Session 5 / Week 1
Motivational Interviewing
PatientK.M.
ClinicianL.S., LCSW
SettingTelehealth, 45 min
CPT90834
ICD-10F41.1
PayerBCBS commercial
Chief complaint, this session
Patient presents for continuing psychotherapy. Reports persistent ambivalence about identifying the source of her anxiety and difficulty completing journaling task assigned previously. Stated, "I keep telling myself I'm gonna sit down and journal like you said. I just stare at the page for ten minutes."
HPI since last visit
Continued difficulty completing reflective writing between sessions. Alternating attribution of anxiety to her 6-month-old rescue dog and to "everything." Continuous hypervigilant attention to the dog's location, including during today's session. Parallel pattern at work: continuous tracking of Slack messages despite phone being out of reach. Sleep disruption, irritability, difficulty disengaging endorsed in prior session, ongoing. No new psychosocial stressors. No substance use. No medication. No SI/HI.
Subjective
Patient described her week as "kind of a blur." Reported being unable to complete the journaling assigned in the prior session, citing both the dog's barking and her own difficulty answering the prompt "What am I anxious about." Voiced ambivalence about identifying a single anxiety source ("I don't think one thing is wrong, I think a lot of things are wrong"). Named guilt around having anxiety despite "objectively a great life."
Voiced fear that her current presentation reflects a stable trait change rather than a state response ("I just got rewired at some point") and worried about a future in which she could not enjoy things. Reported continuous tracking of the dog throughout the session and identified the same hypervigilance at work, acknowledging this always-on quality predates the dog. Came to describe the dog as "an amplifier" of pre-existing patterns.
Voiced strong reluctance to consider pharmacotherapy, attributing this to her mother's psychiatric medication use during her childhood. Described a 5-minute moment of regulated connection with the dog the previous evening (hand on dog's head, calm) when prompted to recall a positive moment.
Mental status exam
- Appearance: well-groomed, casually dressed, eye contact appropriate to telehealth.
- Behavior: cooperative, engaged. No psychomotor agitation or retardation.
- Speech: normal rate, rhythm, prosody. Hesitation when discussing diagnostic labels.
- Mood: "a blur." Anxious, ambivalent.
- Affect: congruent, full range, briefly tearful when discussing fear of being "unfixable."
- Thought process: linear, goal-directed. Some circumstantiality around anxiety attribution.
- Thought content: no SI, no HI, no perceptual disturbance, no delusions. Worry content focused on identity, capacity for enjoyment, fear of medication changing self.
- Cognition: alert, oriented x4.
- Insight: good (named ambivalence as ambivalence).
- Judgment: good.
Risk assessment
SI/HI denied. No plan, no intent, no means. Risk factors: female, parental psychiatric history, generalized anxiety symptoms, recent significant life stressor (new pet, ongoing marital tension). Protective factors: actively engaged in treatment, strong therapeutic alliance, supportive marriage, no history of self-harm, stable employment and housing, no substance use, intact insight. Risk level: low.
Therapeutic interventions used
Motivational interviewing approach used throughout the session given the patient's stated and observed ambivalence around accepting an anxiety formulation, considering pharmacotherapy, and committing to between-session work. Specific techniques deployed:
- Open-ended questions to surface meaning and elicit elaboration ("What's the worry there?" "When you imagine that future, what's the part that scares you most?")
- Reflective listening, including complex reflections to surface the unspoken ("There's a part of you that wants to identify the thing, and a part that thinks that's not even the right question")
- Affirmations of patient's self-observation capacity and her vulnerability in disclosing maternal medication history
- Periodic summarizing of two competing positions (dog-as-cause vs dog-as-amplifier)
- Eliciting change talk (DARN): patient generated her own desire ("I want to figure out why I can't relax"), reasons (loss of capacity to enjoy things), ability statement (willingness to track on phone)
- Developing discrepancy between stated value (wanting to enjoy the dog) and current behavior (continuous monitoring)
- Rolling with resistance around medication concerns: clinician reflected the patient's stated model without directive push
- Collaborative goal renegotiation: prior journaling task replaced with a lower-friction alternative (notes-app symptom logging) tailored to her stated constraints
Patient response to intervention
Engaged actively with the MI process. Reported a felt-sense shift when the dog-as-amplifier framing was offered. Generated her own modified between-session task when prior structure had not been workable, indicating self-efficacy. Voiced ambivalence in real time. Accepted the framing of "gathering data" rather than "naming it," suggesting reduced defensiveness around diagnostic labeling. Volunteered an example of regulated connection with the dog without prompting.
Progress toward treatment goals
Treatment goal per intake: reduce daily worry frequency, improve ability to disengage from work and home stressors. Initial GAD-7: 14 (moderate). Re-administration deferred this session to allow for naturalistic data collection. Today's session represents progress toward "develop awareness of triggers and patterns": no longer attributing anxiety solely to a single external cause; integrating trait-level versus state-level distinctions. Therapeutic alliance is strong; patient initiated a vulnerable disclosure (maternal medication history) that had not been raised before.
Plan
- Continue weekly individual psychotherapy.
- Between-session task: log anxiety episodes via phone notes app, intensity 0-10, brief trigger note. Log both anxious and regulated/calm episodes.
- Defer GAD-7 re-administration to next session, after one week of self-tracking data is available.
- Defer pharmacotherapy discussion. Will revisit when clinical indication and patient readiness align.
- Continue MI-informed approach to address ambivalence around diagnosis and treatment commitment.
- No referrals indicated. No medication considerations (patient is not on psychiatric medication).
Medical necessity
Patient continues to meet F41.1 criteria with daily excessive worry across multiple life domains, persistent hypervigilance, sleep disruption, irritability, and functional impairment in interpersonal (marital) and recreational (capacity to engage with new pet) domains. Today's session addressed core anxiety processes (cognitive avoidance, ambivalence, identity-level worry) with active patient engagement and observable in-session progress. Continued weekly outpatient psychotherapy at the 90834 level is medically necessary to address the underlying anxiety presentation, prevent escalation, and build foundation for an evidence-based treatment course. Lower level of care not clinically appropriate; higher level not indicated.
Session start 09:00, session end 09:45, total face-to-face 45 min. Electronically signed by L.S., LCSW. NPI [redacted]. License LCSW #[redacted].
Read full transcript
L.S.: Hi K. How's your week been?
K.M.: Uh, it's been... I don't know. Honestly, kind of a blur. I keep telling myself I'm gonna sit down and journal like you said, but every time I do, I get five sentences in and Pip starts barking at, like, the mailman, or the wind, or his own shadow, and I just give up.
L.S.: Mm. So Pip's barking pulled you out of the journaling.
K.M.: Yeah. I mean, that, plus my own brain, I think. It's like, I sit down and I think, okay, what am I anxious about. And then I just stare at the page for ten minutes.
L.S.: It sounds like the journaling itself is asking you a hard question.
K.M.: ...Yeah. I guess it is.
L.S.: What was the question, when you sat down?
K.M.: I think it was just like, what's actually wrong. Like, what's the thing I'm anxious about. Because, you know, my husband keeps saying it's the dog. And I keep saying it's not the dog. And then I sit down and I'm like, I don't know. Maybe it is the dog. Or maybe it's everything.
L.S.: Mhm.
K.M.: Like, I don't think one thing is wrong. I think a lot of things are wrong. And then I feel guilty for thinking that, because objectively I have a great life. My job is fine, I make good money, my husband is great. So.
L.S.: There's a part of you that wants to identify the thing, and a part that thinks that's not even the right question.
K.M.: ...Yeah, that's actually it. That's the thing. Like, what if there isn't a thing? What if I'm just, like, this is who I am now?
L.S.: Tell me more about that. What's the worry there?
K.M.: That it's just, like, baseline. Like I just got rewired at some point and now I'm an anxious person, and I'm gonna spend the rest of my life, like, white-knuckling through it.
L.S.: That's a heavy thought.
K.M.: It is.
L.S.: When you imagine that future, what's the part that scares you most?
K.M.: I don't know, that I won't enjoy things anymore. When we got Pip I was so excited. I was so excited about the dog. And, like, six months in, I'm just overwhelmed. And I keep waiting to have the moment where I'm like, oh my god, I love this dog. And I do love him! I do. I just, it's hard to get to the love because I'm always managing him. Or worrying about him. Or, like, listening for him.
L.S.: It sounds like a lot of the bandwidth that used to go to enjoying things is going somewhere else.
K.M.: Yeah.
L.S.: When you say "always listening" what's that like?
K.M.: It's like, even now, I'm aware of where he is. He's in the other room and I can tell you he's near the window. I've been tracking him this whole call. And he's fine! He's been fine. But I can't turn that off.
L.S.: That awareness, the always-tracking. Does that show up in other places too? Outside of Pip?
K.M.: ...Hmm.
L.S.: Take your time.
K.M.: Yeah. Yeah, it does. I do that with Slack at work. Like, my phone is over there, but I know exactly when the last message came in. And I'm like, did I respond to that. Should I look. I'm in this conversation but I'm also in that conversation. And it was like that before the dog, but the dog made it more. Or maybe more obvious.
L.S.: So the always-on isn't just about the dog.
K.M.: ...No.
L.S.: I want to play back something I'm hearing, and you tell me if I'm getting it right. There's a version of this where the dog is the problem, and we figure out a way to manage Pip, and the anxiety lifts. There's another version where the dog is more like an amplifier. He turned the volume up on something that was already playing.
K.M.: Yeah. The second one is closer.
L.S.: That's a hard thing to look at.
K.M.: It's really hard.
L.S.: What makes it hard?
K.M.: Because if it's the dog I can do something about that. I can train him better. I can hire a trainer. I can be more strict with him. If it's not the dog, it's me. And I don't know what to do about me.
L.S.: There's a sense that the dog is the fixable version of the problem.
K.M.: Yes. Exactly.
L.S.: And underneath that, there's a worry that you might not be fixable.
K.M.: ...Yeah.
L.S.: I want to say something, and then I want to hear what you think about it. You came in here, gosh, three months ago now, and one of the first things you told me was, "I want to figure out why I can't relax." That was the goal, right?
K.M.: Yeah.
L.S.: And in our last session you described some stuff that I'd put under the umbrella of generalized anxiety. The always-on, the not turning off, the sleep stuff, the irritability with your husband. You weren't ready to call it that, last time. I don't want to push the label on you. I just want to come back to it because you're describing it again today.
K.M.: ...Yeah.
L.S.: What's it like to hear me say that?
K.M.: It's a little, it's a relief? And it's also, like, oh god, no. Because if it's a thing then I have a thing. I'm not just, you know, having a hard six months.
L.S.: That's a real tension. Naming it makes you a person with a thing. Not naming it leaves it sort of diffuse.
K.M.: Yeah. And medicated. Right? Because if I have a thing, then am I supposed to be on medication. And I really don't want to be on medication.
L.S.: Tell me about that. The medication piece.
K.M.: I just, I don't know, I think I'm scared of becoming a different person. Or, like, dulling something I need. And my mom was on, like, a lot of stuff in the 90s and she was just, gone. So that's my model.
L.S.: That's really useful context. Your model of medication is shaped by something hard you watched as a kid.
K.M.: Yeah.
L.S.: I don't want to make a decision about medication today. I don't think we have to. I'm hearing two things, though. One, there's a part of you that's open to looking at this more squarely. You've been describing it today in pretty vivid terms. The other thing is that the worry about what naming it means is doing a lot of work to keep things vague.
K.M.: ...Yeah.
L.S.: What would it be like to spend, say, two weeks, just paying attention to it without trying to solve it. Just noticing what triggers it. When it's high, when it's low.
K.M.: Like, just a journal?
L.S.: Could be. Could be just notes on your phone. Whatever doesn't feel like a homework assignment.
K.M.: Yeah. I could do that. I think I could do that without it feeling like a thing.
L.S.: What would make it not a thing?
K.M.: Just, like, not having to write a paragraph. Not having to sit down at a desk. Just, like, here's a moment. It's a 7 out of 10. The dog. Or whatever.
L.S.: Notes on your phone. The 7. The trigger. That's it.
K.M.: Okay.
L.S.: And then we look at it together next time. We don't have to call it anything. We just look.
K.M.: Yeah, okay. Yeah, I can do that.
L.S.: So we're not naming it today. But you're going to gather the data on it.
K.M.: That's a good way to put it. I like that better. Yeah.
L.S.: One more thing before we land. You mentioned you really did love Pip. You were really excited when you got him.
K.M.: I was.
L.S.: When was the last time you had a moment with him where you felt that. Even a small one.
K.M.: Oh god. Um. Last night, he was on the couch with me, and he, like, leaned over and put his head on my leg. And I just sat there for, like, five minutes and didn't do anything. I just had my hand on his head.
L.S.: Beautiful.
K.M.: Yeah, that was nice.
L.S.: Anything to write down on the phone, that one's the same. The 8 out of 10 that's calm. We want both.
K.M.: Okay.
L.S.: Alright. Let's plan to meet next week. Same time?
K.M.: Yeah. Same time.
Session 6 / Week 2
Cognitive-Behavioral Therapy
PatientK.M.
ClinicianL.S., LCSW
SettingTelehealth, 45 min
CPT90834
ICD-10F41.1, F40.218 added today
PayerBCBS commercial
Chief complaint, this session
Patient presents with self-collected symptom-tracking data and a substantively reformulated case. Stated, "I have notes... I have a lot of notes." Reports identification of dog-proximate scenarios as the near-exclusive trigger of anxiety episodes, with associated catastrophic cognitive sequence and physiological arousal previously unrecognized.
HPI since last visit
Patient completed the between-session symptom tracking task assigned in S5, logging anxiety episodes via phone notes app over the past seven days. Self-collected data demonstrated near-exclusive triggering by dog-proximate scenarios (computer, rug, couch, kitchen, sudden movement), with secondary lower-frequency triggering by work email/Slack. Newly identified physiological signs of anxiety arousal (chest tightness, peripheral coolness/cold hands) that were not previously connected to her affective state. No new stressors. No substance use. No medication. No SI/HI.
Subjective
Patient reported completing the phone-based symptom log as agreed in the prior session and presenting today with structured data. The data refuted her previous belief that anxiety was diffuse and multi-domain; the log demonstrated near-exclusive dog-proximate triggers with secondary low-intensity work triggers. She identified specific physiological correlates (chest tightness, cold hands), stating "I never noticed that before."
She articulated a discrete catastrophic cognitive sequence triggered by the dog's proximity to the family couch: dog → chewing of furniture → required replacement at $5,000 → husband's anger → marital instability. Through Socratic dialogue, she generated the actual base rate of furniture chewing (twice in six months across an estimated 360 exposures, ~0.5%), the actual prior repair cost (~$100, sanding only, no replacement), and the recognition that the anger-projection component of the sequence reflected paternal rather than spousal patterns.
Patient voiced commitment to a graded behavioral exposure plan and asked clarifying questions about implementation. She voiced mild self-deprecation about the cognitive distortion ("when you put it that way it sounds insane") which resolved within the session. She made a brief but clinically significant connection between her current catastrophic cost-cognition and her father's reactivity to financial events in childhood.
Mental status exam
- Appearance: well-groomed, casually dressed, eye contact appropriate to telehealth.
- Behavior: cooperative, engaged. Notably more activated and forward-leaning than at prior session. Visible energy when discussing tracking data.
- Speech: normal rate, rhythm, prosody. More fluent than prior session.
- Mood: "good." Engaged.
- Affect: congruent, full range, briefly self-deprecating but quickly recovered. Lighter than prior session.
- Thought process: linear, goal-directed. Capable of stepwise logical analysis (broke catastrophic sequence into discrete components and tested each against evidence).
- Thought content: no SI, no HI, no perceptual disturbance. Worry content narrowed today: focused on dog-proximate property damage. Identified historical roots (paternal financial-reactivity pattern) of the broader catastrophic cognition.
- Cognition: alert, oriented x4.
- Insight: good to very good. Patient identified her own catastrophic sequence as disproportionate to base rates with minimal prompting.
- Judgment: good. Appropriately calibrated which exposure-hierarchy items to attempt this week and which to defer.
Risk assessment
SI/HI denied. No plan, no intent, no means. Risk factors unchanged. Generalized anxiety with newly identified specific-phobia component, parental psychiatric history. Protective factors: demonstrated capacity to complete between-session work, generate clinically useful self-data, engage actively in cognitive-behavioral intervention. Insight notably improved over S5. Stable marriage, housing, employment. Risk level: low.
Therapeutic interventions used
Cognitive-behavioral therapy used today, transitioning from the MI-informed groundwork of prior sessions now that the patient's ambivalence had resolved and she presented with a concrete identifiable target. Specific techniques deployed:
- Socratic questioning to challenge automatic catastrophic appraisals ("How often does Pip actually chew the couch?" "How often is he near the couch?")
- Probability estimation: collaborative calculation of base rate (~0.5%) and explicit comparison to patient's experienced subjective probability (~80%), illustrating the disproportion characteristic of anxious cognition
- Decatastrophizing: stepwise decomposition of the catastrophic chain (chew → replace → $5,000 → husband-anger → marital instability), each link tested against actual evidence
- Evidence-gathering: prompted patient to recall actual prior outcomes (sanded leg, ~$100 repair, no replacement, no marital conflict)
- Cognitive restructuring: helped patient identify that the $5,000 figure was fabricated under panic conditions and that the husband-anger component was a projection of paternal reactivity
- Brief identification of paternal-origin schema for later focused work; deliberately deferred to preserve session focus
- Behavioral exposure planning: collaboratively constructed a 3-item graded exposure hierarchy:
1. Dog in kitchen near trash, no removal action by patient (low intensity).
2. Dog on couch with throw blanket layered over upholstery (moderate).
3. Dog supervised on bed (high; reserved for week 3-4).
- Behavioral homework prescribed: items 1 and 2 for the coming week; item 3 explicitly deferred per principle of mastery before progression
- Cognitive coping skill assigned: "How often does the bad thing actually happen?" question to be self-administered at first sign of physiological arousal
Patient response to intervention
Active participant in the cognitive restructuring process. Generated key data points (base rate, actual repair cost, accurate appraisal of husband's behavior) without requiring extensive clinician prompting. Demonstrated metacognitive awareness consistent with reality-testing capacity that had previously been overridden by anxious arousal. Engaged substantively in exposure hierarchy construction and demonstrated appropriate calibration. Accepted homework and articulated a clear understanding of the cognitive coping prompt. Demonstrated insight into the paternal origin of one cognitive distortion (financial catastrophizing as inherited template), suggesting readiness for schema-level work in subsequent sessions.
Progress toward treatment goals
Significant progress observed today. Patient executed the self-tracking task assigned at S5, generating clinically useful data that substantively reformulated the case. Anxiety previously characterized as generalized and amorphous is now identified as a specific phobic response to dog-proximate property-damage scenarios with a co-occurring generalized component. Patient moved from precontemplation (S5) to active engagement in cognitive-behavioral treatment (S6). Working diagnosis updated today to add F40.218 (Other animal type phobia) given clarified phenomenology: discrete physiological arousal, avoidance pattern, duration ≥6 months, distress and functional impairment, not better accounted for by F41.1 alone. F41.1 retained as primary given persistent generalized worry pattern that exists independently of the dog stimulus.
Plan
- Continue weekly individual psychotherapy.
- Behavioral exposures: practice items 1 and 2 over the coming week. Item 3 explicitly deferred.
- Cognitive coping: self-administer "How often does the bad thing actually happen?" at onset of physiological arousal.
- Continue self-tracking via phone notes app with tighter scope: dog-proximate triggers, intensity, exposure attempts, response to coping prompt.
- Re-administer GAD-7 at next session for objective measure of trajectory.
- Future session focus: schema-level exploration of paternal financial-catastrophizing template (patient-initiated readiness signal today).
- Continue to defer pharmacotherapy. Symptoms appear responsive to psychotherapeutic intervention.
- No referrals indicated. No medication adjustments.
Medical necessity
Patient continues to meet F41.1 criteria with persistent generalized worry across multiple life domains, hypervigilance pattern, and functional impairment. Today's session formalized the addition of F40.218 (Other animal type phobia) given identification of a discrete physiological arousal response to specific stimuli, avoidance behavior, duration consistent with phobia criteria, and functional impairment distinct from the generalized presentation. Today's intervention employed evidence-based cognitive-behavioral techniques (cognitive restructuring, graded exposure planning) that are first-line for both diagnoses. Continued weekly outpatient psychotherapy at the 90834 level is medically necessary to consolidate today's gains, implement and titrate the exposure hierarchy, and prevent symptom escalation. Lower level of care not appropriate during active exposure work; higher level not indicated.
Session start 09:00, session end 09:45, total face-to-face 45 min. Electronically signed by L.S., LCSW. NPI [redacted]. License LCSW #[redacted].
Read full transcript
L.S.: Hi K. How are you?
K.M.: Hi. Good. I have notes.
L.S.: I love that. You have notes.
K.M.: I have a lot of notes. I, okay. I did the phone thing. I just put it in my notes app every time I felt the thing, I'd type a number and what was happening. And then I just scrolled through it last night.
L.S.: And what did you see?
K.M.: Okay. So. I thought it was going to be all over the place. Like, I thought it was going to be Slack and the dog and my husband and traffic, and just, everything. It's not. It's the dog. It's almost all the dog. There's a little bit of Slack. There's almost nothing else.
L.S.: Interesting.
K.M.: Yeah. And it's not even all dog stuff. It's a specific dog thing. It's when Pip is near my computer, or the rug, or the couch. Or when he moves fast through the kitchen. Then it's like, I get, my chest gets tight, my hands get cold. I can feel it in my body. I never noticed that before.
L.S.: You've located it. That's actually a big shift from where we were last time.
K.M.: Yeah. And I wasn't faking it last time. I really thought it was everything. It's just, when I actually paid attention, it wasn't.
L.S.: Tell me what goes through your head when Pip is near the couch.
K.M.: ...Okay. So. He has chewed on the couch before. Twice. We replaced the leg of one cushion, the wood part. So when he's near the couch I'm like, oh god he's gonna chew it. And then I get this whole movie. He chews the couch, we have to replace the couch, and the couch is, like, five thousand dollars, my husband is going to hit the roof, and we already, like, fought about him last month, and it's just gonna be this whole thing.
L.S.: So it goes from "Pip is near the couch" to a fight with your husband, in like, three seconds.
K.M.: Yeah. Pretty much instantly.
L.S.: How often does Pip actually chew the couch?
K.M.: ...He's chewed it twice in, like, six months.
L.S.: How often is he near the couch?
K.M.: I mean, every day. He sleeps on the couch.
L.S.: So if I do the math, of all the times he's been near the couch in six months, let's say twice a day, that's three hundred and sixty exposures, he's chewed it twice.
K.M.: ...Yeah.
L.S.: What's the rate?
K.M.: Like, half a percent.
L.S.: So your brain is throwing you a five-thousand-dollar couch and a husband fight at a half-percent event.
K.M.: When you put it that way it sounds insane.
L.S.: It's not insane. It's just disproportionate. Your brain is treating a 0.5% probability like it's an 80% probability.
K.M.: Yeah. That tracks.
L.S.: Okay. Let's slow this down. The chewing-the-couch movie has a few steps. He chews. We replace the couch. It costs five thousand. Your husband gets angry. The marriage is in trouble. Each one of those is a step. Let's actually look at them.
K.M.: Okay.
L.S.: He chews, we replace the couch. Is that for sure true?
K.M.: ...No. Like, the leg, we just sanded it down. It looked fine. We didn't replace anything.
L.S.: So even when he chewed before, you didn't have to replace the whole couch.
K.M.: No.
L.S.: It costs five thousand. Where does that number come from?
K.M.: I don't even know. I just panicked the first time and looked up couches like ours.
L.S.: How much was the chew repair?
K.M.: I think it was a hundred bucks at a furniture place.
L.S.: So we've gone from five thousand to a hundred bucks.
K.M.: Yeah.
L.S.: Your husband gets angry. Talk to me about that part.
K.M.: I mean, he, we did fight about Pip. But it wasn't really about the couch. It was more like, he didn't want to get a dog and now he feels like I dragged him into it. And he's actually way better with Pip than I am most of the time. He plays with him. He's the one who walks him in the morning.
L.S.: So the husband-anger story doesn't actually match the husband.
K.M.: ...No, that's wrong. Like, that's not him.
L.S.: Where's that fear coming from then?
K.M.: I think... I think that was my dad. My dad would lose it about money stuff. That's a recording from a long time ago, that I just play.
L.S.: Yeah. That's an old tape. That's probably worth a lot more attention later.
K.M.: Yeah.
L.S.: So when we add this up: probability is half a percent, the cost is wrong by a factor of fifty, and the husband-anger part is somebody else's husband. The couch story is, I'm being a little playful here, almost completely fabricated.
K.M.: God.
L.S.: I want to do something with you. Two things, actually. One is just an exercise. Next time you feel that chest tightness, can you stop and ask yourself one question: how often does the bad thing actually happen? Just that one question.
K.M.: Yeah, I can do that.
L.S.: That's the cognitive piece. The other piece is harder. Your body has a real response to Pip moving fast. The cold hands, the tight chest. That's not a thinking problem. That's, like, you've trained yourself to startle around him.
K.M.: Yeah. I have.
L.S.: I want to start working on un-training that. What I'd suggest is something we'd build over a few weeks. We'd start small. You sit on the floor, you have a high-value treat, Pip walks past you. You don't move, you don't react. You give him the treat. We'd do it deliberately. Scheduled.
K.M.: Like, training me, not training him.
L.S.: Bingo.
K.M.: That makes sense.
L.S.: We'd build a list together. Easiest version, most challenging version. We climb the list. Each one, we do it until it stops being a thing.
K.M.: Yeah.
L.S.: Let's start small, today, and just brainstorm. What's the lowest-stakes Pip-near-stuff scenario you could put yourself in this week.
K.M.: Um. Okay. He's allowed in the kitchen but I freak out when he's near the trash. Maybe I just leave him in the kitchen with me and don't move him.
L.S.: Perfect. That's number one.
K.M.: Okay. And then on the couch, but with the new throw blanket on it, so I'm not as worried about the upholstery.
L.S.: Two.
K.M.: And then the bed. He's not allowed on the bed. We could do, like, supervised on the bed.
L.S.: Three. Now, only do one and two this week. The bed's a bigger one, we'll save it for week three or four when one and two are easy.
K.M.: Got it.
L.S.: When the chest tightness comes up during one and two, I want you to do the same question we just did with the couch. How often does the bad thing actually happen.
K.M.: Yeah. Okay.
L.S.: How are you feeling about all this?
K.M.: I feel like I have something to do, which is good. And I feel a little embarrassed about the couch math.
L.S.: Don't be. The math is what brains do under threat. We'd have all stacked the deck the same way.
K.M.: Yeah. Okay.
L.S.: One more thing. The dad piece. The old recording. We're going to come back to that. That's a big one and it deserves real time. Not today.
K.M.: Okay, yeah.
L.S.: Alright, I'll put us on for next week, same time. You're going to do the kitchen and the couch exposures, and you're going to ask the "how often does the bad thing happen" question every time the chest tightness comes up.
K.M.: Got it.
L.S.: Good work today, K.
K.M.: Thanks. Yeah.