NU 672 Unit 8 therapy episode portfolio example

Therapy Episode Portfolio: Sixteen Sessions of Cognitive Behavioral Therapy for Panic Disorder, From Choosing the Approach to a Planned Ending

Student Name

Department of Nursing, Herzing University

NU 672: Counseling and Psychotherapy

Instructor Name

March 11, 2026

Therapy Episode Portfolio: Sixteen Sessions of Cognitive Behavioral Therapy for Panic Disorder, From Choosing the Approach to a Planned Ending

1. Selection

The patient, Ms. J., is a composite dental hygienist of 29 who developed panic attacks after a first attack on the interstate, then began avoiding highways and crowded stores, carrying lorazepam, and working part-time. Three approaches were weighed: cognitive behavioral, panic-focused psychodynamic, and acceptance-based treatment. Cognitive behavioral therapy was chosen because its account of what keeps panic going, catastrophic misreading of bodily sensations sustained by avoidance and safety behaviors (Clark, 1986), matched what she described, because she had a concrete deadline, and because she wanted skills to practice. Values from acceptance and commitment therapy were borrowed to frame exposure around her reasons for doing it, and the psychodynamic approach was held in reserve in case a separation theme emerged.

2. Goals, in the Approach's Terms

Eight goals were set in the order in which they depended on one another: understanding the panic cycle; tolerating deliberately induced sensations without escape; staying in crowded stores; driving the interstate alone; giving up the lorazepam as a safety signal; driving to her sister's wedding; returning to full-time work; and a relapse prevention plan. Each was tied to the part of the maintenance cycle it targeted, so that a stalled goal could be traced to a technique rather than to her effort.

3. A Session Where the Work Stalled

Session 11, a week after the treatment review, is where the work stalled. She arrived saying she had not practiced any highway driving. The excerpt below is from the first ten minutes.

T: "What got in the way this week?" P: "I just didn't. Every time I thought about it, I thought, what's the point, the wedding might not even happen now." T: "Is it still happening?" P: "My sister says yes. But she's barely talking to me." T: "So the drive feels pointless, and the person it's for is pulling away." P: "Yeah. And if I drive there and she doesn't want me there..." [She stops.] T: "What would that mean?" P: "That I ruined it by telling you about Tyler."

Here the exposure work had stalled on a belief, not on fear of sensations. The therapist chose to work on the belief directly for the rest of the session, examining the evidence that her disclosure had caused the conflict, which pointed more to Ryan's behavior and her sister's fear, and what her sister had actually said since. By the end of the session, she agreed to one short highway drive before the next session, framed as practice for the wedding whether or not the relationship was mended by then.

4. The Frame, Tested

After session 11, she sent a text to the clinic's after-hours line late at night: "Can I text you if I panic on the drive?" In session 12, the request was treated as meaningful rather than simply refused. Being able to text during an exposure would make the therapist a safety signal, which would work against the aim of learning that she can manage the sensations herself (Craske et al., 2014). The response was: "I'm glad you're planning the drive. If I were on the other end of your phone, part of you would be leaning on me, and the drive would teach you less. What could you do in the car instead?" She planned to pull over at a rest stop, use the breathing she had practiced, and write down what happened for the next session. She did not need the rest stop.

5. Outcome

Over 16 sessions, her score on the Panic Disorder Severity Scale fell from 16 to 6 (Shear et al., 1997), after leveling at 10 to 11 during the family crisis. She had no panic attacks in the last four weeks of treatment. She stopped carrying lorazepam at session 13. She drove the one-hour practice route twice before the wedding, then drove the three hours to the wedding herself, with her partner in the passenger seat, and drove home again the next day. Her sister thanked her for coming, and the two have since talked about the incident with Tyler, who is back at home with his mother after the fiancé moved out during the investigation. She has not yet returned to full-time work; she has a start date six weeks away.

6. A Planned Ending

The ending was planned from session 13, not decided at the last visit. Sessions 14 to 16 were spaced two weeks apart so that she could practice without weekly support. In session 15, she wrote her relapse prevention plan in her own words: the early signs of a return of panic, such as checking her pulse or avoiding a route; the skills that helped most, interoceptive exercises and testing predictions; what to do after a bad attack, which is to return to the situation within a day; and when to call for a booster session, if she avoids any activity for two weeks. Session 16 reviewed the course, including the stall and what got her past it. A booster session is scheduled in two months, timed for one month after her return to full-time work.

7. How the Parts Connect

The approach chosen in session 1 set the goals, and the goals, tied to a maintenance model, made it possible to see in session 10 that progress had stalled for a reason outside the model's original scope. The stalled session showed the therapist moving from exposure to a belief that was blocking it, without abandoning the approach. The test of the frame was handled as part of the treatment, since a texting lifeline would have become a new safety behavior. And the ending returned to the goals she set at the start: she drove to the wedding, and the plan for work is in place. What remains uncertain is whether the separation theme will return when her sister moves, and the booster session is timed to catch it if it does.

References

Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470. https://doi.org/10.1016/0005-7967(86)90011-2

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23. https://doi.org/10.1016/j.brat.2014.04.006

Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., Sholomskas, D. E., Woods, S. W., Gorman, J. M., & Papp, L. A. (1997). Multicenter collaborative Panic Disorder Severity Scale. American Journal of Psychiatry, 154(11), 1571-1575. https://doi.org/10.1176/ajp.154.11.1571