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  • drnjosefowitz

Three Clinical Nuggets

Updated: Apr 2, 2021

Clinical Nuggets was a feature on the Canadian Association of Cognitive and Behavioural Therapies (CACBT) list serve from 2012 - 2015. They were a discussion of a clinical moment that presented a difficulty, not a comprehensive discussion of a case. The case is based on a real moment in therapy, but disguised to preserve client confidentiality.

Clinical Nugget #1

I Know Logically My Fear Is Irrational, But The Evidence Against It Doesn’t Feel Real”

The Problem. Marc is a 46 year old man. One of his issues concerns his anxiety about his adolescent son’s academic achievement. A component of our therapy was to help Marc identify a specific anxiety provoking situation and to complete a thought record. I wanted to evaluate if specifying the anxiety provoking thought and examining the evidence for and against his specific concern would diminish his anxiety.

Marc chose the following situation. His son, who is in 11th grade, mentioned at 10 pm that he had a test the next day which he had forgotten to study for. Marc became highly anxious (9 out of 10). After exploring his thoughts it became clear that his predominant anxiety provoking thought was “my son will not be able to cope in University because he is not organized enough.” We examined the evidence for this thought: 1) his son had forgotten to study for the upcoming test; 2) his son often started studying after 10 pm for tests, 3) his son often started papers the night before, and Marc spontaneously gave me an example; 4) Marc overheard his son asking a friend when an assignment was due; and 5) his son had gone out with friends on the weekend before a big exam and had come home late (past 1 am). The evidence against was 1) his son was an A student; 2) in addition to school work his son is on two school sports teams; 3) his son was a B+ student in 9th grade and an A student in 10th grade; 4) his son had been successful as a camp counselor; and 5) his son does not do drugs or abuse alcohol.

After looking at all the evidence Marc developed the following balanced thought “while my son is sometimes disorganized, he generally is organized in his life, accomplishes his goals and does well in school; he will probably also cope in University”. After finishing the thought record Marc’s anxiety had gone from a 9 to a 7.5. However, he paused and said “I know intellectually that my son is not always disorganized, and it does help to look at the evidence and write it out, but in my gut I still fear he won’t cope. The evidence that he is organized and will most likely cope in University just doesn’t feel real”.

My Thinking. Clients often need time and repetition to integrate evidence against their anxiety provoking thoughts and a decrease of anxiety from 9 to 7.5 is a good first step. However, I am always concerned when I hear clients say that rationally the evidence makes sense but that on an emotional level they are unconvinced. Given Marc’s feedback, I hypothesized that the evidence against his anxiety that his son was disorganized and would not cope in University might not be sufficiently alive and emotionally engaging. It struck me that the evidence for the anxiety provoking thought was very concrete, contained specific examples and was accompanied by specific memories. The evidence against the anxiety was more general, abstract and intellectual.

Clinical Nugget #2

A Strength Based Approach to Helping Clients Face Their Fears and Try Exposure Therapy

(This nugget has been somewhat modified from the original to take out information that is not currently relevant)

The Problem. Alison is a 55 year old women. She worked in a women’s clothing store in a downtown mall. One evening a women entered the store. The women asked Alison if she could help her try on some clothes in the dressing room. Alison went to help. The women pulled a large knife from her purse and ordered Alison to walk to the cash and give her everything in the cash register. As Alison walked to the cash register, she could feel the sharp tip of the knife digging into her back. Alison believed that she would be killed. She opened the cash register and gave the women all the money. The women ran from the store and Alison phoned the police.

For the past 18 months Alison has been unable to work. When I started therapy with her she had become increasingly depressed. She experienced severe anxiety if she had to go outside, and had been increasingly restricting her life. For example, she was unable to go inside a mall or any store or take a bus. She had not gone into a mall since the assault. She had withdrawn from her family and friends and was experiencing significant marital difficulties due to her lack of interest in almost all activities.

One of her goals for treatment is to return to work, which she had previously enjoyed. Treatment has involved a number of modalities, but one of the modalities has been exposure therapy. In particular we have been doing invivo exposure to being in a mall and entering stores. Alison has made considerable progress. When accompanied by me (her therapist) she is able to enter a mall, walk around for 45 minutes, enter a clothing store and look at the merchandise. The next step on the hierarchy was to start walking around the mall alone, and going into stores alone. She experienced a great deal of anxiety at the thought of taking this next step and was not sure that she could do it.

My Thinking. The clinical issue I faced was how to increase her motivation to continue with exposure. I have also been increasingly interested in how to incorporate a strength based model into CBT. I have difficulty defining a strength based model, but here is my definition. A strength based model explicitly tries to build a client’s strengths as opposed to addressing weaknesses. Furthermore, a strength based model identifies a client’s strengths and values and explicitly tries to expand these strengths by both increasing the valence of the strengths, expanding the areas where the individual feels strong or capable and helping a client act according to their values.

First, I want to clearly articulate the goal of exposure in relation to my client’s values. This involves articulating the client’s values and exploring how exposure is related to these values. Second I want to proceed up the hierarchy when the client was “willing”, and not to wait until the anxiety has decreased. Anxiety is normalized and not considered a reason to avoid.

Clinical Intervention. Given Alison’s hesitancy to attempt to be alone in the mall, I thought I would try incorporating the principles that I discussed above. I hoped that focusing on her values would increase her motivation to continue with the exposure hierarchy. We discussed why it was important for to be able to walk alone in the mall, and how this was related to values that were important to her in her life. Alison is an individual who values her independence, and her ability to work and support herself. We explicitly made the link between her ability to walk alone in the mall and the value of being independent. I realized that previously we had set a clear goal of being able to return to work, and had agreed that being able to walk alone in a mall was an important step in achieving her goal, but we had never clearly linked this goal to her larger values. Some of the questions I asked in eliciting her values were “why is it important to you to be able to walk alone” and “what would it mean to you about yourself if you were able to accomplish this”.

After our discussion, Alison was willing to proceed with the exposure task. The task involved my sitting on a bench in the mall while she walked alone to an agreed upon store, entered the store alone and came back. We spent the next half hour with her extending the distance she was willing to walk alone.

When she returned we briefly discussed how well she had managed and how important it was to her to become more independent. I would then ask her if she was willing to go a bit further and we would collaboratively decide how far she would go. At one point she spontaneously commented that she liked being reminded of why she was doing exposure as it “gave her something to reach for”.

Since this session, we have continued with exposure. At the beginning of each session we spend some time reviewing why the exposure tasks are so important for her from a values perspective. We have also continued to use a willingness model . Alison has continued to make progress.

Clinical Nugget #3

My Client Spaces Out During Exposure Tasks

This nugget is based on the workshop presented by Dr. Deborah Dobson and myself on Showing up for Exposure Therapy: A case formulation approach to reducing avoidance in anxious clients. The workshop was presented at the CACBT Montreal conference in 2013. At the Montreal conference we both Dr. Dobson and myself presented cases. However, this nugget just presents my case, though the case conceptualization was a collaborative effort

The Problem. Lysette is 28 year old women. She works at a shoe store in a strip mall. One evening when she was closing, a man entered the store. She was alone at the cash register. The man held a gun to her head while he ordered her to open the cash register and threatened to kill her. After a number of tries, she was able to open the cash register. He grabbed the money, threw her to the floor, and fled the store. She was able to get up and called the police.

For the past 9 months she has been unable to work. She has difficulty walking alone outside. She can only drive if she avoids the area around the store where she was assaulted. She will not go into any store or shopping mall, as she is afraid she will not be able to cope. She has withdrawn from her family and friends as she feels that they do not understand her and she is ashamed of her reaction. She feels that she is going crazy. She has trouble sleeping, and is chronically tired.

One of her goals for treatment was to walk outside on her own and not avoid the area where the assault occurred. I suggested that we try exposure, described the intervention and she agreed. I tried to create a hierarchy with her, but she rated everything as a 90 out of 100 in terms of how distressing the task was. I decided to start with what she thought was “doable”. She was assaulted on Black Street. We decided we would drive down a street called Green Street, which was perpendicular to Black street. I drove and she sat in the car in the passenger seat. Following completion of the task, she informed me that she had kept her eyes closed the whole time. I was enthusiastic about her accomplishment but concerned that she had not engaged in the exposure task. We decided to attempt the drive again, but this time with her eyes open. When we processed the task, she told me she had “spaced out the whole time”. Again I expressed enthusiasm for her accomplishment, but was concerned about her disengagement.

Our Thinking

Avoidance and safety behaviours are commonly discussed as maintenance factors in anxiety disorders. They maintain fear by interfering with the client’s ability to learn that situations are not dangerous and that the experience of anxiety is not dangerous (see Dobson and Dobson, 2009). Most texts on exposure mention that avoidance and safety behaviours can interfere with successful exposure by interfering with the client’s direct experience of the exposure task, however, there is very little guidance on how to overcome avoidance and/or safety behaviors in the context of an exposure task. Examples of safety behaviours during an exposure task can include: averting your gaze so you do not see the stimuli, zoning out so you do not experience the anxiety, or engaging in the task so quickly that you do not fully experience the task. I thought Lysette’s closing her eyes and “zoning out” was a safety behaviour, as it interfered with learning that she could drive down the street without zoning out and that she could tolerate the anxiety.

I thought that her “zoning out” had similarities to a dissociative experience. When clients dissociate, it is often helpful to use grounding techniques where clients are encouraged to be present by focusing on their senses: what they see, hear, smell, feel, and taste. I thought a similar technique might assist Lysette to stay present during exposure. I also wondered if there was a way of using humour to help her stay present during the exposure task. I thought that if you are laughing, you are not zoning out. I also wondered if driving down Green Street had been too anxiety provoking and if we should start with a task that would be easier for her.

Clinical Intervention. I suggested to Lysette that we park on Green Street, as close to Black Street as she could tolerate and try looking at the street signs in the direction opposite from Black street. We discussed the importance of “looking” rather than “zoning out”. The first task was to look for one second, close her eyes for five seconds, look for one second, close her eyes for five seconds and repeat this five times. She was able to accomplish this. We then did the same task 10 times. We progressed to five seconds of looking and then 10 seconds, each time with a five second break and specifying the number of times she would engage in the task. Each time I counted out loud so that she knew how long she had to look and how long she could close her eyes for. I also checked her eyes that she was actually looking. Each time we processed her accomplishment. When we reached 10 seconds, we started describing details of the scene. I started noting a colour that I saw and then she had to note an additional colour. For example, I would say “I see a green sign for sushi” and she would say, “I see a yellow sign for toys”. She would then close her eyes for 15 seconds and we repeated the task five times. Eventually, we engaged in other tasks that required her to stay present. For example I would say “do you see the pink sign for the donut store? What do you think of the sign? Do you like the colour? As she became more comfortable with the task, I tried to engage her in a humorous way. For example there was a very dirty, old sign for “fried chicken”. We would look at the “gross sign for fried chicken, that no one could possibly want to eat” and discuss all the ways it was dirty.

After a couple of sessions, we progressed to slowly driving down Green Street, each of us noting colours with Lysette keeping her eyes open. As we drove I would try to focus her attention on the exterior world so that she would not “zone out”. I made comments such as “I see a sign for children’s toys, do you see it, take a look at it, what colour is it?” or “look, there is our favorite gross fried chicken store”. At the end of each exposure session we would park sufficiently far from Black Street that she experienced no anxiety and we did a few minutes of grounding where she noticed the colours of the area around her. We would then process the exposure task. We would note what she had been able to accomplish, how the task was easier than she had anticipated and her own ability to manage her anxiety and engage in the task. I was always enthusiastic about her accomplishments.

Whenever I asked her to rate her anxiety it was always 90, but she would indicate that she was willing to move on to the next task. Initially I suggested a task, but very quickly we collaboratively decided on the next task.

We shared a sense of humour and I consciously tried to incorporate humour into the exposure tasks. I conceptualized it both as a step in the hierarchy and as a way to ensure that she stayed present. For example, on the corner of Black and Green Street was a large ad of a basketball player playing basketball in a famous restaurant. Initially, she could not look down Black street. I designed a number of exposure tasks. We started by parking the car and looking at the ad. We utilized the same strategy described above to look at the ad (one second, five seconds, 10 seconds). We then moved on to label the colours. Once she could look at the ad for 15 seconds we started to make fun of it. For example, did it make sense to play basket ball in a restaurant? Would that really make you want to go to the restaurant? We made up silly foods with a basketball theme – for example “eggs for a basketball coach” or “fries with a ball”. It did not matter that our jokes were not particularly funny, I would encourage her to laugh at how bad our jokes were.

Eventually, she was ready to get out of the car and stand on Black street, though far from the store. Again we used grounding techniques. She stood bending her knees so that she could fully feel the pavement under her feet. Dr. Dobson and I have had clients jump and stamp their feet. We labeled what we saw and we identified the sounds we could hear. We set a specific amount of time that she would stand, so that we never ended an exposure task when Lysette could no longer tolerate the anxiety.

After a few sessions I noticed that she could not say the name Black street. I started by singing the name Black street to the tune of Bingo (a well known children’s song). I then sang the words Black Street to other tunes, but kept going back to Bingo. After a couple of times she joined me in singing the word Black Street to the tune of Bingo. We also wrote out the name Black street and matched a word to each letter. For example B is for Boy, L is for lollipop, A is for Apple, C is for Colour and K is for Kite. I first modeled how to do the task, then we each took turns matching a word to the letter. I then made up silly sentences, such as the Boy ate a Lollipop and an Apple while looking at a Colour in his Kite. I encouraged her to make up a silly sentence, and helped her when she had difficulty. The goal was to encourage her to look at the word Back street. I tried to encourage her to laugh, or at least smile.

Once exposure started being effective she progressed quickly so that eventually we were able to drive down Black street, and eventually she was able enter the store alone where she had been assaulted. With each step I made sure she was fully present during the exposure.


Dobson, D. & Dobson, K. (2009). Evidence Based Practice in Cognitive Behavior Therapy. New York: Guilford Press.

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