's [brother].

T: You seem to like the structure and being able to work at your own pace. *Simple reflection,
but looking at this now – I wish I had asked how Jenny felt about mom focusing her attention
more on brother than her

C: Yes.

T: So, what what's going on with [brother]? *Clarifying question – I knew that all siblings had
some sort of medical issue, but wanted Jenny to confirm

C: They think it's a neurological problem. I'm not for sure. It's some muscle. Something. I don't
know. I think they're meeting with some doctor at 10 today. I'm not for sure. They've done a lot.
It's hard to keep up. Um, so it's one of those, we don't know if it's a serious one. We're not for
sure. So, it's kind of crazy. Um, right now, the doctor visits but other than that, I mean, he's
pretty good.

T: Yeah, that sounds super stressful.

Treatment of GAD 67

C: Yeah, it's yeah, it's intense for [brother]. But he's been good about it, staying positive.

T: He's a trooper, hopefully everything works out.

C: Yeah.

T: So, are you doing [trade school] online too?

C: Not this semester, but I will do it senior year.

T: Online?

C: Oh, no, not online. I will go over to the main building. I forget which one but it's one of them.
Yeah. It'll be in person. It's basically the early child development place and is actually a daycare.
So, whether students or workers there have kids, they can drop them off, and we kind of I guess,
do our work or whatnot. So, you kind of learn how to handle those situations and kind of all that
that goes into that. And so, I've had a little bit of experience with kids. At church I helped in the
pre-school room from sixth to seventh grade. I really enjoy that. I do feel like I have a little bit of
a leg up since I have worked with you know, kids. I know that some teenagers you know, haven't
had that opportunity. But, you know, I'm really excited about it and get to learn more and all that.

T: I’m a bit hesitant when someone with anxiety wants to do homeschooling because anxiety
doesn't usually go away by itself. Anxiety actually tends to worsen when we avoid. You said
earlier that you didn’t like the loud lunchrooms and busy hallways, what part of that is your
anxiety talking? *Challenging the client’s thinking is an important aspect of CBT, it is
important that you have some rapport built prior to doing this, especially if the client is
resistant to change

C: Yeah, I guess I didn’t think of it like that, but yeah.

T: Especially since it is your senior year, and you have big dreams and things that you want to
accomplish. One of them included you living in New York, which is a very busy place. People
walking down the street, taxis, cars, very fast paced city. So, doing homeschool will allow you to
avoid those crowded hallways and students walking around you, and how will that impact your
ability to potentially handle crowds in New York City for example? Anxiety likes to try and
make us think that we can’t do certain things, even though we can. Does that make sense?
*Bringing up my observations about client’s avoidance, pulling for client to acknowledge that
giving into her anxiety now may hinder her in the future

C: Yeah.

T: I like the idea that you are still taking some classes in-person, and ultimately you decide what
you want to do. But I also want you to be aware of this and the role that anxiety is playing.
Intelligent kids tend to have the most anxiety because they are aware of themselves and their
thoughts, feelings, physical sensations, but they are also the best at rationalizing their anxiety.
What do you think I mean when I say ‘rationalizing?’ *Positively reframing to keep the session
upbeat, while still asking open-ended questions to check for concept comprehension and
bringing awareness to how detrimental anxiety can be if not addressed
Treatment of GAD 68

C: Um, like, making sense of it?

T: Yes, the anxiety. Rather than challenging the anxiety, there is a tendency to try and make
sense of it. It’s okay to be anxious of XYZ because of XYZ, when in reality, it’s not. So just be
mindful of that moving forward. People tend to not be very good at catching our own tendencies
to avoid, but we can see when other people do it. What do you think? *Consistent with Beck’s
Cognitive Theory, intermediate beliefs are the cognitive level sandwiched between automatic
thoughts and core beliefs, the level that individuals most often use to justify or make sense of
themselves, others, and/or the world.

C: Yeah, yeah, I agree. It’s easier to pick up on other people’s patterns, almost when you're like
the outside kind of looking in. But when it's yourself, it's just like, you become accustomed to it.

T: Exactly. That’s a great way to put it. Is moving to New York still in the cards for future plans?
*Praising client and asking this question about NYC to see if Jenny would give me the real
reason why she decided against it

C: No, not right now. No.

T: What changed? I know dropping out of the cosmetology program was tough for you, but what
else has caused this major shift in plans?

C: Okay, I don't know if I want to say because my statement is a little political. So don't get mad.
Um, I do not want to get the vaccine and right now if you work in New York City, you have to
get it. Um I just don't like the vaccine particularly. Um, so that's one of the reasons. Also, the
high crime rate made me not want to move there and be alone without someone just because, I
don't know, just doesn’t seem safe. I'm going to go be teacher now. The schools in New York
aren't as good as in the Midwest. And also, my friends are here, my family's here. And so, it's
like moving really far away would be hard because I'm really close with all of them, and it would
be hard because I'd have to make new friends. And I mean, I can make new friends really easily,
and I can meet people and just start talking. But just not having anyone that I know there at first
would be a little isolating and be a little, like, depressing.

T: I'm hearing a little bit of anxiety there as well. Especially with the being the being alone piece
and having to make new friends. Working on those exposures in-between sessions can help with
those feelings and really help boost your self-esteem and your confidence. I do understand that
you've lived your whole life with your family, so that can be a little bit intimidating. But I'm glad
that you're excited about the new path and the teaching. *Jenny shared something that she
initially was hesitant to share – perhaps for fear of how I’d react? Or if I’d perceive her in a
negative way? Rather than going the route I did, I wish that I had praised Jenny for sharing
that with me and acknowledged that she just faced one of her biggest anxieties – sharing
something a bit controversial and not knowing how I’d respond or perceive her

C: Right. I think I just got in my own head, and I’d miss a lot being so far away.

T: Do you think you'll have to get the vaccine if you work with children?
Treatment of GAD 69

C: I'm not for sure because it all depends how the church runs. I don't know if the daycare inside
will require it. So, I’m not sure on that, but yeah maybe.

T: Gotcha. And just before I forget to ask, because I've been wondering this, so you and your two
brothers are all adopted, correct?

C: Yes, correct. Yeah, we are all adopted but not related.

T: Gotcha, thanks for clarifying. I know you have had more than your fair share of medical and
health problems, and unfortunately it sounds like [brother] is now kind of experiencing that. Has
[second brother] ever had any medical or health issues? *In the moment, it felt appropriate to
ask these questions because it is a bit of an unusual situation

C: Oh, yeah. When he was a baby, he had colic and some other things, but I’m not sure what
they were called. He did have one problem with his spine I think, and like, the chiropractor fixed
it and basically saved his life because he was going to die.

T: That sounds intense. How did you handle that? *Assessing for coping skills

C: I don’t remember a ton, but with the colic he would you know, obviously scream all day and
almost all night. I remember that. Then after the chiropractor saved him, it got better. Now he is
super healthy, just really allergic to MiraLAX and latex and a bunch of other stuff.

T: I'm glad to hear that he's healthy. You guys have definitely had some health struggles which
can be stressful as a family unit for sure.

C: Yeah.

T: Your family has moved around quite a bit. Do you see the family staying in Kansas for a
while? *Was curious if client knew the answer to this or if her mom makes those decisions for
the family

C: Well, so. My mom is obviously from Mississippi. She wants to move back eventually once
my dad retires and all the kids are out of the house and we're old enough to you know, obviously
live by ourselves. She wants to move back to Mississippi and be with her friends and her family
is down there. So, I don't think we're going to stay in Kansas. I might, just because my friends
are here. I'm not for sure. It also depends in the future, you know, if I do get married or not. It'll
just depend on kind of what happens. So, it's different factors can kind of play a role.

T: So, you mentioned how your friends are all here. I’m wondering how homeschool will impact
that? Your senior year, it's a pretty big year. Many students tend to really look forward to it, or at
least I did, because it's finally like, yes, we're the oldest in the building and there's so many fun
events. With homeschool, do you feel like you’ll miss out on those types of things? ike social
relationships, football games, prom, etc.? *Pulling for negative or anxious thoughts. I was
curious if Jenny realized all of the events that she would be missing out on during senior year

C: I am not a prom person. And if I did go to prom or homecoming, it would be with my friends.
And all my friends come from church so homeschool won’t really impact that because I see them
Treatment of GAD 70

at bible study and stuff. I don't really have too many friends from school. There's one girl that I
do know from another church around here, she is the pastor's daughter. She's really nice. And so
yeah, at school. I just kind of keep to myself. I don't really have many things in common with the
people. You know, I mean, I can talk to them about class or grades and whatnot. But those are,
you know, just surface things. Those aren't really you know, meaningful things as in where my
you know, friends who are Christians, you know, we just, were closer. We have the same beliefs.
We see each other every Wednesday, every Sunday, hang out a lot. Me and my best friend hung
out a lot during the summer because we did a Bible study at our house. So, it was just really fun
to have them around. There's a couple of people that I know at the high school that are in my
classes that are fine that I've known since sophomore year, but I wouldn't say we're “friends,” so
we just don't have a ton in common. I'm very mature for my age and they all kind of act like
children who don’t care about their grades. Too relaxed. And so, I feel like sometimes it's hard to
figure out what to talk about. And you know, we obviously don't talk about school all the time,
so it depends on if they're religious or not.

T: What do you mean by that? *In the moment, Jenny was speaking very quickly so I didn’t
catch the sentence about her not knowing what to talk about. I would have offered a reflection
and then asked a more specific question about feeling like she doesn’t fit in or know what to
talk about

C: Like if they are Christian, we can talk about stuff that goes into that and just understand each
other better.

T: Can you talk to other students who are not Christian? I’m wondering if they were open about
not being Christian, would you still talk with them?

C: Yeah, I mean, I'm open to anyone who wants to be my friend. Um, I mean, this is my belief
and it’s super important in my life so sometimes, you know, if you're not Christian, I feel like
sometimes it's hard to connect on that level. They don't believe in the same thing I believe, so
sometimes I feel like it's hard to connect with them and sometimes they don't understand my
views.

T: What do you mean by ‘your views?’ *Needed clarification and was also curious to see how
Jenny would respond

C: I feel like sometimes other kids are like, ‘oh, you just need to like, you know, go out and drink
or whatnot to have fun’ and I'm like, no, like, that's not what I believe in. I already know I'm not
doing that when I'm older. I've already said that I'm not gonna go be stupid. I want to graduate
and not mess up my life right now. I have to be smart with my decisions. But I mean, yeah, I'm
open to talking to really whoever. I mean, I’m not against any of that.

T: Do many of your classmates go out and do those things? Drink, party, ‘act stupid?’ *I should
have praised Jenny for her positive behavior/choices first before asking about her classmates.
I could have also asked about what “messing up her life” would look like? Is the no drinking
part of her religious views or is it a rule set by her parents?

C: Yeah, I hear about it a lot.

Treatment of GAD 71

T: How does that make you feel?

C: Um, I guess a little different but in a good way. I know how I want to act though and what the
Lord wants for me.

T: How do you think your family or even God would feel if you did poorly on an assignment,
went to a party, or acted in a way that isn’t ‘perfect?’ *Open ended questioning to pull for a
detailed, emotional response that would provide insight into client’s values/morals

C: No, yeah, not good. I wouldn’t want that. I’m a positive person and the ord lit my path, so I
have to do good by Him.

T: You care a great deal about your reputation and faith. *Slightly rephrased reflection

C: Yes.

T: How does that feeling of needing to be perfect play into your anxiety? *Pulling for client to
connect the dots. What’s the root cause here? If I had implemented spirituality into CBT, I
may have asked a question relating to her faith, e.g., if God created us in his image, does he
make mistakes? Is he perfect? Is anyone perfect?

C: I’m my own worst critic for sure.

T: Meaning?

C: I don’t know, um, like very ‘type A.’ I just want to do good things and not upset anyone, so
it’s pressure. A lot. I probably overthink.

T: Overthinking plays a large role in that cognitive piece of anxiety. In the CBT triangle. What
do you think? *Bringing back the CBT triangle to reinforce the connection that our thoughts
have on our feelings and behaviors

C: Yeah, true. I really haven’t thought about it because that’s just how I’ve always been, you
know? My mom is like that too. My brothers, not so much.

T: It’s good to reflect and think about these things. With that said, what would you like to talk
about for the remainder of our session? *We were short on time, but I would have liked to
explore Jenny’s understanding of why her brothers aren’t “overthinkers.” Does she feel closer
to mom knowing that they both are “type A and overthinkers?” or does she wish she could be
more carefree like her brothers?

C: I don’t know. Hmm.

T: What do you feel like would be most helpful for us to work on going forward? *CBT is a
collaborative treatment modality

C: I would say, probably goals, like having my room clean or, you know, finishing my laundry.
Or deep cleaning my room because it's gross. Really gross. I know that I feel better when my
Treatment of GAD 72

room is clean, like I can think clearer and relax. Talking about things like moving towards being
an adult and moving out those kinds of things. I feel like my anxiety is better when I am clean.

T: How do you feel like I can help you with that? *I could have asked why she lets her room get
to such a messy state in the first place if it bothers her so much?

C: Um, I feel like setting goals and checking in would be helpful. And then obviously, when my
mom comes in for a session, we can get all that feedback. I think that would be the most
beneficial, writing out the goals and then deciding which ones to focus on. And then going from
there, I think that would be the most like beneficial.

T: Okay. What do you think the primary barrier is that stopping you from doing those things kind
of on your own? *Assessing barriers to treatment and troubleshooting is an important part of
CBT

C: Um, I would probably say um, I would say my phone, but I've been pretty good about not
being on my phone. Um, I would just say like sitting in bed, being lazy, because sometimes I just
get tired, or I just don't want to get out of bed. And I just want to sit on the couch or watch a
movie or, like, do a craft or go hang out with a friend instead of like, cleaning my room when I
know I probably should clean my room. Because I can barely move. Um, I have like a journal.
So, I guess just like that, so avoid that

T: Sounds like lack of motivation or wanting to do other more exciting things is the barrier. Do
you think that part of wanting everything clean is part of your anxiety and desire to be a certain
way? Perfect? *Pulling for recognition of a pattern or anxious thoughts

C: Hmm.

T: There is a tendency for some people to want perfection, want something a certain way, but
then if it’s not that way, they tend to just quit or give up. For example, I see kids that like to do
art, but they feel like it's never completely perfect, so they don’t finish it. Then they start to
associate every unfinished project as some kind of proof or evidence that they are unable to
finish things or that they’re not good enough. So, I was wondering if there is a little bit of that is
true for you.

C: I mean, I am an extreme perfectionist. If I do something wrong, it stresses me out. Like if I

paint something and it's not like, perfect, like I can't put it up.

T: If I had you paint something, but you painted just a little bit outside the lines, could you hang
it on your wall? *If treatment had continued and we had an in-person session, this would have
been a good exposure

C: No way. Not unless I cleaned up the edges. And that's like even with my makeup. If I do
eyeliner and it's messy. I have to immediately clean it up or redo it because it's not the perfect
wing. Or it's too messy or, or too thin or not even or it's not straight. So, I do like to be you
know, perfect, but obviously perfection. You can’t be perfect. Only God is perfect. But I do
strive to do really well.
Treatment of GAD 73

T: I’m wondering if that has something to do with you quitting the cosmetology program?
*Attempting to make connections to various parts of client’s life that are seemingly all
impacted by anxiety in some way

C: I mean, in cosmetology school, we didn't really get to do actual make up yet, so I really didn't
get a chance to fully practice. That would have been second semester. I don't know I just feel like
I kind of quit because I feel like at the beginning, I felt like oh wow, the teacher believes in me,
like, I got this. I felt like she was on my side but then at the end once I started kind of going
downhill and not doing as good an hour and not having that motivation because I didn't enjoy it.

T: What made you start to not enjoy it?

C: The teacher would correct every mistake that I would make, like whether or not like, I feel
like sometimes she would get mad because I couldn't remember how to do something. And that's
my personality. Like you have to tell me multiple times for me to remember, that's just how I am.
And it's how I grasp things and that’s probably how it always will be. I was tired of being put
down but then told, oh well you need to be motivated, you need to be good. If she was, you
know, putting me down, then why would I be motivated to work harder?

T: You felt criticized and pressured by the teacher. *Reflection to show active listening

C: Yes, for sure. It made something I loved miserable.

T: Did you ever tell the teacher you were feeling this way? *I had a feeling client would say no
due to anxiety. I should have empathized how much it probably hurt for her to give up
cosmetology

C: No.

T: What stopped you?

C: I didn’t want to bother her or make her mad.

T: Okay, so let’s take the last few minutes here and talk this through using what we learned
about automatic thoughts, thinking errors, etc.

C: I don’t know for sure that she would have been mad, but like, she was busy and I was
anxious.

T: Anxious about what?

C: She would think I’m being disrespectful or rude.

T: So, we have our automatic thought that relates to that tendency to want to be perfect and have
a positive reputation. What thinking error could be assigned here?

C: Labeling? Um, no, wait. Let me find that list. Hang on. Oh, yeah, mind reading.
Treatment of GAD 74

T: How do you see those fitting?

C: Maybe she wouldn’t have thought I was being rude. ots of students ask questions and stuff
all the time.

T: Amazing job. Isn’t it cool how a situation can be totally different when we change how we
look at it? *Praising client to boost morale and instill hope toward the end of the session

C: Yeah, honestly, I wish I would have talked to her but, it is what it is.

T: I really appreciate you working so hard today and being so engaged. Before we wrap up
today’s session, what questions do you have for me?

C: None that I can think of. Is there homework?

T: Since you said it would be helpful to have goals and be held accountable, let’s plan on
discussing how you felt before, during, and after cleaning your room. What do you think?
*Homework is an important part of CBT and it is also collaborative, hence why I asked client
what she thought about my homework idea

C: Yes, sounds good.

T: Okay, so what does “clean” look like for you? *Clarifying question to help both client and I
get on the same page. It’s much easier to complete a goal if it is explicitly defined, measurable,
observable, etc.

C: Everything in its spot, clothes put away and none on the floor. Um, cleaning off my dresser
too, maybe vacuuming too. Making my bed.

T: Okay, great. Before you start cleaning, list out the thoughts and feelings you have. Do that in
the middle of cleaning, as well as once you are finished. Sound good? *Important to check for
any remaining questions or comments from client

C: Okay, yes, good. I can do that.

T: Alright, great seeing you today. Thanks again for all your hard work and honesty. See you
next session! *Ending the session with praise can help motivate the client to continue working
on skills outside of session and increase the likelihood of homework compliance and
consistent session attendance

C: Okay, yep, thank you, bye!