{\rtf1{\info{\title CBT Made Simple}{\author Nina Josefowitz & David

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}}

\par\pard\plain\hyphpar} \par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page } {

{\i
{\qc
\u8220?Josefowitz and Myran have written a tremendously useful and practical book
for new and seasoned practitioners alike. CBT Made Simple is accessible, engaging,
and provides a wealth of clinical examples, resources, and applications that will
be turned to time and time again. The authors\u8217? experience and wisdom shines
through in providing guidance to help the reader apply cognitive behavioral therapy
(CBT) not only to their clients, but to learn through applications on themselves.
Each chapter follows the structure of a CBT session, and guides the reader through
learning in the same way that they will teach their clients. CBT is made simple
through this elegantly written
book!\u8221?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar
} {
{\qc
{\b
\u8212?Deborah Dobson, PhD, RPsych}, adjunct professor in the department of
psychology at the University of Calgary, and coauthor of {\i
Evidence-Based Practice of Cognitive-Behavioral Therapy}; and {\b
Keith} {\b
Dobson, PhD, RPsych}, professor of clinical psychology at the University of
Calgary, and editor of {\i
Handbook} {\i
of} {\i
Cognitive-Behavioral Therapies}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\i
{\qc
\u8220?This book provides a clear and structured approach to learning and
practicing CBT. Nina and David have incorporated active learning strategies, visual
and auditory techniques, and lots of opportunities to practice new skills. In
addition, a wealth of resources is available online to supplement the text. This
book is an invaluable resource for therapists learning CBT for the first time, and
for those more experienced who need a refresher in the core principles and
practices of
CBT.\u8221?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\qc
{\b
\u8212?Enid Grant MSW, RSW}, senior director of Children\u8217?s Mental Health at
Skylark Children, Youth & Families\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\i
{\qc
\u8220?Josefowitz and Myran\u8217?s innovative approach to teaching CBT skills
engages the reader in a way that I haven\u8217?t seen in previous books on the
topic. Each chapter of the book is organized like a CBT session\u8212?setting an
agenda, presenting experiential exercises, and assigning homework. The book
describes CBT in a step-by-step, accessible way that is sure to be helpful for both
new therapists and seasoned clinicians wanting to brush up on their skills. I
highly recommend CBT Made
Simple!\u8221?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphp
ar} {
{\qc
{\b
\u8212?Martin M. Antony, PhD}, professor of psychology at Ryerson University, and
coauthor of {\i
The} {\i
Shyness} {\i
and} {\i
Social} {\i
Anxiety} {\i
Workbook} and {\i
The} {\i
Anti-Anxiety Workbook}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\i
{\qc
\u8220?This is a program hidden in a book, which encourages an experiential
approach to CBT learning. With the additional web resources (videos, handouts) it
will thoroughly engage CBT learners and teachers. A \u8216?must-have\u8217? text in
the era of expanding CBT
practice\u8221?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyph
par} {
{\qc
{\b
\u8212?} {\b
Sanjay} {\b
Rao, MD}, clinical director of the Mood and Anxiety Program at Royal Ottawa Mental
Health Centre, associate professor of psychiatry at the University of Ottawa, and
executive member of the Canadian Association of Cognitive Behavioural
Therapies\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\i
{\qc
\u8220?Much has been written on CBT. Still there is a need\u8212?indeed a
hunger\u8212?for a clear and practical how-to book. This volume fills that need
remarkably well. Its pragmatic, skill-based, experiential approach will be
extremely helpful especially for clinicians new to CBT for whom it is intended.
However, clinicians with all levels of sophistication and experience will find much
to deepen their knowledge and
practice.\u8221?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyp
hpar} {
{\qc
{\b
\u8212?Michael Rosenbluth, MD, FRCPC}, chief of the department of psychiatry at
Toronto East General Hospital, and associate professor at the University of
Toronto\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\i
{\qc
\u8220?CBT Made Simple offers an innovative, cutting-edge method of understanding
and using CBT using the effective adult learning model. This unique and practical
resource will be of great help to clinicians who are new to CBT, as well as those
who\u8217?ve been practicing for years. I highly recommend this
book!\u8221?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar
} {
{\qc
\u8212?{\b
Matthew} {\b
McKay, PhD}, psychologist and coauthor of several books, including {\i
The} {\i
CBT} {\i
Anxiety} {\i
Solution} {\i
Workbook}, {\i
Thoughts} {\i
and} {\i
Feelings}, and {\i
Self-Esteem}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc

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}}

\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Publisher\u8217?s Note\par\pard\plain\hyphpar} {
{\i
This publication is designed to provide accurate and authoritative information in
regard to the subject matter covered. It is sold with the understanding that the
publisher is not engaged in rendering psychological, financial, legal, or other
professional services. If expert assistance or counseling is needed, the services
of a competent professional should be sought.}\par\pard\plain\hyphpar} {
Distributed in Canada by Raincoast Books\par\pard\plain\hyphpar} {
Copyright \u169? 2017 by Nina Josefowitz and David Myran\par\pard\plain\hyphpar} {
New Harbinger Publications, Inc.\par\pard\plain\hyphpar} {\s2 \afs28
{\qc
5674 Shattuck Avenue\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Oakland, CA 94609\par\pard\plain\hyphpar} {
www.newharbinger.com\par\pard\plain\hyphpar} {
Cover design by Amy Shoup\par\pard\plain\hyphpar} {
Acquired by Elizabeth Hollis Hansen\par\pard\plain\hyphpar} {
Edited by Rona Bernstein\par\pard\plain\hyphpar} {
Indexed by James Minkin\par\pard\plain\hyphpar} {
All Rights Reserved\par\pard\plain\hyphpar} {
{\qc
Library of Congress Cataloging-in-Publication Data on
file\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
We would like to dedicate this book with love to our children, Laura, Aaron, and
Daniel, who have grown into caring, capable, and wonderful
adults.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
We would also like to dedicate this book to the memory of Paul Josefowitz and his
unending curiosity.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
Contents\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Foreword
vii\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Introduction
1\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Part 1: CBT
Foundation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\b
{\ql
1. Use CBT Theory to Understand Your Clients
6\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
2. Focus on Your Clients\u8217? Problems and Strengths
25\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
3. Develop Goals for Therapy
46\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
4. Structure Your Sessions
60\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Part 2: Understand Your Clients\u8217?
Problems\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
5. Identify Your Clients\u8217? Feelings, Physical Reactions, and Behaviors
82\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
6. My Clients Have So Many Thoughts\u8212?Which Do I Focus On?
104\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
7. Identify Your Clients\u8217? Thoughts
122\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Part 3: Cognitive and Behavioral
Interventions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpa
r} {
{\b
{\ql
8. Look for Evidence and Create Balanced Thoughts
146\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
9. Problem Solving\u8212?Finding a Better Way
173\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
10. Behavioral Activation\u8212?Action Plans for Depression
196\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
11. Exposure Therapy\u8212?Clients Face Their Fears
222\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Part 4: CBT in
Action\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
12. Suzanne\u8217?s and Raoul\u8217?s Therapy
246\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Acknowledgments
260\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
Appendix: Answers to YOUR TURN! Exercises
261\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
{\ql
References
277\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
Foreword\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It is fair to say that cognitive behavioral therapy (CBT) has undergone a
tremendous evolution over the past twenty-five years. Some of these changes, such
as moving from a five-column to a seven-column thought record, have been triggered
by internal innovations and have helped extend CBT\u8217?s relevance to disorders
falling outside the orbit of its initial validation for depression and anxiety.
Other modifications, such as focusing on strengths and balancing acceptance and
change, have come in response to external challenges from other therapy models.
With all this movement in the field it can be difficult for therapists to return to
the basic elements of this approach in a way that is shorn of trends and niche
applications. On this point, in fact, I am frequently approached by trainees who
are interested in learning about mindfulness-based cognitive therapy. When I ask
them about their CBT background, they say it is minimal and they don\u8217?t see
much need for it. The impression I have is that they are eager to leapfrog past the
CBT essentials in order to get to the work they find more interesting. They tend to
be surprised at my response, which often runs counter to their wishes and stresses
that one can\u8217?t get very far in learning new CBT variants when the basic model
is only weakly understood.\par\pard\plain\hyphpar} {
{\i
CBT Made Simple} does an enviable job in providing just this type of clinically
pragmatic and skill-based grounding in CBT theory and interventions. Stemming from
Nina Josefowitz and David Myran\u8217?s two-decade-long careers as cognitive
therapists, teachers, supervisors, and academics, this book exemplifies the best
qualities of user-friendly, explicit guidance that offers valuable insights into
the nuts and bolts of CBT to all levels of learners.\par\pard\plain\hyphpar} {
For example, the decision to write this book with a structure that coheres to an
actual therapy session is highly innovative. Agendas are set, homework is assigned
and reviewed, and learning covers specific skill sets that are relevant to the
material being covered. Here we see CBT at its finest. Rather than imparting this
information in a purely theoretical manner, {\i
CBT Made Simple} invites the reader to learn through doing.\par\pard\plain\hyphpar}
{
Nina and David rightly argue that it is only through the experiential immersion in
CBT principles and interventions that the reader will optimize their book\u8217?s
value. How much more can be learned from giving yourself a homework assignment and
monitoring its performance or even nonperformance? Or scheduling your activities in
a typical day and noticing whether life permits them to be achieved in their
predetermined order? This approach, to my mind, is what separates {\i
CBT Made Simple} from many other books touching on the same theme. It also shows
how one of the metaconcepts in CBT, guided discovery, can be brought to bear on all
aspects of therapeutic learning, whether inside or outside the actual therapy
session. Readers who agree to take the plunge and work with the book in this manner
will not be disappointed.\par\pard\plain\hyphpar} {
{\i
CBT Made Simple} is divided into parts that follow the different phases of CBT work
and emphasize important formulation principles along with ongoing assessment in
order to ensure that the most appropriate techniques are being employed. The early
chapters focus on identifying client strengths and problem complaints as well as
setting therapy goals. The reader then moves on to unpacking and helping clients
regulate emotionally evocative situations through seeing the interplay of thoughts,
feelings, physical sensations, and behavior. Problem solving and action plans
follow, along with the specific application of exposure and activation exercises.
The writing is very accessible and the numerous graphics and interactive forms used
ensure that the reader is engaged, present, and invited to use these empirically
supported interventions to enhance emotional and cognitive well-being. This may be
a tall order for any book to fill, but {\i
CBT Made Simple} has filled it in an exemplary manner.\par\pard\plain\hyphpar} {
{\qc
\u8212?Zindel SegalProfessor of Psychology, University of Toronto Co-founder,
Mindfulness-Based Cognitive Therapy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
Introduction\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Hello, I am Nina Josefowitz. I have been a psychologist, cognitive behavioral
therapist, and teacher for over twenty-five years. My partner in writing this book
is David Myran, a psychiatrist who has also practiced and taught cognitive
behavioral therapy (CBT) for over twenty-five years. We hope this book will help
you start to use CBT in your own therapy practice as well as your own life. While
we have written the book together, we decided to mainly use my writing style, and
therefore the book is written from the singular first person point of
view.\par\pard\plain\hyphpar} {
Let\u8217?s begin with defining CBT. CBT is an evidence-based approach to
understanding and treating psychological problems. It is a structured, active form
of therapy in which the client\u8217?s goals are set in the beginning and are
addressed throughout therapy. CBT is based on four fundamental
principles:\par\pard\plain\hyphpar} {
How people understand the world, or how they think, influences how they feel, their
physical reactions, and how they behave. This means that clients\u8217? problems
can be understood in terms of how their thoughts, feelings, physical reactions, and
behavior interact and maintain their problems.\par\pard\plain\hyphpar} {
Clients can learn to become aware of their thoughts, and CBT interventions can help
clients change their thoughts.\par\pard\plain\hyphpar} {
When clients change how they think, their feelings, physical reactions, and
behaviors will also change.\par\pard\plain\hyphpar} {
Because thoughts, feelings, physical reactions, and behaviors are interrelated,
when clients change their behaviors, this will also impact their thoughts,
feelings, and physical reactions.\par\pard\plain\hyphpar} {
CBT was first developed in the 1970s as a treatment for depression (Beck, 1970;
Beck, Rush, Shaw, & Emery, 1979). At the time, I was a young graduate student at
the University of Toronto, just learning how to be a therapist. The dominant
therapeutic orientations were Rogerian, gestalt, and psychodynamic. The focused
structure of CBT, combined with actively addressing thoughts, was a completely
novel and very exciting approach.\par\pard\plain\hyphpar} {
I can remember the moment I became a committed CBT therapist. I was about to apply
for my first practicum in graduate school. Try to imagine: I am sitting on the bus
on the way to the interview, feeling anxious. For some reason, the bus stops for
twenty minutes. I realize that I am going to be late and that there is absolutely
nothing I can do (at that time there were no cell phones). My anxiety rises.
Then\u8230?I remember my CBT class from the previous day. I take a deep breath and
ask myself, {\i
What am I thinking?} Well, my thoughts are {\i
I will be late; my career is ruined! I will never get a practicum placement,} {\i
and I will fail graduate school}. I start to laugh at myself. Even in my highly
anxious state, I knew I was catastrophizing. That was the moment I became a CBT
therapist.\par\pard\plain\hyphpar} {
In the past fifty years, hundreds of studies have examined both the underlying
theory as well as the effectiveness of CBT for children and adults of all ages
(Beck & Dozois, 2011). Let me give you an idea of the extensiveness of the
research. Hofmann, Asnaani, Vonk, Sawyer, and Fang (2012) examined meta-analyses of
the effectiveness of CBT. They found that while the research is stronger for some
disorders than others, generally CBT has been found to be an effective therapy
compared with a placebo or waiting list control group for a great variety of
problems, including depression, bipolar disorder, anxiety disorders, abuse of
alcohol and drugs, schizophrenia, eating disorders, insomnia, personality
disorders, anger and aggression, criminal behaviors, general stress, distress due
to a variety of medical conditions, and chronic pain.\par\pard\plain\hyphpar}
{\s2 \afs28
{\b
{\qc
How This Book Is
Organized\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
You can think of therapy as similar to constructing a building; you need to start
with a solid foundation. In part 1 we are going to learn how to lay the foundation
of CBT. A good foundation consists of obtaining a clear sense of your client\u8217?
s problems and goals, explaining CBT to your client, and starting to use a
structured format. You want a foundation that is waterproof, that will stand up to
storms and support a heavy building, which means that even if your client is very
distressed and goes through hard times, the early work you do in laying down the
foundation will serve you and your client well.\par\pard\plain\hyphpar} {
The next step is putting up the scaffolding. Without a good framework, you
can\u8217?t put up the walls and windows. In part 2 you will learn to identify your
clients\u8217? feelings, physical reactions, behaviors, and thoughts and create a
four-factor model that will provide the framework for understanding your
clients\u8217? problems.\par\pard\plain\hyphpar} {
The final stage in building a house involves putting up the walls, windows, and
doors. Good contractors take their time; they know that the building needs a solid
structure. The same is true in CBT. Part 3 covers cognitive and behavioral
interventions. We will focus on a variety of cognitive interventions, including
examining the evidence for negative thoughts, helping clients take a new
perspective, and developing balanced or alternative thoughts. We will also cover
three behavioral interventions: problem solving, behavioral activation, and
exposure therapy.\par\pard\plain\hyphpar} {
Finally, in part 4 we look at the complete house. We bring CBT to life with an
overview of CBT for two hypothetical clients we will follow throughout the book,
Suzanne and Raoul. This final section also delves into core beliefs and their
importance in CBT. As you work through the book and start to master CBT concepts
and skills, you will be laying a solid foundation you can draw upon to help your
clients achieve their goals and solve the problems that brought them into
therapy.\par\pard\plain\hyphpar} {
CBT theory and interventions are relevant to people of all ethnic backgrounds,
sexual orientations, cultures, and religions. Throughout the book I have tried to
refer to \u8220?partners\u8221? rather than specify the gender of the partner to
ensure that heterosexuality is not assumed. In my own practice I never assume a
client\u8217?s sexual orientation without first checking. Also, when I refer to
hypothetical clients in the book, I alternate the client\u8217?s gender with each
chapter. For simplicity\u8217?s sake, the therapist is always
female.\par\pard\plain\hyphpar} {
CBT sessions follow a specific structure, so I thought it would be helpful if the
structure of each chapter in this book mimicked the structure of an actual therapy
session. Each chapter begins with a check-in and review of the homework from the
previous chapter and then sets the agenda, which outlines the main focus of the
chapter. We then work through the agenda, learning the specific skills covered in
the chapter. At the end of each chapter I assign homework, and you are given an
opportunity to review what you have learned. My hope is that the structure of the
chapters will give you a sense of what a structured CBT session is
like.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
How People Learn\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The research is clear: to learn a new skill, you not only need new information, but
you also need active strategies to help you remember and practice the material you
learn (O\u8217?Brien et al., 2001). The challenge is how to incorporate active
learning into a book.\par\pard\plain\hyphpar} {
First, if you want to remember something, you need to regularly review. The review
can be quick; even spending a minute or two will make a difference. At the end of
every chapter is a review section, where you will have a chance to think about what
was important to you. In addition, I start every chapter with a quick review of the
preceding chapter.\par\pard\plain\hyphpar} {
Second, research also indicates that actively answering questions and testing
yourself helps you remember (Roediger & Karpicke, 2006). At the end of each chapter
is a list of the main topics we have covered, and after each topic is a question.
Try to answer the questions. If you are unsure of the answers, then go back to that
section of the chapter.\par\pard\plain\hyphpar} {
Third, it is hard to remember what you learned unless you apply the material and
practice. The data is very clear: the more you practice, the better you get. There
is simply no getting around it\u8212?if you want to learn a new therapy skill, you
need to practice. Throughout the text I have included exercises that I call YOUR
TURN! They are an opportunity for you to practice the concept we have just covered.
The answers to the YOUR TURN! exercises are in the appendix. You can download
additional exercises at http://www.newharbinger.com/38501 (see below). Finally, at
the end of each chapter I have suggested homework for you to complete before moving
on to the next chapter. This is an opportunity for you to bring CBT into your own
therapy practice. I think you will enjoy doing the various
exercises.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
CBT and You\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Over the years I have found that applying CBT to my own life has not only helped me
cope better with various situations, but has also enhanced my CBT skills. Recent
research supports my experience that when we apply CBT to ourselves, we become
better CBT therapists (Bennett-Levy & Lee, 2014). Throughout the book I have
exercises where I ask you to apply CBT to your own life. Try them; I think you will
find them helpful.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Online Materials\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In addition to all of the content in this book, there is a wealth of reproducible
supplemental material available for you to download at New Harbinger\u8217?s
companion website, http://www.newharbinger.com/38501.\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Handouts.} On the website, you will find handouts that you can use with your
clients, including worksheets and lists of helpful
questions.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Exercises.} These are opportunities for extra practice and for delving into
concepts at a more complex level. These exercises are clearly marked in the book
with the icon shown here.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Audio files.} You can find audio files, including the YOUR TURN! Practice in Your
Imagination exercises, which are marked with the icon shown
here.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Video clips.} Starting in chapter 2, I have short video clips where I demonstrate
the skill we have just covered. They are marked with the icon shown here. We will
follow two clients, Charlotte and John, who are a combination of many of my clients
over the years. Before watching the video clips, please go to
http://www.newharbinger.com/38501 and download the short written overview,
Charlotte\u8217?s and John\u8217?s Psychosocial Histories and Presenting
Problems{\i
.}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Conclusion\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
Throughout our careers, David and I have remained enthusiastic about CBT\u8217?s
capacity to help clients make practical, helpful changes in their lives. We have
found that practicing CBT is often fun and engaging as clients start to make real
changes. If you are new to CBT, we think this book will give you a solid start; if
you have been practicing CBT for a while, we think this book will help you increase
your effectiveness. This book demonstrates how David and I do therapy. All
therapists have their own style, and there is clearly no one right way to practice
CBT. As you read over the sample dialogues, see if there are ways that we practice
that you would like to incorporate into your own therapy
style.\par\pard\plain\hyphpar} {
One last word before you start reading the first chapter: do try the exercises. The
reality is if you want to learn something new, you have to
practice!\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
Part 1\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
CBT Foundation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }
{\page } {\s1 \afs32
{\qc
Chapter 1\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Use CBT Theory to Understand Your
Clients\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s get started with laying our foundation. In this chapter, you\u8217?ll
learn the basics of CBT and will have the opportunity to put your knowledge into
practice with hypothetical clients, your own clients, and
yourself.\par\pard\plain\hyphpar} {
At the beginning of each chapter, we will do a check-in and review. This is also
the first step in a CBT session. It is an opportunity for you to reflect on how you
have used CBT in your clinical practice and in your own life, as well as to think
about the previous chapter\u8217?s homework. Since this is the first chapter, there
is no homework to review. However, before you start reading the next section, take
a moment and pay attention to your thoughts and feelings about starting to learn
CBT. Try to separate your thoughts from your feelings. Did you learn anything from
this simple exercise?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The second step in a CBT session is to set the agenda for the session, or specify
the topics you will be addressing. In this chapter, we are going to start to use
CBT to understand clients\u8217? problems. I have four agenda items that are
related to learning basic CBT theory.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} CBT building blocks: thoughts, feelings, physical reactions, and
behavior\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} How thoughts maintain problems\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} How behaviors maintain problems\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} How core beliefs influence thoughts\par\pard\plain\hyphpar}
{\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The third step in a CBT session is to work the agenda, or address your
clients\u8217? problems; in our case, this means learning the information and
skills related to each agenda item.\par\pard\plain\hyphpar} {
Clients come to you with a variety of problems. They may be depressed; they may be
using drugs or drinking too much; they may be feeling anxious; or they may be
unhappy for a variety of reasons and want to find a way to make their lives better.
When a client first comes into my office, two main questions go through my mind.
First, how can I help my client understand his problems in a way that makes sense
to him and helps him feel hopeful? Second, how can I understand my client\u8217?s
problems in a way that leads to helpful interventions? To answer these questions,
you need a good theory\u8212?one that is extremely practical and helps both you and
your client understand the factors that caused his problems, and that are currently
maintaining his problems. A good theory also leads to effective interventions that
make sense to the client. So, before we start with how to \u8220?do\u8221? CBT, it
is important to understand the underlying theory of CBT.\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #1{\i
: CBT Building Blocks: Thoughts, Feelings, Physical Reactions, and
Behavior}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
When we are upset, our reactions can feel overwhelming. It can be hard to figure
out what is making us upset, and we often blame the situation. Imagine a client
named Rose. She is twenty-five years old, lives at home, and has just finished
college. She is trying to find a job and has applied for a number of different
positions. Yesterday Rose received another rejection letter. She sat in her room
all night, feeling very depressed, surfing the Internet, and crying. The next day,
Rose tells her therapist that she is depressed because she didn\u8217?t get the
job. It is natural that Rose is upset and, of course, if she had gotten the job she
would be feeling differently. You can think of Rose\u8217?s reaction to the
rejection letter as a big jumble of thoughts, feelings, physical reactions, and
behaviors, all crammed into a heavy backpack that she lugs around. You are going to
help her unpack the backpack. She will open the backpack and sort out her thoughts,
feelings, physical reactions, and behaviors separately. I call this the four-factor
model. The four-factor model provides a structure that you and your clients can use
to understand the factors that are maintaining their problems. When clients have a
structure for understanding their reactions, they often start to feel less
overwhelmed and believe change is more possible.\par\pard\plain\hyphpar} {
Once unpacked, the backpack is lighter. When her feelings, physical reactions,
behaviors, and thoughts are on the floor in neat piles, Rose can start to think
about what she wants to keep for the journey, what she wants to change, and what
she no longer needs to lug around. I can almost hear her say, \u8220?Whew\u8212?
what a relief!\u8221?\par\pard\plain\hyphpar} {
Let\u8217?s see what happens when we unpack her backpack and sort Rose\u8217?s
reaction into the four factors.\par\pard\plain\hyphpar} {
{\i
Situation:} Another rejection letter\par\pard\plain\hyphpar} {
{\i
Rose\u8217?s Thoughts:} I will never get a job, I am such a
failure.\par\pard\plain\hyphpar} {
{\i
Rose\u8217?s Feelings:} Depressed and hopeless.\par\pard\plain\hyphpar} {
{\i
Rose\u8217?s Physical Reactions:} Stomach hurts and is
exhausted.\par\pard\plain\hyphpar} {
{\i
Rose\u8217?s Behavior:} She stayed in her bedroom, surfed the Internet, and cried.
Rose skipped her gym class the next morning because she slept in. She did not
bother applying for another job that was advertised in the paper the next
day.\par\pard\plain\hyphpar} {
As you and Rose sort out her reaction using the four-factor model, her reaction
begins to make more sense to her and is less of an overwhelming
jumble.\par\pard\plain\hyphpar} {
Padesky and Mooney (1990) include a fifth factor\u8212?the environment\u8212?in
their model of how the factors influence each other, as shown in figure
1.1.\par\pard\plain\hyphpar} {
{\i
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}}

Figure 1.1. Five-part model to understand life

experiences.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar
} {
When you look at figure 1.1, you see how change in one of the four factors
influences change in the other three areas. Once we have a model for understanding
our clients\u8217? reactions, we can start to think about how to change their
reactions so that they are less upset and can cope better. The four-factor model
also makes sense to clients; they can start to use it immediately to understand
their distress.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What Is a Situation?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The four-factor model separates thoughts, feelings, physical reactions, and
behavior from the situation. The situation is what actually occurred, or the
objective reality without any interpretation. For example, an upcoming test is a
situation; a \u8220?hard\u8221? upcoming test is a situation and an
interpretation\u8212?the interpretation is that the test will be hard. Let\u8217?s
take another example of a situation: your client tells you that a kid at school
approached him in the hallway and said, \u8220?You\u8217?re ugly.\u8221? This is a
situation. If your client adds, \u8220?That kid is mean and trying to show
off,\u8221? this is your client\u8217?s interpretation.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
What Is the Difference Between Feelings and
Thoughts?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the four-factor model, you want to separate feelings from thoughts. This seems
like a fairly easy task, but in our everyday language, we tend to confuse thoughts
and feelings. For example, we say, \u8220?I {\i
feel} like he doesn\u8217?t like me,\u8221? when what we really mean is, \u8220?I
{\i
think} he doesn\u8217?t like me.\u8221? Because of our tendency to confuse thoughts
and feelings, one of the hardest skills to learn in CBT is differentiating the two.
For starters, feelings are usually one word, such as sad, mad, happy, worried,
embarrassed, anxious, and excited, whereas thoughts generally come in the form of
sentences or phrases.\par\pard\plain\hyphpar} {
In CBT we refer to the thoughts we have in specific situations as automatic
thoughts. Our automatic thoughts happen very quickly and are just below a conscious
level of awareness. Thoughts are based on what a situation means to us, or our
interpretation. For example, a man approaches you on the street and asks for
directions. If your initial thought is {\i
He is part of a pickpocket scam}, you will also think, {\i
He\u8217?s dangerous; I want to get away}. However, if your initial thought is {\i
He\u8217?s a tourist}, you may also think, {\i
How can I help him? I want to be friendly}.\par\pard\plain\hyphpar} {
Automatic thoughts are words or images that go through our head. Many of our
automatic thoughts are about very ordinary things, such as {\i
I wonder if it will rain today?} or, as you leave the house, {\i
Do I have my shopping list?} We don\u8217?t have strong emotional reactions to
these kinds of thoughts, and in CBT we usually don\u8217?t pay much attention to
them. In CBT, we are more interested in thoughts that are connected to strong
negative feelings as well as those that are judgments about ourselves, others, or
the future. For example, a thought about oneself might be {\i
I am stupid}, while a thought about others might be {\i
My mother is inconsiderate}, and a thought about the future might be {\i
Everyone will laugh at me}. These thoughts are usually just below your awareness,
but if you ask yourself, {\i
What was I thinking?} you can usually identify them.\par\pard\plain\hyphpar} {
Automatic thoughts are spontaneous and rapid; we have a lot of them, and they come
and go so quickly that we often don\u8217?t notice them. However, once we notice
our thoughts, we can start to examine them, and in the process begin to change
them. Once we change our thoughts, our feelings and behaviors also
change.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What Is the Difference Between Feelings and Physical
Reactions?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Physical reactions are changes in your body (e.g., sweating, tingling, or tension).
Strong feelings are accompanied by physical reactions, and it is often hard to
separate out a feeling from how your body is reacting. For instance, when you feel
anxious your body may become tense, your heart may beat more quickly, and you may
sweat. People can have the same feelings but different physical reactions.
Individuals also differ in the intensity of their physical reactions. It can be
very helpful to ask about your client\u8217?s specific physical reactions and their
intensity. Some people are aware of their physical reactions but are unaware of how
they are feeling. For these clients, identifying physical reactions can be a good
place to start understanding feelings.\par\pard\plain\hyphpar} {
People can also have thoughts about their physical reactions. For example, if you
blush, does this just mean your cheeks are flushed or does blushing mean you are
making a fool of yourself and that others will make fun of
you?\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What About Behavior?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Behavior is what we do (e.g., sit, talk to a child, give a presentation). It is
helpful to identify behavior as a separate factor so you can start to explore how
the other three factors influence your client\u8217?s behavior and also look at the
consequences of your client\u8217?s behavior. When we look at symptom maintenance
cycles later in the chapter, we will focus on how a client\u8217?s behavior can
maintain his symptoms.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Identify Situations, Thoughts, Feelings, Physical Reactions, and
Behavior\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Throughout this book you will come across YOUR TURN! exercises. This is an
opportunity to practice what you just learned. I think you will find them
interesting! Try this first one.\par\pard\plain\hyphpar} {
Look over the following examples and see if you can identify whether they are
situations, thoughts, feelings, physical reactions, or behaviors. You can find my
answers in the appendix.\par\pard\plain\hyphpar} {\b
{\qc
Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior}} {\b
Situation, Thought, Feeling, Physical Reaction, or Behavior?} {
Staying up late and studying\par\pard\plain\hyphpar} {
No matter what I do, no one likes me.\par\pard\plain\hyphpar} {
I feel tense all over.\par\pard\plain\hyphpar} {
Even if I study hard, I will still fail.\par\pard\plain\hyphpar} {
I am so happy.\par\pard\plain\hyphpar} {
My boss hates my work.\par\pard\plain\hyphpar} {
I am late for work.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #2{\i
: How Thoughts Maintain Problems}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
We\u8217?ve talked about the importance of sorting out your client\u8217?s
reactions using the four factors: thoughts, feelings, physical reactions, and
behavior. We now want to use the four-factor model to understand what is
maintaining your clients\u8217? problems. Let\u8217?s start with understanding the
role of thoughts.\par\pard\plain\hyphpar} {
Our thoughts, or our interpretation of the situation, lead to our feelings,
physical reactions, and behavior. For example, when Rose received the rejection
letter, she thought, {\i
I will never get a job, I am such a failure}. If these are her thoughts, it makes
sense that she feels depressed and hopeless. However, if she had thought {\i
I will try again, something else will come along}, she would have felt neutral or
mildly hopeful. Different thoughts lead to very different feelings, physical
reactions, and behavior. Look at figure 1.2. We start with a specific situation;
our immediate understanding of the situation leads to our thoughts, which lead to
our feelings, physical reactions, and behavior. For the moment we are going to put
feelings and physical reactions in the same box, as they are so closely
related.\par\pard\plain\hyphpar} {
{\i
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}}

Figure 1.2. Our thoughts influence our feelings, physical reactions, and
behavior.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s start with looking at an example of how thoughts influence feelings,
physical reactions, and behavior in everyday life. I have a very cute, little black
dog called Shadey. Despite my best efforts, he barks furiously every time I come
home. I don\u8217?t pay much attention to his barking; I think, {\i
He\u8217?ll stop in a minute. He is so cute}. Even though he barks, I am happy to
see him and give him a pat. Meanwhile, Alicia, a good friend of mine, has started
coming over for a morning walk. Alicia rings the bell, Shadey barks, and Alicia
thinks, {\i
He\u8217?ll jump on me and get me dirty. Dogs are unpredictable}. Alicia feels
slightly anxious, a bit physically tense, and not very happy to see Shadey. As a
result, she tries to avoid Shadey. Figure 1.3 shows how Alicia\u8217?s and my
different thoughts can lead to very different feelings and
behavior.\par\pard\plain\hyphpar} {
{\i
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}}

Figure 1.3. Shadey the dog

barks.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
YOUR TURN!How Thoughts Influence Feelings and
Behavior\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Two friends, Maria and Jane, work in the same company. They are both going to a
conference, where they won\u8217?t know anyone. Maria is anxious and dreading the
conference. When she imagines going, she thinks, {\i
This will be awful. No one will talk to me. Everyone will think I\u8217?m stupid},
and she gets a sick feeling in her stomach. Jane meanwhile thinks, {\i
This is a good opportunity to network and meet new people. It will be fun to have
something different to do}. She is excited, full of energy, and can\u8217?t wait
for the conference to begin. When we examine their thoughts, we can begin to
understand why their reactions are so different.\par\pard\plain\hyphpar} {
When they get to the conference, Maria sits down in a corner of the room by
herself, while Jane mingles with the other attendees. Complete figure 1.4 to see
how Maria\u8217?s and Jane\u8217?s different thoughts in the same situation led to
very different paths with different feelings, physical reactions, and behavior. You
can check your answers in the appendix.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

Figure 1.4. Maria and Jane attend a

conference.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
This is the first additional practice exercise you will find at
http://www.newharbinger.com/38501. You will find many more throughout the
book.\par\pard\plain\hyphpar} {
Exercise 1.1\par\pard\plain\hyphpar} {
Practice understanding how thoughts can influence feelings.\par\pard\plain\hyphpar}
{
What do my dog Shadey and two colleagues attending a conference have to do with
therapy? Clients usually start therapy feeling overwhelmed and hopeless, with
little understanding of the factors that are causing and maintaining their
difficulties. Separating thoughts from feelings, physical reactions, and behavior
provides clients with a framework for understanding their problems. When clients
understand their problems, they feel more in control and less hopeless. This is the
first step in starting to change. Let\u8217?s see how helping a client of mine,
Alfred, identify the way his feelings are related to his thoughts, physical
reactions, and behavior can help him understand his
problems.\par\pard\plain\hyphpar} {
Alfred is a seventeen-year-old boy who wants to be a car mechanic. He hates school
but needs the high school credits to get into a car mechanic training program. He
is in therapy because he is depressed and failing two of his subjects. He has an
average IQ and no learning disabilities. He starts the session with a big sigh and
says, \u8220?I am so down and depressed. I have a really hard math test tomorrow.
It\u8217?s too hard for me. I\u8217?ve had a splitting headache all day. I\u8217?m
really anxious about this test. I haven\u8217?t started studying. I\u8217?m going
to fail anyhow. I\u8217?m just going to go home and play computer games. I
don\u8217?t know what\u8217?s wrong with me. Why don\u8217?t I
study?\u8221?\par\pard\plain\hyphpar} {
Let\u8217?s look at figure 1.5 and see how using the four-factor model can help us
understand Alfred\u8217?s problems. Imagine that his therapist says to him, \u8220?
Sounds like you\u8217?re having a tough time; let\u8217?s make sure we understand
what\u8217?s going on for you. I want to start with separating out your thoughts
from your feelings, physical reactions, and behavior. Let\u8217?s see if once we
understand your reaction, we can understand why it\u8217?s so hard for you to
study.\u8221?\par\pard\plain\hyphpar} {
{\i
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}}

Figure 1.5. Alfred has a math test

tomorrow.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Was it helpful to look at Alfred\u8217?s reaction in terms of the four factors? Did
identifying Alfred\u8217?s thoughts help explain his feelings and
behavior?\par\pard\plain\hyphpar} {
Exercise 1.2\par\pard\plain\hyphpar} {
Practice identifying the four factors.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN!Identify Clients\u8217? Thoughts, Feelings, Physical Reactions, and
Behavior\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Sara is in therapy because she is not sure whether she wants to break up with her
long-term boyfriend. She complains that he does not respect her and takes her for
granted. She starts the therapy session by telling her therapist that she is very
upset. Last night her boyfriend was thirty minutes late picking her up for dinner
and had not bothered to let her know he would be late. When he finally arrived, he
explained casually he had been caught at work. Look at the following dialogue with
a non-CBT therapist and see if you can identify the four factors in Sara\u8217?s
reaction.\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} What\u8217?s it like for you when your boyfriend comes half an hour
late without contacting you?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Sara:} I am just so depressed at how he is treating
me.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} How did you react?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Sara:} I gave him dirty looks and was cold all evening. What else can I do? I just
feel so irritated and tense all the
time.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} It is hard for you to know what else you could
do.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Sara:} That\u8217?s right.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} What is that like for
you?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Sara:} I hate it. He treats me as if he doesn\u8217?t care about me. He takes me
for granted. It makes me feel
worthless.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this type of dialogue the client\u8217?s thoughts, feelings, physical reactions,
and behavior are a jumble; it is hard to know how best to continue therapy.
Let\u8217?s see what happens if you take the information from the above example and
use the four-factor model as a structure to understand how Sara\u8217?s thoughts
influenced her feelings, physical reactions, and behavior. Complete the exercise
below, then turn to the appendix to see how I completed the
model.\par\pard\plain\hyphpar} {
{\i
Situation:}\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Thoughts:}\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Feelings:}\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Physical Reactions:}\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Behavior:}\par\pard\plain\hyphpar} {
How did identifying Sara\u8217?s thoughts, feelings, physical reactions, and
behavior help you understand her experience differently from when you read the
therapy dialogue? Did writing make a difference? Often, helping clients identify
their thoughts and feelings separately starts a process of self-reflection, which
is the first step to change.\par\pard\plain\hyphpar} {
Exercise 1.3\par\pard\plain\hyphpar} {
Practice identifying the four factors from a therapy
dialogue.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: How Behaviors Maintain Problems}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
To understand how your clients\u8217? behaviors maintain their problems, you want
to understand how their behavior influences their thoughts, feelings, and physical
reactions. Start by looking at the consequences of your client\u8217?s behavior.
Let\u8217?s examine first how the consequences of a behavior can reinforce your
client\u8217?s thoughts, and second, how the consequences of a behavior can
influence the situation so as to reinforce the client\u8217?s original thoughts or
interpretation.\par\pard\plain\hyphpar} {
Let\u8217?s go back to Alfred, my seventeen-year-old client in the earlier example
with the math test. Here is a summary of Alfred\u8217?s reaction using the four-
factor model. Alfred thinks, {\i
The test is too hard for me and I\u8217?m going to fail anyhow}. He feels anxious
and he gets a headache. His behavior is to go home and play computer
games.\par\pard\plain\hyphpar} {
How do the consequences of Alfred\u8217?s behavior reinforce his thoughts and the
situation? Alfred did not study, he failed the test. When Alfred failed the test he
thought, {\i
The test really was too hard for me since I failed,} and{\i
I was going to fail anyhow}. Failing the test becomes evidence that the test is
\u8220?too hard.\u8221? Thus, the consequences of the behavior reinforce his
original thoughts. Does this make sense so far? In addition, Alfred never gets a
chance to test out his prediction, {\i
I\u8217?m going to fail anyhow}. Perhaps if Alfred had studied, he would have
passed, but he will never know. He will take his failure as evidence that he
would \u8220?fail anyhow.\u8221?\par\pard\plain\hyphpar} {
Now, let\u8217?s now look at how the consequences of Alfred\u8217?s behavior impact
the situation. Since Alfred failed the test, he probably does not understand the
material. Since math concepts tend to build on each other, this makes it more
probable that he will fail, or do poorly, on the next test. Thus, his behavior
changes the actual situations in his life so that his negative thoughts are more
likely to be true. Figure 1.6 shows how Alfred\u8217?s behavior can reinforce his
thoughts and influence the situation. Alfred is caught in what CBT therapists call
a {\i
symptom maintenance cycle}.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

Figure 1.6. Alfred\u8217?s symptom maintenance

cycle.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
YOUR TURN!Maria\u8217?s Symptom Maintenance
Cycle\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s return to the example of Maria, who had to attend a conference where
she would not know anyone. Let\u8217?s see how her behavior is maintaining her
difficulties. I will fill in the first part for you. You can see how I completed
her symptom maintenance cycle in the appendix.\par\pard\plain\hyphpar} {
{\i
Maria\u8217?s Situation:} Attending a conference where she does not know
anyone\par\pard\plain\hyphpar} {
{\i
Maria\u8217?s Thoughts:} This will be awful. No one will talk to me. Everyone will
think I am stupid.\par\pard\plain\hyphpar} {
{\i
Maria\u8217?s Feelings:} Anxious\par\pard\plain\hyphpar} {
{\i
Maria\u8217?s Physical Reaction:} Sick stomach\par\pard\plain\hyphpar} {
{\i
Maria\u8217?s Behavior:} Sits by herself in a corner\par\pard\plain\hyphpar} {
{\i
Consequences:}\par\pard\plain\hyphpar} {
What are the consequences of Maria\u8217?s behavior? Ask yourself: If she is
sitting by herself, will people talk to her? Do you think she will enjoy
herself?\par\pard\plain\hyphpar} {
How do the consequences of her behavior reinforce her thoughts? ({\i
Hint}: If she is sitting alone, what is the likelihood that people will talk to
her? If she does not talk with the other people, will they have a chance to see
that she is not stupid?)\par\pard\plain\hyphpar} {
How do the consequences of her behavior influence the situation? ({\i
Hint}: Maria started the conference not knowing anyone. If she sits in a corner,
how many people will she know at the end of the
conference?)\par\pard\plain\hyphpar} {
Exercise 1.4\par\pard\plain\hyphpar} {
Practice using a symptom maintenance cycle.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: How Core Beliefs Influence
Thoughts}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this book, we are going to focus on automatic thoughts, but I want you to
understand core beliefs too, which underlie automatic thoughts. Core beliefs are
stable, deeply held beliefs that cut across situations and influence automatic
thoughts. (Some CBT books use the term {\i
schema}; core beliefs and schemas are virtually identical.)\par\pard\plain\hyphpar}
{
There are generally three types of core beliefs (Clark, Beck, & Alford,
1999):\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Simple rules about life.} These are rules about how to manage in life or how the
world works. They usually have very little influence on your client\u8217?s
emotional well-being. Examples might be:\par\pard\plain\hyphpar} {
Be polite to strangers.\par\pard\plain\hyphpar} {
To succeed in life, get a good education.\par\pard\plain\hyphpar} {
Always wear a life jacket in a boat.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Intermediary beliefs and assumptions.} These are rules for living that often take
the form of {\i
if\u8230?then} statements or {\i
unless I\u8230?} statements. These rules play an important role in determining
feelings and behaviors. Examples might be:\par\pard\plain\hyphpar} {
Unless I am perfect, I will fail.\par\pard\plain\hyphpar} {
If I yell, {\i
then} people will listen to me.\par\pard\plain\hyphpar} {
If people see the real me, {\i
then} they will reject me.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Core beliefs.} These are deeply held beliefs about self, others, or the world that
affect how people feel and behave in many different situations. They are absolute
and general statements that are felt at a very deep level and can be captured in a
few words. Core beliefs can be adaptive or maladaptive, and, unlike automatic
thoughts, they can be hard to identify and modify. Examples might
be:\par\pard\plain\hyphpar} {
Core beliefs about self: I am smart, I am lovable, I am selfish, I am incompetent,
I am unlovable.\par\pard\plain\hyphpar} {
Core beliefs about others: Others are kind, others will take care of me, others are
mean, others will take advantage of me.\par\pard\plain\hyphpar} {
Core beliefs about the world: The world is just, the world is stable, the world is
dangerous, the world is unjust.\par\pard\plain\hyphpar} {
Although an individual\u8217?s core beliefs are influenced by his innate
temperament, they tend to be formed mainly by early life experiences and are
modified by the individual\u8217?s later life experiences (Young, Klosko, &
Weishaar, 2006). For example, do you remember Maria from the first YOUR TURN!
exercise? She was anxious about attending the conference. When Maria was in grade
four, she had some trouble in math and was badly bullied by a group of girls. Her
classmates regularly called her \u8220?stupid.\u8221? All of the girls she
previously played with refused to play with her, and school became a nightmare. She
did not tell her parents until late in the year, and had no support from her
parents or teachers. Let\u8217?s look at how this experience affected her core
beliefs.\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Maria\u8217?s Core Beliefs:\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Self: I am stupid and unlikable.\par\pard\plain\hyphpar} {
Others: People will be critical and mean to me.\par\pard\plain\hyphpar} {
World: The world is unpredictable.\par\pard\plain\hyphpar} {
The power of core beliefs is their capacity to influence how you react to a variety
of different situations. For example, when Maria meets a new neighbor, she will
likely think, {\i
We will not get along}. When her supervisor does not comment on her last report,
she thinks, {\i
He probably thought it was terrible}. Her automatic thoughts in these situations
are all influenced by her core beliefs. Now imagine that Maria receives an email
from the human relations department of her firm asking for a meeting. What are her
likely thoughts? (a) {\i
I did something wrong}, {\i
I will be punished}, {\i
this is terrible}, or (b) {\i
I wonder what they want}, {\i
it will probably be fine}, {\i
if there is a problem I can explain myself to them}. Figure 1.7 is a diagram of how
core beliefs influence automatic thoughts.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

Figure 1.7. Maria\u8217?s core beliefs influence her automatic

thoughts.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 1.5\par\pard\plain\hyphpar} {
Practice understanding the relationship between core beliefs and automatic
thoughts.\par\pard\plain\hyphpar} {
Let\u8217?s look at the situation where Maria meets her new neighbor in more
detail. When Maria thinks, {\i
We will not get along; she will not like me}, she is hesitant to reach out to her
neighbor and tends to avoid any contact with her. Consequently, her neighbor thinks
Maria is unfriendly and also avoids Maria. The consequences of Maria\u8217?s
behavior reinforce her thoughts, which confirm her core beliefs. Figure 1.8 shows
how Maria is caught in a vicious cycle where the consequences of her behavior
reinforce not only her thoughts but also her core beliefs.\par\pard\plain\hyphpar}
{
{\i
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}}

Figure 1.8. Maria\u8217?s vicious cycle also influences her core

beliefs.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 1.6\par\pard\plain\hyphpar} {
Practice understanding how vicious cycles can involve core
beliefs.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Clinical Implications.} CBT therapists usually start with focusing on
clients\u8217? automatic thoughts and behavior as this teaches clients basic CBT
skills and can lead to fairly rapid improvement in clients\u8217? behaviors and
moods. Because core beliefs are connected to automatic thoughts, often as clients
change their automatic thoughts and behavior, their core beliefs also start to
change.\par\pard\plain\hyphpar} {
It is helpful to start hypothesizing about your client\u8217?s core beliefs from
the beginning of therapy. Noticing the type of situations that cause difficulty for
your client together with noticing the pattern of your client\u8217?s automatic
thoughts provides clues to his core beliefs.\par\pard\plain\hyphpar} {
Clients either don\u8217?t notice information that contradicts their core beliefs,
or they minimize the information. How would you expect Maria to react when her
neighbor says, \u8220?I am so happy to see you\u8221?? Would she think, {\i
She\u8217?s just saying that to make me feel good}, or would she think, {\i
She really likes me}? Hypothesizing about your client\u8217?s core beliefs can help
you notice what types of information your client is likely to ignore or
minimize.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
At the end of each chapter I list the additional exercises that are mentioned in
the chapter and available on the website (http://www.newharbinger.com/38501). I
also suggest exercises for homework that focus on applying what you learned to your
own life and therapy practice. When you learn a new approach, it is important to
practice; otherwise, it never becomes part of your own therapy style. Doing the
homework is a key component to learning CBT.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Clinical
Examples\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 1.1:} What Is This Person Thinking?\par\pard\plain\hyphpar} {
{\b
Exercise 1.2:} Sharon Is Invited for Coffee\par\pard\plain\hyphpar} {
{\b
Exercise 1.3:} Roger Doesn\u8217?t Want to Go to the Doctor\par\pard\plain\hyphpar}
{
{\b
Exercise 1.4:} Lee Learns to Ask a Question\par\pard\plain\hyphpar} {
{\b
Exercise 1.5:} Understand Janice\u8217?s Reactions\par\pard\plain\hyphpar} {
{\b
Exercise 1.6:} Understand Janice\u8217?s Vicious Cycle and Core
Beliefs\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It takes practice to become aware of our thoughts, feelings, physical reactions,
and behavior. This coming week, when you are having a strong negative emotional
reaction, notice your thoughts and write them down. Then ask yourself if noticing
your thoughts as separate from your feelings changed anything. What was it like to
write down your thoughts and feelings?\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Use the Four-Factor Model to Understand Your Own
Situation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once you have had some practice noticing your thoughts and feelings, try to use the
whole four-factor model. Complete the four-factor model below for one situation in
which you had a strong negative reaction. Write out your answers; it makes a
difference. How did using the four-factor model affect your understanding or your
own reaction?\par\pard\plain\hyphpar} {
{\i
Situation:}\par\pard\plain\hyphpar} {
{\i
Thoughts:}\par\pard\plain\hyphpar} {
{\i
Feelings:}\par\pard\plain\hyphpar} {
{\i
Physical Reactions:}\par\pard\plain\hyphpar} {
{\i
Behavior:}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s see if applying the four-factor model to your own clients can help you
understand their problems differently.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Use the Four-Factor Model to Understand a Client\u8217?s
Situation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Think of a situation involving a current client. Try to complete the four-factor
model below using the situation you selected. Don\u8217?t gather additional
information; use what you already know. Notice if you are missing information for
one of the factors. How did using the four-factor model help you understand your
client differently?\par\pard\plain\hyphpar} {
{\i
Situation:}\par\pard\plain\hyphpar} {
{\i
Thoughts:}\par\pard\plain\hyphpar} {
{\i
Feelings:}\par\pard\plain\hyphpar} {
{\i
Physical Reactions:}\par\pard\plain\hyphpar} {
{\i
Behavior:}\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
At the end of a CBT session, the therapist and client spend a few moments reviewing
what was covered in the session. Similarly, let\u8217?s take a moment to review
what we just covered. For each agenda item, try to answer the questions. If you are
unsure of an answer, you can find it in that section of the
chapter.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} CBT building blocks: thoughts, feelings, physical reactions, and
behavior\par\pard\plain\hyphpar} {
Why is it helpful to divide your client\u8217?s reactions into thoughts, feelings,
physical reactions, and behavior?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} How thoughts maintain problems\par\pard\plain\hyphpar} {
How do thoughts lead to feelings, physical reactions, and
behavior?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} How behaviors maintain problems\par\pard\plain\hyphpar} {
What do we mean by symptom maintenance cycles?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} How core beliefs influence thoughts\par\pard\plain\hyphpar} {
What are core beliefs?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
The more you can relate the material you have just read to your own life, the more
you will remember. Take a moment to answer the following questions. They are an
opportunity for you to reflect on the chapter and how it is relevant to your own
practice.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concepts would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What was it like to review? Did it help consolidate what you
learned?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 2\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Focus on Your Clients\u8217? Problems and
Strengths\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s start with a check-in and review. In the last chapter we covered basic
CBT theory, and we started using the four-factor model. Remember, the four-factor
model involves exploring your client\u8217?s reaction to a situation by identifying
thoughts, feelings, physical reactions, and behaviors. We also looked at how
thoughts and behaviors can maintain problems. Did you try using the four-factor
model? What did you notice when you differentiated thoughts from
feelings?\par\pard\plain\hyphpar} {
If you did not have a chance to use the four-factor model, try this exercise. Think
of a situation in the past few days where you had a strong negative emotional
reaction. Imagine yourself back in that situation. Now, try to identify your
thoughts, feelings, physical reactions, and behavior. Afterwards, take a moment to
reflect on the experience. Did you learn anything about
yourself?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this chapter, I want to focus on forming a good therapy relationship,
understanding your clients\u8217? presenting problems and strengths, and explaining
CBT to your clients.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} Develop a good therapeutic relationship.\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Understand your client\u8217?s presenting
problems.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Meet Suzanne.\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} Understand your client\u8217?s stressors and
strengths.\par\pard\plain\hyphpar} {
{\b
Agenda Item #5:} Meet Raoul.\par\pard\plain\hyphpar} {
{\b
Agenda Item #6:} Understand your client\u8217?s psychosocial
history.\par\pard\plain\hyphpar} {
{\b
Agenda Item #7:} Explain CBT.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Shortly, I\u8217?ll introduce you to two clients, Suzanne and Raoul, whom we will
work with throughout the book as we learn and practice CBT skills. But first,
let\u8217?s start where all good therapy starts\u8212?with the therapeutic
relationship.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: Develop a Good Therapeutic
Relationship}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
For all types of therapy, including CBT, a good therapeutic relationship predicts a
positive outcome (Martin, Garske, & Davis, 2000; Norcross & Wampold, 2011).
Effective therapy happens in the context of a supportive relationship where your
client feels understood and accepted. As with any form of therapy, when practicing
CBT, it is important to be warm and nonjudgmental. You want to develop a
collaborative relationship with your client, working together to solve her
problems. You bring your knowledge about psychology and CBT, and your client brings
her knowledge about her own life and experience.\par\pard\plain\hyphpar} {
Multiple studies have demonstrated that empathy is a central component of any
effective therapy (Norcross & Wampold, 2011). I would guess that you agree, but
take a moment to think about how you define empathy. Usually, when I ask my
students this question they answer, \u8220?walking in someone else\u8217?s
shoes\u8221? or \u8220?understanding someone else\u8217?s feelings.\u8221? My
students always mention feelings; almost no one mentions thoughts. Understanding
feelings is important, but understanding thoughts is just as important (Elliott,
Bohart, Watson, & Greenberg, 2011).\par\pard\plain\hyphpar} {
Let\u8217?s consider an example. Sorena, your client, tells you that she {\i
feels} sad and tired. She also tells you that she {\i
thinks} she is an inadequate parent and that her children don\u8217?t respect or
love her. If you wanted to be truly empathic, would you focus just on Sorena\u8217?
s feelings or also on her thoughts? It seems to me that using the four-factor model
and asking about both feelings and thoughts increases an empathic
connection.\par\pard\plain\hyphpar} {
Over the years, some therapists have told me that they think CBT is a cold type of
therapy because we pay attention to thoughts. If you look at the previous example,
what do you think? It seems to me that thoughts are as private and emotional as
feelings. It is important to remember that when you ask clients what they \u8220?
think,\u8221? you are asking them to reveal a very private part of themselves. In
this book we will focus on how to be a warm, empathic therapist while also using
structured CBT interventions (Josefowitz & Myran, 2005).\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #2{\i
: Understand Your Client\u8217?s Presenting
Problems}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
There is an order to CBT therapy. While there is some flexibility, typically the
following order is implemented:\par\pard\plain\hyphpar} {
Explore your client\u8217?s presenting problem and obtain an overview of her
current life situation, including difficulties and
strengths.\par\pard\plain\hyphpar} {
Take a psychosocial history.\par\pard\plain\hyphpar} {
Explain CBT in general and in particular the four-factor
model.\par\pard\plain\hyphpar} {
Set goals for therapy.\par\pard\plain\hyphpar} {
Focus on helping your client change.\par\pard\plain\hyphpar} {
In the initial phase of therapy, you start to form a good relationship and at the
same time get an overview of your client\u8217?s problems and how they are
affecting her life. You also want to obtain a sense of your client\u8217?s
strengths and how she has coped in the past.\par\pard\plain\hyphpar} {
There are three main steps to obtaining an initial understanding of your
client\u8217?s problems or why she came to therapy:\par\pard\plain\hyphpar} {
Ask your client about her problems and make a list.\par\pard\plain\hyphpar} {
Explore how your client\u8217?s problems are affecting her life and how she is
coping.\par\pard\plain\hyphpar} {
Collaboratively decide which problem(s) your client wants to start working on in
therapy.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Ask your client about her problems and make a list.} CBT therapists usually start
with \u8220?How can I help you?\u8221? or \u8220?Tell me, what brings you to
therapy?\u8221? It is important for your client to explain her problems in her own
words. Initially, I focus on listening, using summary statements to be sure I have
understood, and then ask open questions. Open questions encourage exploration and
are not answered with just one word. For example, \u8220?Do you have a
problem?\u8221? is a closed question. The answer is yes or no. \u8220?What kind of
problem do you have?\u8221? is an open question. One way to think about this stage
is that when your client starts therapy, the picture is blurry. Good questions help
you gradually focus and sharpen the picture so that it is crisp and bright, or at
least clearer.\par\pard\plain\hyphpar} {
After you have a general sense of your client\u8217?s problems, it is helpful to
make a list so that you can explore her problems more fully, one at a time. Writing
out a list gives the message that therapy will address specific problems and not
just be a place where she comes and talks in general terms. Making a list also
starts to give direction to therapy.\par\pard\plain\hyphpar} {
I usually say, \u8220?I am starting to have an idea of some of your concerns. I
would like to make a list of your problems to be sure we have covered
everything.\u8221? Most non-CBT therapists are not used to writing as part of
therapy. Next time you have a new client, try writing out your client\u8217?s
problems and share the list with your client. Pay attention to how making a written
list affects therapy.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Explore how your client\u8217?s problems are affecting her life and how she is
coping.} Often clients describe general problems, such as difficulty with their
marriage or feeling anxious. To understand how a problem is affecting your
client\u8217?s life, you need to explore further. You will find the following list
of questions helpful. (You can download them in handout format at
http://www.newharbinger.com/38501.)\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Questions to Explore Your Client\u8217?s Problems}\par\pard\plain\hyphpar} {
{\b
Question 1:} What are some examples of situations where this problem arises? When
you have this problem, what are your main thoughts, feelings, physical reactions,
and behavior?\par\pard\plain\hyphpar} {
{\i
I usually start with this question. Once you have examples of specific situations,
the problem usually becomes much more defined.}\par\pard\plain\hyphpar} {
{\b
Question 2:} What is the worst part of the problem?\par\pard\plain\hyphpar} {
{\i
It is important to ask this question and not just assume that you know the answer.
I am often surprised by my client\u8217?s answer.}\par\pard\plain\hyphpar} {
{\b
Question 3:} How is this problem affecting your life? What are some of the
difficulties this problem has created for you? In particular, are there activities
you have stopped doing or are avoiding because of the problem? Are there activities
you have started doing or are doing more of because of the
problem?\par\pard\plain\hyphpar} {
{\i
If my client is avoiding specific activities, I follow up by asking what she thinks
would happen if she did not avoid them.}\par\pard\plain\hyphpar} {
{\b
Question 4:} What have you done to try and cope with the problem? Have any of your
coping methods helped?\par\pard\plain\hyphpar} {
{\i
You want to know whether anything has helped, even a little, so that you can expand
upon this coping strategy later. In addition, you want to acknowledge and support
any active attempt to cope with the problem.}\par\pard\plain\hyphpar} {
{\b
Question 5:} When did this problem start?\par\pard\plain\hyphpar} {
{\i
Sometimes a client can immediately identify a triggering situation. Sometimes she
has not thought about whether her difficulties were related to specific changes or
events in her life. A series of relatively minor changes, over a short period of
time, can equal a lot of stress.}\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Practice in Your Imagination: Use One of the Five
Questions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I want you to imagine using the questions we just covered. Sports psychologists
have known for years that imagining practicing a new skill significantly enhances
skill development (Weinberg, 2008). It seems to me that if athletes can use imagery
to practice, why not therapists?\par\pard\plain\hyphpar} {
You can do the exercise by reading along, but I think you will find the exercise
more meaningful if you listen to the guided audio file available at the website for
this book.\par\pard\plain\hyphpar} {
Look at Questions to Explore Your Client\u8217?s Problems. Choose a question which
you rarely or never use. Now, choose a client with whom you want to try asking this
question. Imagine yourself back in your office. Take a moment to look around;
notice the sounds and smells of your office. Now imagine yourself asking this
question with your client. Now, imagine asking this question with a different
client. Each time, imagine that your client responds
positively.\par\pard\plain\hyphpar} {
Write down the question you choose, and try it with two clients this coming
week.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Meet Suzanne}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Throughout this book we are going to follow two clients, Suzanne and Raoul. They
are based on a number of my clients and the clients of students I have supervised
or taught. I want to start with introducing you to Suzanne. We will meet Raoul
later in the chapter.\par\pard\plain\hyphpar} {
Suzanne is thirty-four and is married with two young children, Jennifer, age six,
and Andrew, age four. She is a fourth-grade teacher and her husband works in a
local hardware store. Her husband was her high-school sweetheart, and she is still
in love with him. They live in the suburbs of a medium-size city. Her parents and
her in-laws live nearby; she sees them regularly and they have a good
relationship.\par\pard\plain\hyphpar} {
Suzanne\u8217?s doctor referred her for therapy because she is always tired and
feels chronically overwhelmed by the children, her job, and her other
responsibilities. Her physical exam was normal, and her doctor thought it would be
helpful for her to \u8220?talk to someone.\u8221? Suzanne calls the
therapist\u8217?s office and makes an appointment.\par\pard\plain\hyphpar} {
Suzanne is a small, thin woman who smiles timidly when she walks into her
therapist\u8217?s office for the first time. She perches on the edge of the couch
and looks nervously around. When Suzanne\u8217?s therapist asks, \u8220?How can I
help you?\u8221? she responds softly with, \u8220?I\u8217?m not sure\u8230? I
don\u8217?t know even know where to start,\u8221? and looks down. Her therapist
gently asks, \u8220?Tell me what brings you here; I know it can be hard to
start.\u8221? Suzanne explains she does not know what is wrong with her. She has a
great house, great kids, a good job, and a great husband, but she is just so
overwhelmed all the time that she isn\u8217?t enjoying life anymore. She starts to
cry and says she feels like she isn\u8217?t coping. Her therapist asks Suzanne to
tell her a bit more. Suzanne explains that she is always tired, cries over silly
things, and quickly gets angry with the kids. She looks very sad and says, \u8220?
I\u8217?m not even a good mother anymore.\u8221? Suzanne explains that she used to
like her job as a fourth-grade teacher, but she dreads going into work these days.
She is teaching at a new school, which is a thirty- to forty-minute commute. Her
old school was walking distance from home. She is often angry with her husband. He
works long hours and she feels she is expected to take care of the children and
house without any appreciation from him. She is scared that he will leave her if
she stays this depressed. She feels anxious all of the time. She has always been a
shy person, but her anxiety is getting much worse; she worries over
everything.\par\pard\plain\hyphpar} {
Let\u8217?s see how we can start to understand Suzanne\u8217?s problems using
Questions to Explore Your Client\u8217?s Problems.\par\pard\plain\hyphpar} {
{\i
Therapist:} Sounds like a lot. I think it would help if we made a list of your
problems so we can start to understand them one at a time.\par\pard\plain\hyphpar}
{
Suzanne\u8217?s therapist\u8217?s response is both empathic and structured. Suzanne
was feeling overwhelmed; her therapist thought that making a list might help her
start to feel that her problems were more manageable.\par\pard\plain\hyphpar} {
Suzanne lists being tired all of the time, yelling at her children, not doing
anything fun, hating work, and wondering if teaching is the right job. These are
all general problems, and we don\u8217?t really understand how they are affecting
her life.\par\pard\plain\hyphpar} {
{\i
Therapist:} I think it would be helpful to understand a bit more about what is
happening with you. Let\u8217?s pick one problem and look at it in more depth.
Let\u8217?s start with exploring what is the worst part of this problem for you.
(Question 2) Note how Suzanne\u8217?s therapist explains what she wants to do by
saying she wants \u8220?to understand a bit more about what is happening with
you.\u8221? At the same time, she reinforces hope by saying \u8220?it would be
helpful.\u8221? This is a good example of combining the structure of CBT with
creating a good therapy relationship and instilling hope.\par\pard\plain\hyphpar} {
{\i
Suzanne:} I think the worst thing is that I\u8217?m always yelling at my kids and
feeling like I am not coping.\par\pard\plain\hyphpar} {
This is a very general statement. You want a more specific idea of Suzanne\u8217?s
difficulties. Before looking at Suzanne\u8217?s therapist\u8217?s response, think
about how you could ask Suzanne to identify specific situations that are difficult
for her.\par\pard\plain\hyphpar} {
{\i
Therapist:} Could you give me some examples so I have a better idea of the
situations that are difficult for you? (Question 1) {\i
Suzanne:} Sure, I used to come home and make dinner for the family, and then play
with my kids. These days just making dinner seems to take up all of my energy; I
never seem to have time or energy to spend time with my children, and when I do, I
am pretty irritated.\par\pard\plain\hyphpar} {
As a CBT therapist, you are using the four-factor model to think about your
clients\u8217? problems. When Suzanne gave an example of a difficult situation, did
she describe her thoughts, feelings, physical reaction, and
behaviors?\par\pard\plain\hyphpar} {
We have an idea of Suzanne\u8217?s feelings (overwhelmed and irritated/angry) and
her physical reaction (tired); we don\u8217?t know her behavior or her thoughts.
She mentioned earlier the thought {\i
I am not even a good mother anymore}. You can guess that\u8217?s what she is
thinking about herself in these situations, but it is important to
check.\par\pard\plain\hyphpar} {
{\i
Therapist:} Suzanne, when you are feeling overwhelmed and irritated, what are some
of the thoughts that are going through your mind? (Question 1) {\i
Notice that Suzanne\u8217?s therapist linked her thoughts to her
feelings.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} I\u8217?m usually thinking that I am a terrible mother and the kids
deserve better. But I am also thinking that I wish I could just go to bed and not
have to take care of the kids.\par\pard\plain\hyphpar} {
{\i
Try to think of an empathic comment that would summarize what Suzanne said and
indicate that you had heard Suzanne\u8217?s thoughts. How could you ask Suzanne
about her behavior and how she is coping? Think of how you would respond before
checking what Suzanne\u8217?s therapist said.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Those sound like pretty difficult thoughts to be having. Lots of self-
critical thoughts and then wishing you could just go to bed and get away from it
all. Tell me, how do you cope in these situations? (Question 4) {\i
Suzanne:} I just try to control my anger and take care of the kids. But I am pretty
short with them. I have been trying to take it easy and go to bed early, to be less
tired, but it hasn\u8217?t helped.\par\pard\plain\hyphpar} {
{\i
Therapist:} Have you tried anything that has helped?\par\pard\plain\hyphpar} {
{\i
Suzanne:} No, not really.\par\pard\plain\hyphpar} {
{\i
How could you introduce Question 3?}\par\pard\plain\hyphpar} {
{\i
Therapist:} I wonder if there are things you have stopped doing since you have been
feeling so bad, or situations you are avoiding?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I generally do less fun things with my husband and children. Lately
I am just too tired.\par\pard\plain\hyphpar} {
{\i
This is a very general comment. How could you help Suzanne become more specific
about what \u8220?fun things\u8221? she is doing less of?}\par\pard\plain\hyphpar}
{
{\i
Therapist:} When you say you do less fun things with your husband and children, can
you give me some examples?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I used to take my daughter, who is six, to a playgroup in the afternoon
with some of my neighbors. I have a half day off from work each week. But I\u8217?
ve been too tired to do that. Also my husband and I used to take the kids to the
park on weekends, which was a fun family time; but I often send them over to my
parents\u8217? so that I can nap, or my husband takes them without
me.\par\pard\plain\hyphpar} {
{\i
When you look at Suzanne\u8217?s response, is there anything Suzanne has been doing
more of? Suzanne\u8217?s therapist thought that she had been doing more resting and
napping. This is a good place to ask about changes in alcohol consumption, drugs,
and medication.}\par\pard\plain\hyphpar} {
Her therapist discovers that Suzanne has stopped doing most afterschool activities
with her children as she is \u8220?too tired\u8221? and that she has also stopped
seeing and talking with most of her girlfriends. She and her husband have also
stopped seeing many of their friends and family because Suzanne feels that she is
too tired. Suzanne\u8217?s problems started when she changed schools. She is
unhappy at her new school, has made no friends, and feels like an outsider. Suzanne
has not started consuming alcohol, nor did she report abusing prescription or
nonprescription medication.\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist suggested that they write down a preliminary list of the
problems that Suzanne would like to work on in therapy{\i
.}\par\pard\plain\hyphpar} {
Suzanne suggested the following problems:\par\pard\plain\hyphpar} {
Not having any friends at my new school\par\pard\plain\hyphpar} {
Yelling at my children and husband\par\pard\plain\hyphpar} {
Being tired all of the time\par\pard\plain\hyphpar} {
Not doing fun things with my husband and children\par\pard\plain\hyphpar} {
Being depressed and anxious and just not enjoying life
anymore\par\pard\plain\hyphpar} {
Wondering if teaching is the right job for me\par\pard\plain\hyphpar} {
{\i
This is a long list; the therapist and Suzanne have to figure out where to
start.}\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Collaboratively decide which problem(s) your client wants to start working on in
therapy.} If you remember from earlier in the chapter, there are three main steps
to obtaining an initial understanding of your client\u8217?s problems. First, ask
about your client\u8217?s problems and make a list; second, explore how your
client\u8217?s problems are affecting her life; and third, collaboratively decide
which problem your client wants to start working on. We are now ready for the third
step.\par\pard\plain\hyphpar} {
Some clients come to therapy with one main problem, but most have a number of
different problems. You and your client need to decide which problem to address
first, or therapy can feel like wandering around without a focus. The easiest
approach is to be direct and say, \u8220?I think it\u8217?s helpful to try and
address one problem at a time. When we look over your problem list, which problem
would you like to start with?\u8221? You want to pick a problem where there is a
good chance you can help your client fairly quickly and that will have an immediate
impact on her life.\par\pard\plain\hyphpar} {
Marsha Linehan (1993) suggested some very useful criteria for prioritizing your
client\u8217?s problems. First, if your client is actively suicidal, your first
priority is to make sure that she is safe. Second, if your client is behaving in a
manner that is dangerous or that is likely to significantly interfere with her
life, these behaviors need to be addressed. Examples of these types of behavior
include major substance abuse, missing work or school, and being involved in a
physically or emotionally abusive relationship. In addition, if a client regularly
engages in behavior that interferes with therapy, for example, coming late to
therapy, insulting the therapist, or skipping sessions, these behaviors need to be
addressed.\par\pard\plain\hyphpar} {
If we consider each of Suzanne\u8217?s problems, the first four that she listed are
more specific and concrete than being depressed and not enjoying life anymore or
wondering whether teaching is the right job for her. The therapist explained to
Suzanne that because the first four problems are more specific and concrete, she
would want to start with one of these so she will be able to help Suzanne in a
shorter period of time and with more focus to therapy. She then asked Suzanne which
problem she wanted to start with. Suzanne wanted to start with making friends at
her new school and not doing any fun things with her husband and
children.\par\pard\plain\hyphpar} {
Video 2.1\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: Understand Your Client\u8217?s Stressors and
Strengths}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In addition to understanding your client\u8217?s presenting problems, you need to
understand how these problems fit into her overall life. You want a picture of her
current life, how she is functioning, and any other stressors or difficulties in
her life besides her presenting problem, as well as the positive supports in her
life and her areas of strengths.\par\pard\plain\hyphpar} {
You can introduce this section by saying, \u8220?I am starting to get an
understanding of your problems. I think it would be helpful if I could also get a
sense of other parts of your life.\u8221? Notice that I explain what I will be
doing and indicate that it will be helpful to my client.\par\pard\plain\hyphpar} {
The basic categories that I ask about are family, friends and social contacts,
recreation and involvement in organizations outside of the home, work or school,
health, and finances. Finances includes the ability to budget, pay bills on time,
and all that is involved in being financially responsible. When asking about
health, if you did not already ask about alcohol and drug use, this is a good place
to do so. I also ask about self-care, either under recreation or health. I want to
know if my client is engaging in activities that are nurturing for her and if she
is participating in any regular exercise. In addition, I ask whether over the past
year or few years there have been any major changes in my client\u8217?s life, or a
number of small changes.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Understand Your Client\u8217?s
Stressors\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s start by seeing what we already know about Suzanne\u8217?s stressors or
difficulties in each category.\par\pard\plain\hyphpar} {\b
{\qc
Suzanne\u8217?s Difficulties or Stressors}} {\b
Family} {
Often angry with children and husband\par\pard\plain\hyphpar} {
Believes she is no longer a good mother\par\pard\plain\hyphpar} {
Responsible for the children and home because husband works long hours Frightened
husband will leave her if she doesn\u8217?t change her mood and
behavior\par\pard\plain\hyphpar} {\b
Friends and Social Contacts} {
Unknown\par\pard\plain\hyphpar} {\b
Recreation & Organizations} {
Unknown\par\pard\plain\hyphpar} {\b
Work or School} {
Fourth-grade teacher who \u8220?dreads\u8221? work\par\pard\plain\hyphpar} {\b
Health} {
Always tired\par\pard\plain\hyphpar} {
Otherwise unknown\par\pard\plain\hyphpar} {\b
Finances} {
Unknown\par\pard\plain\hyphpar} {\b
Changes} {
Started teaching at a new school that is a 30- to 40-minute commute from home Can
no longer walk to work every day and instead has to drive\par\pard\plain\hyphpar} {
Used to do fun things with girlfriends and participate in afterschool activities
with children Used to like her job\par\pard\plain\hyphpar} {
When we use the table above, we can start to see areas where we need more
information. Suzanne\u8217?s therapist continues to ask about her life. She learns
that Suzanne has always been shy but has a small group of friends with whom she is
close. However, recently she has been avoiding her friends, as she is just too
tired to go out. Her husband is the main salary earner, and she feels guilty about
asking him to help more in the home since she earns less than he does. She used to
like work, but this year she changed schools. She has had trouble fitting into the
new school; she feels different from the other teachers, who seem to form a tight
group. In her previous school she was active in the school play, but she has been
hesitant to volunteer for afterschool activities at her new school, where everyone
seems to know each other. She reported that apart from lack of energy and being
tired, her health was good and she had no problem with alcohol or drug use. She
also indicated that generally, while they would like more money, finances were not
a major problem. Between work and taking care of the children, she has no time for
hobbies or recreation, though she enjoyed doing the school play last
year.\par\pard\plain\hyphpar} {
Suzanne indicated that she had not experienced any major stressors or changes other
than her new job in the past few years. However, her mother-in-law, who used to
babysit the children, had some health problems and was no longer able to help. Her
daughter has had chronic ear infections. Suzanne often had to take time off from
work to care for her daughter and take her to the doctor. Although her daughter is
better, Suzanne is worried about the upcoming winter. Also, Suzanne\u8217?s best
friend, Genia, moved away and she misses her. Suzanne was surprised at the amount
of change in her life over the past few years and was able to see that all these
changes together had caused a lot of stress.\par\pard\plain\hyphpar} {
Let\u8217?s stop for a moment. At this point we have quite a bit of information.
However, we forgot to notice strengths and areas of resilience. This often happens;
as therapists, we are so used to thinking about our clients\u8217? problems that we
sometimes forget to think about their strengths.\par\pard\plain\hyphpar} {\s4
\afs23
{\b
Understand Your Client\u8217?s
Strengths\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before you can help your client see her strengths, first {\i
you} need to see her strengths. It sounds easy, but it can be hard to see
strengths. One way I use to recognize my client\u8217?s strengths is to remember
that good things do not happen by magic. For example, a client of mine said her son
\u8220?was lucky\u8221? because he was asked back for a full-time job after his
internship. Stop for a moment\u8212?from what you know of the world, what needs to
happen in order for a young man to be asked back for a full-time job after an
internship? Does a fairy godmother just come and say, \u8220?Here is your
job\u8221?? Her son had to get to work on time, work hard, do a good job, and
probably be pleasant to work with. All of these characteristics are reflective of
her son\u8217?s strengths. Now, he also had to be lucky, but luck is rarely
enough.\par\pard\plain\hyphpar} {
Here are some questions to help you think about your clients\u8217? strengths based
on the work by Christine Padesky and Kathleen Mooney (2012). You can download these
questions in handout form (Questions to Explore Strengths) at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Are there any areas of your client\u8217?s life that are going well, or any areas
where your client has persevered in the face of difficulties or adversity? {\i
I do not mean just overcoming unusual challenges, but also being able to maintain a
routine. For example, Suzanne gets up on time every day, gets her children dressed,
gets to work, and has dinner ready for her family. This takes thought, care,
organization, and perseverance; it doesn\u8217?t just happen by magic. It is
important to recognize strengths involved in accomplishing everyday activities. It
can also be helpful to examine strategies people use to persevere in everyday
activities.}\par\pard\plain\hyphpar} {
Has your client been able to accomplish developmental tasks? {\i
For example, has your client been able to pass school grades, develop friendships,
participate on sports teams, or have a steady job? These accomplishments suggest
that your client was able to keep commitments, learn new information, and have
positive relationships with other people.}\par\pard\plain\hyphpar} {
Does your client have a responsible and caring relationship with either a person or
an animal? {\i
Caring relationships involve commitment and putting aside one\u8217?s own
needs.}\par\pard\plain\hyphpar} {
Is your client acting according to her values or goals? {\i
Acting according to values and goals can be difficult and often involves putting
aside what you immediately want to do in favor of long-term
goals.}\par\pard\plain\hyphpar} {
Is your client accomplished or competent in a specific area? {\i
People often have pockets of achievements and skills. Being competent in a
particular area does not have to be a huge achievement; it could be that you are
the person who always makes the birthday cakes, or the person your friends turn to
for computer help. Frequently the coping mechanisms that people have developed to
succeed in these areas can be transferred to other areas of their
lives.}\par\pard\plain\hyphpar} {
Let\u8217?s think about Suzanne and see how we would fill in the different
categories for both her stressors and her strengths. You can download a Identify a
Client\u8217?s Stressors and Strengths worksheet at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
Suzanne\u8217?s Stressors and Strengths}} {\b
Difficulties or Stressors} {\b
Strengths or Areas of Resilience} {\b
Family} {
Often angry with children and husband\par\pard\plain\hyphpar} {
Believes she\u8217?s no longer a good mother\par\pard\plain\hyphpar} {
Husband works long hours\par\pard\plain\hyphpar} {
Mainly responsible for children and home\par\pard\plain\hyphpar} {
Stable, long-term marriage\par\pard\plain\hyphpar} {
Caring parent\par\pard\plain\hyphpar} {
Previously engaged in children\u8217?s activities\par\pard\plain\hyphpar} {
Maintains household routines\par\pard\plain\hyphpar} {
Provides stable home for family, last year able to care for sick child Parents live
nearby, good relationship\par\pard\plain\hyphpar} {
In-laws live nearby, good relationship\par\pard\plain\hyphpar} {\b
Friends and Social Contacts} {
Shy\par\pard\plain\hyphpar} {
Currently avoiding friends\par\pard\plain\hyphpar} {
Small group of close, long-term friends\par\pard\plain\hyphpar} {\b
Recreation & Organizations} {
No hobbies\par\pard\plain\hyphpar} {
Enjoyed organizing school play last year\par\pard\plain\hyphpar} {\b
Difficulties or Stressors} {\b
Strengths or Areas of Resilience} {\b
Work or School} {
Dreading work\par\pard\plain\hyphpar} {
New school, avoiding interaction with other teachers\par\pard\plain\hyphpar} {
Avoiding afterschool activities\par\pard\plain\hyphpar} {
Grade four teacher (indicates completed undergraduate and graduate training)
Previously enjoyed work\par\pard\plain\hyphpar} {
Enjoyed colleagues at previous job\par\pard\plain\hyphpar} {
Participated in afterschool activities (school play)\par\pard\plain\hyphpar} {\b
Health} {
Daughter has history of ear infections, not currently a
problem\par\pard\plain\hyphpar} {
Own health is good\par\pard\plain\hyphpar} {
Does not use alcohol or drugs as coping mechanism\par\pard\plain\hyphpar} {
Daughter\u8217?s ear difficulties have resolved\par\pard\plain\hyphpar} {\b
Finances} {
Earns less than her husband and consequently feels guilty about asking for
help\par\pard\plain\hyphpar} {
Earns a regular salary\par\pard\plain\hyphpar} {
Has a job with benefits\par\pard\plain\hyphpar} {
No particular financial stress\par\pard\plain\hyphpar} {\b
Changes} {
Change in school\par\pard\plain\hyphpar} {
Longer commute\par\pard\plain\hyphpar} {
Mother-in-law no longer babysits\par\pard\plain\hyphpar} {
Some health problems with her daughter\par\pard\plain\hyphpar} {
Genia, her best friend, moved away\par\pard\plain\hyphpar} {
Despite all of the changes maintaining a stable home\par\pard\plain\hyphpar} {
Responsible teacher\par\pard\plain\hyphpar} {
Organized babysitting\par\pard\plain\hyphpar} {
Recognized difficulties and coming for therapy\par\pard\plain\hyphpar} {
Often in the beginning of therapy, clients are very hesitant to notice their
strengths. In the next few chapters we\u8217?re going to talk more about how to use
your clients\u8217? strengths. Before we continue, ask yourself: how did thinking
about Suzanne\u8217?s problems using the different categories affect your
understanding of her problems and strengths? What was it like to consciously notice
her strengths?\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #5{\i
: Meet Raoul}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It\u8217?s now time to meet the second client we will be following throughout the
book, Raoul.\par\pard\plain\hyphpar} {
Raoul is fifty-eight and lives with his wife in a medium-size city. He has three
grown children who all live about an hour\u8217?s drive away. For the past twenty
years he has worked at the same job as a government employee in the tax department.
His daughter was home for a visit and noticed that he did not seem like himself. He
told her that he was not sleeping well and was pretty anxious about work. She
suggested that he see a therapist, and he reluctantly agreed. His daughter called
and made an appointment for him.\par\pard\plain\hyphpar} {
Raoul introduced himself to his therapist with a formal handshake and gave his full
name. He walked slowly into the room and lowered himself onto the couch with
effort. He gave a small smile and said it was his daughter\u8217?s idea that he
come. His therapist asked how she could help him. Raoul explained that in the past
he has had periods when he felt depressed, but he was always able to get over them
on his own. Lately he was depressed again, and things were not going well at work.
To better understand Raoul\u8217?s concerns, his therapist used Questions to
Explore Your Client\u8217?s Problems. Raoul said that his problems had started when
a younger man was promoted to the job that should have been his. He explained in
some detail how unfair the hiring process had been. Since then, he said, he has
been having difficulty concentrating at work, and for the first time ever, he
recently received a poor work evaluation. He is worried about the work evaluation
and what the consequences would be if he receives another one. He stressed that for
the past twenty years he has only received good year-end
evaluations.\par\pard\plain\hyphpar} {
Since the poor work evaluation there has been some tension with his boss. His
therapist asked for examples of situations with his boss that were difficult, or
projects where he was having difficulty concentrating. Raoul had trouble giving
specific examples of tension with his boss but was able to list the projects on
which he was procrastinating.\par\pard\plain\hyphpar} {
Raoul\u8217?s therapist asked about other aspects of his life, but he was very
hesitant to talk about anything but his problems at work. Everything else was
\u8220?fine.\u8221? He reported that he and his wife \u8220?have no
problems.\u8221? He occasionally has a couple of beers when he goes out, but
otherwise doesn\u8217?t drink. He said his health was good. He told his therapist
that he was usually shy, but for the past five years he has been part of a bowling
league, which his wife had encouraged him to join. His therapist assumed that as
therapy progressed and Raoul learned to trust her, she would find out more about
the other areas of his life. For the time being, she thought it would be helpful to
focus on his work difficulties.\par\pard\plain\hyphpar} {
Raoul and his therapist made the following list of problems he wanted to work
on:\par\pard\plain\hyphpar} {
Feeling anxious\par\pard\plain\hyphpar} {
Not completing projects on time\par\pard\plain\hyphpar} {
Sleeping poorly\par\pard\plain\hyphpar} {
Tension with his boss\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Raoul\u8217?s Stressors and
Strengths\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Consider the information you already have about Raoul in relation to his stressors
and strengths. Try to fill in the chart below. You can find my answers in the
appendix.\par\pard\plain\hyphpar} {\b
{\qc
Raoul\u8217?s Stressors and Strengths}} {\b
Difficulties or Stressors} {\b
Strengths or Areas of Resilience} {
{\b
Family}\par\pard\plain\hyphpar} {
{\b
Friends and Social Contacts}\par\pard\plain\hyphpar} {
{\b
Recreation & Organizations}\par\pard\plain\hyphpar} {
{\b
Work or School}\par\pard\plain\hyphpar} {
{\b
Health}\par\pard\plain\hyphpar} {
{\b
Finances}\par\pard\plain\hyphpar} {
{\b
Changes}\par\pard\plain\hyphpar} {
Exercise 2.1\par\pard\plain\hyphpar} {
Practice seeing a client\u8217?s stressors and strengths.\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #6{\i
: Understand Your Client\u8217?s Psychosocial
History}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Most therapists take a history of the presenting problem as well as a general
psychosocial history. Some therapists spend a whole session taking a detailed
history; others ask for a quick thumbnail overview. Even if you only take a brief
history, it\u8217?s helpful to place your client\u8217?s current problems in the
overall history of her life, being sure to also listen for her strengths and areas
of resilience.\par\pard\plain\hyphpar} {
Generally, when taking a history you are trying to figure out how your
clients\u8217? past experiences relate to their current problems. As a CBT
therapist, I take a psychosocial history in a similar manner as any other
therapist; however, there are two main areas that I emphasize and that might be
slightly different from non-CBT therapists. First, therapists usually ask clients
how they {\i
felt} about a given event in their past; I make sure that I also ask what it {\i
meant} to them, or what their {\i
thoughts} were at the time. I am particularly interested in the messages my client
learned about herself, others, and the future. Some of the questions I ask
are:\par\pard\plain\hyphpar} {
How did you understand this event?\par\pard\plain\hyphpar} {
How did you explain this event to yourself?\par\pard\plain\hyphpar} {
What did this event mean about you?\par\pard\plain\hyphpar} {
What did this event mean about other people?\par\pard\plain\hyphpar} {
What did this event mean about your future?\par\pard\plain\hyphpar} {
For example, a client of mine, Lisa, failed grade six when her parents divorced,
and she went to live with her grandparents. When I asked if she thought that
failing grade six meant anything about her, she replied, \u8220?I am not very
smart, and without my parents\u8217? help I couldn\u8217?t manage.\u8221? This is
important information. Another client of mine, Michael, was sexually abused by his
uncle over a period of three years, starting when he was eight years old. When I
asked him how he understood the sexual abuse, he explained that he thought it
happened because something was wrong with him and that he can\u8217?t trust anyone;
he then added that bad things are always going to happen to him in the future.
Early messages such as these will influence how your client feels, thinks, and
behaves in her current life.\par\pard\plain\hyphpar} {
The second area I emphasize is listening for strengths and evidence that my client
is competent and lovable. I am starting to gather evidence that I can use later to
counter any negative beliefs. Although it is not a hard-and-fast rule, I usually
don\u8217?t share my perception of my client\u8217?s strengths this early in
therapy. I have found that if I share my perception of strengths too early, it is
just rejected. For example, my client Lisa, who failed a grade the year her parents
divorced, mentioned that she passed the next year and completed nursing training.
She was also one of the few students in her class to be offered a job immediately
upon graduating. I kept that information in my back pocket, so that down the road
when we start to explore her belief that she is not smart and can only manage with
her parents\u8217? help, I know that I have some evidence to counter that
belief.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #7{\i
: Explain CBT}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After you have an understanding of your client\u8217?s problems and have taken a
history, it is time to explain how CBT works. Here is an example of how I might
explain CBT. (A copy of Explain CBT to Your Client is available at
http://www.newharbinger.com/38501.)\par\pard\plain\hyphpar} {
I have heard a bit about your problems and how they are affecting your life. I want
to tell you how I work. I use a CBT model. CBT is a goal-oriented form of therapy.
I am going to ask you to set some goals for yourself in therapy and together we are
going to focus on working toward them.\par\pard\plain\hyphpar} {
Therapy will involve us first understanding your problems by identifying your
thoughts, feelings, physical reactions, and behavior and how they fit together. We
will then start to help you make some changes by focusing on one of these factors
at a time. Since they are all related, a change in one factor will influence all of
the other factors.\par\pard\plain\hyphpar} {
At this point I often take a situation from my client\u8217?s life and together we
explore her thoughts, feelings, physical reactions, and behavior. For example, in
Raoul\u8217?s case we might pick his discomfort when he has to interact with his
colleagues at work. You do not want to choose a situation in which your client has
a very strong emotional reaction, as she will be too overwhelmed to listen to you
and apply the four-factor model. After exploring a situation using the four-factor
model, ask if this makes sense to your client.\par\pard\plain\hyphpar} {
If you are working with children or teens, there are many wonderful games you can
use to explain how thoughts can influence feelings, physical reactions, and
behavior (see, for example, Kendall, Choudhury, Hudson, & Webb, 2002; Stallard,
2005).\par\pard\plain\hyphpar} {
Video 2.2\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Clinical
Examples\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercise.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 2.1:} Ruda Attends Playgroup\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Try looking at your life in terms of your own stressors and
strengths.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Explore Your Own Stressors and
Strengths\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Use the table below to write down your stressors and strengths. Writing them down
is important as it helps you step back and look at them. Did you learn anything
about yourself?\par\pard\plain\hyphpar} {\b
{\qc
My Own Stressors and Strengths}} {\b
Difficulties or Stressors} {\b
Strengths or Areas of Resilience} {
{\b
Family}\par\pard\plain\hyphpar} {
{\b
Friends and Social Contacts}\par\pard\plain\hyphpar} {
{\b
Recreation & Organizations}\par\pard\plain\hyphpar} {
{\b
Work or School}\par\pard\plain\hyphpar} {
{\b
Health}\par\pard\plain\hyphpar} {
{\b
Finances}\par\pard\plain\hyphpar} {
{\b
Changes}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
For the next assignment, think of a client you will be seeing this coming week and
identify a problem he or she is currently working on.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2Explore a Client\u8217?s
Problem\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three questions below from Questions to Explore Your Client\u8217?s
Problems. Complete the following table using the information you already have. What
did you learn from this exercise?\par\pard\plain\hyphpar} {
When you see your client, ask the necessary questions to fill in any missing
information. Take a moment to reflect on what you learned from asking about the
additional information.\par\pard\plain\hyphpar} {
Client:\par\pard\plain\hyphpar} {
Client\u8217?s Problem:\par\pard\plain\hyphpar} {\b
{\qc
Explore Your Client\u8217?s Problems}} {\b
Question} {\b
Client\u8217?s Response} {\b
Was this a helpful question? If yes, how was it helpful?} {
How has the problem affected your client\u8217?s life?\par\pard\plain\hyphpar} {
Is your client avoiding any situations because of the
problem?\par\pard\plain\hyphpar} {
How has your client coped with the problem?\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3Choose a Question to Explore a Client\u8217?s Problem Choose
one of the three questions above that you have rarely or never used, and that you
would like to practice using, or choose a different question from Questions to
Explore Your Client\u8217?s Problems. This coming week, use the question you chose
with two different clients. Be sure to notice each client\u8217?s response and the
information you obtained. You can use the following table to record your
experience.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\b
Question You Want to Practice:} {\b
Client} {\b
Client\u8217?s Response} {\b
Was this a helpful question? If yes, how was it helpful?} {
Client #1:\par\pard\plain\hyphpar} {
Client #2:\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #4Identify a Client\u8217?s Difficulties and Strengths Choose a
client you are currently working with and see if you can identify his or her
stressors in the following areas: family, friends, recreation/organizations,
work/school, health, finances, and any recent major changes or stress. Now look at
Questions to Explore Strengths. See if you can identify any strengths and areas of
resilience. Complete the table below. After you have completed the table, ask
yourself how the exercise impacted your awareness of your client\u8217?s stressors
and strengths.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\b
{\qc
Identify a Client\u8217?s Stressors and Strengths}} {\b
Difficulties or Stressors} {\b
Strengths or Areas of Resilience} {
{\b
Family}\par\pard\plain\hyphpar} {
{\b
Friends and Social Contacts}\par\pard\plain\hyphpar} {
{\b
Recreation & Organizations}\par\pard\plain\hyphpar} {
{\b
Work or School}\par\pard\plain\hyphpar} {
{\b
Health}\par\pard\plain\hyphpar} {
{\b
Finances}\par\pard\plain\hyphpar} {
{\b
Changes}\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under the agenda items.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} Develop a good therapeutic relationship.\par\pard\plain\hyphpar} {
How are your client\u8217?s thoughts important in developing an empathic
relationship?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Understand your client\u8217?s presenting
problems.\par\pard\plain\hyphpar} {
What are two questions that would be helpful in exploring your client\u8217?s
presenting problems?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Meet Suzanne.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Understand your client\u8217?s stressors and
strengths.\par\pard\plain\hyphpar} {
What are three categories you want to cover in exploring your client\u8217?s
current life situation?\par\pard\plain\hyphpar} {
What are two questions that would be helpful in exploring your client\u8217?s
strengths?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #5:} Meet Raoul.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #6:} Understand your client\u8217?s psychosocial
history.\par\pard\plain\hyphpar} {
When taking a psychosocial history, what two areas might a CBT therapist emphasize
that other therapists might not?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #7:} Explain CBT.\par\pard\plain\hyphpar} {
How could you explain CBT to your clients?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 3\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Develop Goals for Therapy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In chapter 2 we focused on assessing your client\u8217?s problems and strengths and
on how to explain CBT. Did you try using Questions to Explore Your Client\u8217?s
Problems? Did you see your client\u8217?s strengths differently after using any of
these questions? I am curious whether you have started noticing your own thoughts.
Has this made a difference in your life?\par\pard\plain\hyphpar} {
When clients complete their homework, therapy is more effective and clients are
more likely to make real changes in their lives (Rees, McEvoy, & Nathan, 2005).
Similarly, the extent to which you incorporate CBT into your own work will depend
on how much you use the material in the book and practice. The homework at the end
of each chapter is simply a structure for encouraging you to
practice.\par\pard\plain\hyphpar} {
If you did not have a chance to do the homework from chapter 2, try to identify
what factors got in the way. Maybe you did not see any clients, or you were
particularly busy. Sometimes therapists\u8217? thoughts get in the way of trying
the homework with their clients. Did you have any of the following
thoughts?\par\pard\plain\hyphpar} {
I don\u8217?t need to do the homework, or I already understand the
material.\par\pard\plain\hyphpar} {
The homework is not relevant to my clients, or if I try the CBT homework, my
clients will react negatively.\par\pard\plain\hyphpar} {
I will feel awkward doing the homework.\par\pard\plain\hyphpar} {
Did any of these thoughts stop you from doing the homework and practicing your CBT
skills? Did you have other thoughts that got in the way of practicing? The reality
is that you won\u8217?t know whether doing the homework is helpful unless you try.
What if you were surprised and the homework really helped? If you are worried about
feeling awkward the first time you try an intervention, you are right; you probably
will feel uncomfortable because you are doing something new. I would guess that the
first time you tried any new skill you felt awkward. What would your life be like
if you gave up whenever you felt awkward?\par\pard\plain\hyphpar} {
What would help you complete the homework for this chapter? Remember, the more you
practice, the easier it will be. If you did not do the homework from chapter 2,
before starting this chapter, try these two exercises:\par\pard\plain\hyphpar} {
Think of a client with whom you are currently working. Try to think of both the
stressors and the strengths in his or her life. Look at Questions to Explore
Strengths from chapter 2 for ideas of good questions to ask yourself to assess his
or her strengths.\par\pard\plain\hyphpar} {
If you have not started noticing your own thoughts, choose a recent situation in
which you had a moderate to strong emotional reaction. Take a moment to remember
your thoughts at the time. Try to write them down. How did noticing your thoughts
affect your reaction?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
CBT is an active form of therapy where the therapist and client set goals in the
beginning of therapy and work toward these goals.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} Set goals.\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Develop specific, measurable goals.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Which goal do I focus on first?\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Goals are different from problems. Problems describe what is wrong in your
client\u8217?s life. Goals are how your client would like his life to be different,
or what he would like to work toward. Setting effective goals is a key element in
CBT.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: Set Goals}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It is important that the therapist and client agree on the goals they are going to
work on, or the sessions will tend to wander and feel as though nothing is getting
accomplished. In addition, the therapy relationship is strengthened when your
client feels that you understand his goals and that therapy is going to focus on
those goals that are important to him.\par\pard\plain\hyphpar} {
Having goals in therapy is similar to starting out on a road trip. If someone asks
me which road I want to take, I have to first know where I want to end up. The road
I would choose to get to Toronto is different from the road to Detroit. The more
specific and clear the goal, the more I can plan how to get there. Goals give
direction to therapy.\par\pard\plain\hyphpar} {
Clear Goals \u8594? Focused Therapy \u8594? Effective Therapy and Satisfied
Clients\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What If My Client Has More Than One
Problem?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If a client identified two problems, you would most likely set goals for both
problems and then focus on the one he identified as his first priority. However,
clients often have multiple problems. In this case, you and your client need to
pick one or two problems that he wants to work on first and develop goals for those
problems. Later in therapy, when the client is ready to start working on a new
problem, you would develop goals for the new problem. Often as therapy progresses,
goals change.\par\pard\plain\hyphpar} {
I encourage my clients to write down their goals. It makes their goals more
concrete, and it gives us a written document to refer back to. Most importantly,
research indicates that setting goals early in therapy significantly increases
client satisfaction and the likelihood of a positive outcome (Safran & Wallner,
1991).\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Explain Goal Setting\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Below are some suggestions for how to introduce goal setting with new clients as
well as current clients with whom you have been working for some time but had never
set goals. You can download a handout with these prompts (Explain Goal Setting) at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
When explaining setting goals to a new client, you might start with the
following:\par\pard\plain\hyphpar} {
What I would like to do next is spend some time exploring your goals for therapy. I
find that having clear goals gives therapy a sense of direction. I would like to
start with identifying goals for the first problem you said you would like to work
on.\par\pard\plain\hyphpar} {
The explanation would start off differently for a current client with whom you had
not set goals at the beginning of therapy:\par\pard\plain\hyphpar} {
I have been thinking about our sessions. At this point, I think it would be helpful
for us to spend some time thinking about your goals, and what you would like our
future sessions to focus on. Setting goals can be helpful in giving therapy a sense
of direction.\par\pard\plain\hyphpar} {
But from that point on, the explanation would be the same with both
clients:\par\pard\plain\hyphpar} {
I also want to spend some time making your goals as specific as we can, as I find
the more specific the goal, the more helpful it is. Specific goals can also help us
measure whether therapy is working for you. As we talk about each goal, I would
like to write it down. Would that be okay with you?\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Practice in Your Imagination: Explain Setting
Goals\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I am going to ask you to imagine explaining goal setting first with a new client
and then with a current client. Before you start this exercise, rate from 1 to 10
how comfortable you feel introducing setting goals with your clients, with 1 being
very comfortable and 10 being very uncomfortable. At the end of the exercise, rate
your level of comfort again to see whether it changed. Now, let\u8217?s try the
exercise.\par\pard\plain\hyphpar} {
{\ql
{\b
Practice with a new client.} Imagine yourself in your office with a new client.
Take a moment to look around; notice the sounds and smells of your office. Now,
imagine that you have just gone over your client\u8217?s problems and you want to
introduce goal setting. Read over how I suggested explaining goal setting while
imagining yourself saying the words. You can also use your own phrases. Really hear
and feel yourself explaining goal setting. Now imagine explaining goal setting two
more times with the same client. Each time imagine that your client responds
positively.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Practice with a current client.} Choose a current client who you think would
benefit from setting goals, and who you also think would like the approach. Try to
get a picture of him or her in your mind. Now imagine yourself in your office. Read
over how I suggest explaining goals with a current client while imagining yourself
saying the words. You can also use your own phrases. Now imagine explaining goal
setting two more times more with the same client. Each time imagine that your
client responds positively.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3
\afs28
{\b
Agenda Item #2{\i
: Develop Specific, Measurable
Goals}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once you have introduced goal setting, you need to help your client develop more
specific goals. The more specific and clear the goal, the more helpful it is.
However, what do we mean by specific, measurable goals?\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
What Are Specific and Measurable
Goals?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Clients often start with very general goals, such as \u8220?I would like to be less
depressed [or less anxious],\u8221? \u8220?I would like to have better self-
esteem,\u8221? or \u8220?I would like to have a better relationship with my
partner.\u8221? The problem with these general goals is that you don\u8217?t have a
specific idea of how your client wants his life to be different, nor does your
client have any way of knowing whether he is on his way to achieving his goals.
Goals that are specific and measurable give therapy a direction and provide a
yardstick for measuring whether therapy is on the right track. The easiest way to
understand the difference between general and specific goals is to look at some
examples.\par\pard\plain\hyphpar} {\b
{\qc
Examples of Goals}} {\b
General Goals} {\b
Specific, Measurable Goals} {
Be more assertive.\par\pard\plain\hyphpar} {
Talk to my partner about some of my concerns about our
relationship.\par\pard\plain\hyphpar} {
Set more limits with my boss (e.g., tell my boss that I can\u8217?t take on new
clients; ask my boss not to regularly call me on weekends or
evenings).\par\pard\plain\hyphpar} {
Express my opinion when I am out with friends.\par\pard\plain\hyphpar} {
Be less anxious.\par\pard\plain\hyphpar} {
Give a presentation at work.\par\pard\plain\hyphpar} {
Don\u8217?t check on my kids as much (e.g., don\u8217?t phone them on their cells
if they are 10 minutes late, but wait until they are half an hour late; only ask
once a night whether their homework is done).\par\pard\plain\hyphpar} {
Don\u8217?t blow up over little things, like my husband forgetting to pack the
children\u8217?s lunch.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Identify Specify, Measureable
Goals\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
At first the difference between a general goal and a specific, measurable goal can
be hard to identify. Look at the goals below and decide how you would rate them.
You can find my answers in the appendix.\par\pard\plain\hyphpar} {\b
{\qc
Assess Whether the Goal Is General or Specific and Measurable}} {\b
Goals} {\b
Is This Goal General or Specific and Measurable?} {
Talk to my boss about getting paid for working overtime\par\pard\plain\hyphpar} {
Be less demanding of my friends\par\pard\plain\hyphpar} {
Stop smoking by the end of the month\par\pard\plain\hyphpar} {
Take better care of my health\par\pard\plain\hyphpar} {
Get along better with my parents\par\pard\plain\hyphpar} {
Do a pleasant activity with my partner on a weekly basis\par\pard\plain\hyphpar} {
Learn better parent management skills for when my eight-year-old has a temper
tantrum\par\pard\plain\hyphpar} {
Let\u8217?s look at two of the above goals in detail. The goal \u8220?talk to my
boss about getting paid for working overtime\u8221? is a specific goal. We know
exactly what behavior the client wants to do and we can measure whether he was able
to do the behavior. The goal \u8220?be less demanding of my friends\u8221? is a
general goal. Since we don\u8217?t know what specific thoughts, feelings, physical
reactions, or behaviors the client would like to increase or decrease, we will have
no way of knowing whether the client was successful in working toward this
goal.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Help Your Client Develop Specific and Measurable
Goals\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It can be challenging to move your client from general goals to more specific
goals. Below are some questions that can help. You can download them in handout
form (Questions to Develop Helpful Goals) at http://www.newharbinger.com/38501. You
can substitute one of your client\u8217?s general goals for \u8220?less
depressed.\u8221?\par\pard\plain\hyphpar} {
{\b
Question 1:} Are there specific situations that you would like to be handling
differently? How would you like to behave in these
situations?\par\pard\plain\hyphpar} {
{\b
Question 2:} If you met your goal (e.g., to be less depressed), what would you be
doing differently? Or how would you be reacting to situations
differently?\par\pard\plain\hyphpar} {
{\b
Question 3:} If you met your goal (e.g., to be less depressed), how do you think
your life would be different?\par\pard\plain\hyphpar} {
A client of mine, Barbara, came to therapy because of low self-esteem and \u8220?
wanting to like myself more.\u8221? When I asked, \u8220?If you liked yourself
more, what would you do differently?\u8221? she paused and responded, \u8220?I have
never thought about that.\u8221? She was able to list a number of specific issues,
including applying for a promotion, not saying yes to her girlfriends in situations
where she thought they were taking advantage of her, and standing up to her mother.
We explored each goal. At the end she turned to me and commented, \u8220?You really
heard me. I feel that we have something specific to work
toward.\u8221?\par\pard\plain\hyphpar} {
When developing specific goals, you don\u8217?t want to be rigid. If your client
wants to keep a general goal that is meaningful to him, I would keep it, but try to
add some more specific goals to guide therapy.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Raoul\u8217?s Goals Become More
Specific\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
One of Raoul\u8217?s initial goals was to be less anxious. This is a good general
goal. Let\u8217?s see how Raoul\u8217?s therapist uses Questions to Develop Helpful
Goals.\par\pard\plain\hyphpar} {
{\i
Therapist:} Being less anxious is a good general goal, and a good place to start. I
think it would be helpful if you could be a bit more specific or
concrete.\par\pard\plain\hyphpar} {
{\i
Raoul:} What do you mean?\par\pard\plain\hyphpar} {
{\i
Take a moment and think about how you could you use Question 1 to make Raoul\u8217?
s goals more specific.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I think it would be helpful to think of some specific ways that we
could know you were on your way to achieving your goal. For example, are there any
particular situations where you would like to be less anxious? (Question
1)\par\pard\plain\hyphpar} {
{\i
Raoul:} I guess at work, I am just really stressed.\par\pard\plain\hyphpar} {
{\i
Raoul\u8217?s goals are starting to be more focused, but we still do not have
specific, measurable goals. How could you use Question 2 to make Raoul\u8217?s
goals more specific?}\par\pard\plain\hyphpar} {
{\i
Therapist:} If you were less anxious about work, I am wondering what you would be
doing differently? (Question 2)\par\pard\plain\hyphpar} {
{\i
Raoul:} Mainly I wouldn\u8217?t procrastinate over my big
projects.\par\pard\plain\hyphpar} {
{\i
Raoul is starting to be more specific. Take a moment to think about how you could
use what he just said and turn it into a goal.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Might one goal be to stop procrastinating on your big
projects?\par\pard\plain\hyphpar} {
{\i
Because Raoul did not explicitly state this as a goal, his therapist used the
term \u8220?might\u8221? when she turned Raoul\u8217?s words into a goal. Using
\u8220?might\u8221? permits Raoul to disagree with his
therapist.}\par\pard\plain\hyphpar} {
{\i
Raoul:} Definitely.\par\pard\plain\hyphpar} {
{\i
Raoul has made the goal more specific, but it would still be hard to measure. How
could you use Question 2 to make Raoul\u8217?s goals more
measurable?}\par\pard\plain\hyphpar} {
{\i
Therapist:} If you stopped procrastinating, what would you like to do differently?
(Question 2)\par\pard\plain\hyphpar} {
{\i
Raoul:} I would stop avoiding my colleagues on the project, get down to work, and
talk to my boss about the project.\par\pard\plain\hyphpar} {
{\i
Therapist:} It sounds like some of your goals might be to stop avoiding your
colleagues, talk to your boss about the project, and get down to
work.\par\pard\plain\hyphpar} {
{\i
Raoul:} Yeah, those would be good goals. I am not sure that I want to talk to my
boss, but it would be good to start the project.\par\pard\plain\hyphpar} {
{\i
Therapist:} It seems that a first goal might be to contact your colleagues and
start work on the project, and then a longer-term goal might be to talk to your
boss. Does that sound right?\par\pard\plain\hyphpar} {
{\i
The therapist realized that talking to the boss might not be Raoul\u8217?s goal at
the moment. The therapist wondered whether breaking the goals down into immediate
and longer-term goals was more in line with what Raoul
wanted.}\par\pard\plain\hyphpar} {
{\i
Raoul:} ({\i
looking a bit more energetic}) Yes, I think that would be very
helpful.\par\pard\plain\hyphpar} {
{\i
Therapist:} Those are good goals. Let\u8217?s write down the goals we have talked
about so far and then see whether there are any other ones. When you think about
what we just talked about\u8212?how would you write out the
goals?\par\pard\plain\hyphpar} {
{\i
Notice that the therapist gives Raoul positive reinforcement for developing good
goals.}\par\pard\plain\hyphpar} {
The therapist and Raoul continue to explore his general goal \u8220?be less anxious
at work.\u8221? They develop the following list of specific
goals:\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Raoul\u8217?s Goals:\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Cope better at work, particularly concentrate on my work and get my projects done
on time.\par\pard\plain\hyphpar} {
Socialize with people at work the way I used to. This includes talking to people,
having lunch in the lunchroom, going out for lunch, and chatting in the
hallways.\par\pard\plain\hyphpar} {
Not get anxious every time the boss talks to me.\par\pard\plain\hyphpar} {
Start to like work again.\par\pard\plain\hyphpar} {
You will notice that some of Raoul\u8217?s goals are very specific and measurable,
for example, \u8220?get my projects done on time.\u8221? Some of the goals are
still fairly general, for example, \u8220?start to like work again.\u8221? The
therapist thought they had made a good start and did not want to push developing
specific goals too much, as they were just forming a relationship. The specific
goals could be used immediately to give direction to therapy, and the more general
goals could be worked on later in therapy.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Help Suzanne Make Her Goals More
Specific\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Imagine that you have just introduced goal setting to Suzanne. Try to help Suzanne
set specific goals that can be measured.\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, to start, my main goal is to be less
depressed.\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Suzanne
develop a more specific goal:\par\pard\plain\hyphpar} {
{\ql
I am so glad you are willing to work on your depression. What could you do to be
less depressed?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I hear how down you are feeling. You have a lot going on in your life. I am
impressed that you came for help. It is an important first
step.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
That sounds like an excellent goal. It is pretty broad. If you were less depressed,
how do you think your life would be different? {\i
Response #3 is the most likely to help Suzanne develop a specific goal and to start
thinking about what she would like to be different in her life. Response #1 starts
to problem solve. This is too early in therapy. Response #2 is a supportive
comment, but it does not help Suzanne become more specific.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} That sounds like an excellent goal. It is pretty broad. If you were
less depressed, how do you think your life would be
different?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} Well, I would go out more for sure and not just want to stay home all the
time.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Ask yourself whether \u8220?go out more and not want to stay home all the
time\u8221? is specific enough. Look at the three possible responses below and pick
the one you think will help Suzanne be more specific.\par\pard\plain\hyphpar} {
{\ql
I hear you would like to go out more. Did you used to go out more? What are some of
the things that are in the way of you going out more
now?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
If you were to go out more, what are some of the things that you would like to
do?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I hear you would like to go out more. Can you tell me more about that? {\i
Response #2 is most likely to focus the client on identifying specific activities
she would be doing. Response #1 starts a problem-solving process without being
clear what \u8220?going out more\u8221? refers to. Response #3 is too vague. You
might get helpful information, but Suzanne may also talk about being depressed in a
general manner.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} If you were to go out more, what are some of the things that you would
like to do?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} Well, for sure taking my kids to some of their activities, probably
seeing friends, maybe going out with my
husband.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne and her therapist continue to explore her goals and what might be some good
indicators that she is on the path to feeling less depressed. Here are the goals
that Suzanne and her therapist developed:\par\pard\plain\hyphpar} {
{\ql
{\b
Suzanne\u8217?s Goals:}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Fit into the new school. Try to make friends with the other teachers and
join some of the extracurricular
activities.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Not be so overwhelmed, but feel I am managing more; better morning and
afternoon routine.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Not yell at the kids so much and play with the kids
more.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Have good times with my husband and not be so angry all of the
time.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Reconnect with my friends.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\ql
\u8226? Enjoy my husband and children, start to do some fun things with
them.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Have more energy, not be tired all of the time. (As part of this goal
Suzanne agreed to look at lifestyle issues. Depending on the client, this might
include smoking, alcohol consumption, exercise, diet, and sleep
hygiene.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
When you look at Suzanne\u8217?s goals, you will see that some are still very
vague, such as \u8220?have more energy\u8221?; however, some are concrete and
specific. You\u8217?ll also notice that some of the goals are stated in the
negative and involve what Suzanne wants to stop doing, for example, not be angry
all of the time, and some are positive goals, or what she wants to do. If your
client has a negative goal, it is important to balance it with a positive
goal.\par\pard\plain\hyphpar} {
Exercise 3.1\par\pard\plain\hyphpar} {
Practice using Questions to Develop Helpful Goals{\i
.}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Which Goal Do I Focus on First?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
The third stage in goal setting involves choosing where to begin. The therapist can
simply say, \u8220?Let\u8217?s look over your goals and pick one to start
with.\u8221? Frequently a client\u8217?s goals are interrelated, in which case it
will be possible to work on more than one goal during a therapy session. For
example, many of Raoul\u8217?s goals are related to work. You want to start with
goals that are doable and where there is a good chance of success. When therapy
helps clients make changes in their lives, clients become more committed to therapy
and more hopeful that their lives can improve.\par\pard\plain\hyphpar} {
When Suzanne and her therapist looked at her goals, Suzanne\u8217?s first priority
was to fit into her new school and try to make some friends among the other
teachers. Her second goal was to do some fun things with her children and husband.
Suzanne\u8217?s therapist thought these were good places to start and that it might
be possible to address both goals early on in therapy.\par\pard\plain\hyphpar} {
Video 3.1\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before moving on to the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Clinical
Examples\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercise.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 3.1:} Miriam Wants a Better Marriage\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before practicing this week\u8217?s skills with your clients, let\u8217?s start
with focusing on your own goals.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Set Goals for
Yourself\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Step 1:} Take a moment to think about what you hoped to learn when you started
reading this book. How did you hope to change your therapy practice? Now think
about how you would like your life to be different. Identify one goal for yourself
in relation to learning CBT and one goal in relation to your personal
life.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Step 2:} Try to make your goals more specific and measurable by using Questions to
Develop Helpful Goals. For each goal, see whether you can identify a measurable
indicator that would put you on the road to accomplishing your
goal.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Step 3:} Complete the following
table.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\b
{\qc
Your Goals}} {\b
Your General Goal(s)} {\b
Specific and Measurable Goal} {\b
What Was It Like to Set Specific Goals?} {\b
What Did You Learn That Is Relevant to Your Therapy with Clients?} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose both a new client and a current client who you think would be open to
setting goals for therapy. If you don\u8217?t have a new client this coming week,
choose two current clients.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Set Specific Goals with Your
Clients\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete these steps with each client you selected.\par\pard\plain\hyphpar} {
{\ql
{\b
Step 1:} Ask your client to identify his or her goals for
therapy.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Step 2:} Ask your client to pick the goal that is most important to him or her.
Help your client make the goal more specific and measurable by using Questions to
Develop Helpful Goals. See whether you can identify a measurable indicator that
would put your client on the road to accomplishing his or her
goal.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Step 3:} Complete the following table for a new client and a current
client.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\b
{\qc
Help Your Client Set Specific Goals}} {\b
Client\u8217?s General Goal} {\b
Specific and Measurable Goal} {\b
How Did the Client React to Setting Specific Goals?} {\b
What Did You Learn?} {
Client #1\par\pard\plain\hyphpar} {
Client #2\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under the agenda items.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} Set goals.\par\pard\plain\hyphpar} {
How could you introduce setting goals in therapy with a new client and with a
current client?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Develop specific, measurable goals.\par\pard\plain\hyphpar} {
What is an example of a specific, measurable goal?\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Agenda Item #3:} Which goal do I focus on first?\par\pard\plain\hyphpar} {
How might you decide which goal to start with?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concepts would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try with a client this coming week? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 4\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Structure Your Sessions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Did you have a chance to try setting goals with a new or current client? Did you
try any other homework assignments from previous chapters? When you think of the
interventions that you\u8217?ve tried, what would you like to continue
doing?\par\pard\plain\hyphpar} {
If you did not have a chance to try setting goals, take a moment and identify what
obstacles got in the way. Choose a specific client you will see this coming week
who you think would be open to setting goals. Now imagine yourself in your office
setting goals with this client, and then try it!\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
We have identified your client\u8217?s problems, taken a history, explained the CBT
model, and set goals. This usually takes between one and two sessions. You are now
ready to start addressing your client\u8217?s problems. In this chapter, I want to
focus on how to structure or organize your therapy
sessions.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} Organize your therapy sessions.\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Start with a check-in.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Collaboratively set an agenda.\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} Work the agenda.\par\pard\plain\hyphpar} {
{\b
Agenda Item #5:} Develop helpful homework for the next
session.\par\pard\plain\hyphpar} {
{\b
Agenda Item #6:} Review the session and ask for feedback.\par\pard\plain\hyphpar}
{\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Research shows that having a structure, and in particular setting an agenda,
keeping to the agenda, and giving homework are key factors in effective therapy
(Shaw et al., 1999). Many of my students tell me that structuring a session is one
of the most helpful CBT skills that they learned; I think you will also find it
helpful.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: Organize Your Therapy Sessions}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
A structured session means that there is an order and organization to the therapy
session. Here is a brief overview of the five basic components. I will go over each
one in more detail later in the chapter.\par\pard\plain\hyphpar} {
{\b
Check in.} This is a quick update on what has happened since the previous session
and includes a bridge to the previous session.\par\pard\plain\hyphpar} {
{\b
Set the agenda.} You and your client decide together which problems to focus on in
the current session. Homework from the previous session can be reviewed during the
check-in or as part of the agenda-setting process.\par\pard\plain\hyphpar} {
{\b
Work the agenda.} This involves addressing the identified problems on the
agenda.\par\pard\plain\hyphpar} {
{\b
Homework.} You and your client collaborate to develop homework for the following
session.\par\pard\plain\hyphpar} {
{\b
Review.} At the end of the session you briefly review with your client what was
covered in the current session and ask your client for
feedback.\par\pard\plain\hyphpar} {
At first, covering all of these components in one session may seem like a lot.
However, once you get used to using a structure, it will flow naturally; my
prediction is that you will wonder how you ever worked any other way. Learning to
use a structure is similar to learning to drive a car. When I first learned to
drive I was quite overwhelmed with how much I had to do all at once. I remember the
first time I parked my parents\u8217? car in the garage. I was so focused on not
putting too much pressure on the gas, remembering where the brake was, and making
sure that I did not hit anything on the right side that I scratched the whole left
side of the car on the garage wall. I didn\u8217?t even have the necessary reflexes
to hit the brake. With practice, driving became easy; and, you will be happy to
know, I have not smashed into any walls in years! Just as driving is now a routine
activity for me, using a structure will feel like the normal way of working once
you have practiced with a few clients.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Your Attitude Toward a Structured
Session\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Some therapists immediately like the idea of a structured session; others have
negative reactions such as {\i
I will find a structure too rigid}, {\i
My clients won\u8217?t like it}, and {\i
It will interrupt the flow of therapy}. However, I believe that after you try
structuring sessions with a few clients you will start to think, {\i
Structure gives my therapy more focus}, and {\i
My clients will like having a chance to let me know what they want to focus on}.
Take a moment to notice your own thoughts about using a
structure.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Explain the Structure of the Therapy Session to Your
Client\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Explaining the structure of a therapy session will help your client feel more
comfortable, as she will know what to expect. I think of therapy as similar to
visiting a foreign country. If you don\u8217?t know the customs, and you don\u8217?
t know what to expect, you will be uncomfortable. When I was in my twenties I spent
a year in Indonesia. I remember the first time I went to an Indonesian wedding. I
walked into the room, looked around, and had absolutely no idea what to do. To say
the least, I felt very awkward. I can still remember my relief when my friend who
had invited me took my arm, gently sat me down, and explained what was going to
happen and what I needed to do. Explaining the structure of therapy is similar to
explaining the customs of a foreign country. Your clients will be more relaxed and
trusting if they know what to expect. You can find a Explain the Structure of a
Therapy Session handout at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Explain the structure of a therapy session with a new client.} Here is an example
of how you can explain structuring a session to a new client. I explain both what I
am going to do and why.\par\pard\plain\hyphpar} {
We\u8217?ve spent some time getting an idea of your problems and setting goals for
therapy. I want to explain how I\u8217?d like to structure the actual therapy
sessions. Each week when you come in I want to start with a brief check-in so that
you can bring me up to date on anything that has happened in your life since our
last session and we can get a sense of how you are doing. Then I want to make a
list of what you would like to talk about during our therapy session. I find this
helps make our sessions more focused, and that way I can be sure that we talk about
what is most important for you. I call this setting an agenda. Often you and I will
have decided on some homework that you are going to try in between sessions. If you
had any homework, I will check on how it went. At the end of the session, we\u8217?
ll spend some time summarizing what we\u8217?ve covered and make sure that we are
on the right track for you. We will also see if there is any homework that makes
sense for you to try before our next session. How does that sound to
you?\par\pard\plain\hyphpar} {
Most clients just say \u8220?Fine,\u8221? after which I say, \u8220?Let\u8217?s
start. Could you bring me up to date on how your week has been and then we can see
what you would like to focus on today?\u8221? With a new client, this is a
straightforward process, and it almost always goes
smoothly.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Explain the structure of a therapy session with a current client.} If you have not
been using a structured format, you may feel awkward about introducing a structure
with a current client. Here is an example of how you could
begin.\par\pard\plain\hyphpar} {
I\u8217?ve been thinking about our sessions, and I would like to try something new
today. I thought we would start with a brief check-in, so that you can bring me up
to date on anything that has happened in your life since our last session and we
can get a sense of how you are doing. I would then like to make a list of what you
would like to focus on during our therapy session today and decide which issue you
would like to start with. I think this will help focus our sessions, and that way I
can be sure that we talk about what is most important for you. At the end we\u8217?
ll spend some time summarizing what we covered and see how you liked working this
way.\par\pard\plain\hyphpar} {
Notice I am very clear about what we will do and that I will check whether my
client likes this new way of working. My guess is that almost all of your clients
will find having a structure helpful. Once you have explained setting a structure,
it becomes a normal part of therapy. Clients who are used to the structure tend to
spend time before the session thinking about what they want to talk about. Therapy
becomes more focused; clients usually come in with one or two agenda items. When a
client is used to a structured format, I start with, \u8220?Hello, good to see you.
I want to check in and see how you have been doing, see what you would like to
focus on today, and check how your homework went.\u8221?\par\pard\plain\hyphpar} {
{\qc
Your Turn! Practice in Your Imagination: Explain How a Session Is
Structured\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I would like you to imagine explaining how a session is structured, first with a
new client and then with a current client. Before you start this exercise, rate
from 1 to 10 how comfortable you feel explaining structuring a session with both a
new and a current client, with 1 being very comfortable and 10 being very
uncomfortable. At the end of the exercise, rate your level of comfort again to see
if it has changed. Now, let\u8217?s try the exercise.\par\pard\plain\hyphpar} {
{\ql
{\b
Practice with a new client.} Imagine yourself in your office with a new client.
Take a moment to look around; notice the sounds and smells in the room. Now imagine
you want to explain how you would like to structure the sessions. Read over how I
explain structuring a session with a new client while imagining yourself saying it.
You can also use your own phrases. Really hear and feel yourself explaining how you
want to structure the therapy sessions. Now imagine explaining how you want to
structure a session two more times with the same client. Each time imagine that
your client responds positively.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Practice with a current client.} Choose a current client who you think would
benefit from, and would like, a structured approach. Try to get a picture of him or
her in your mind. Now, imagine yourself in your office. Read over how I explain
structuring a session with a current client while imagining yourself saying it. You
can also use your own phrases. Now imagine explaining setting a structure two more
times with the same client. Each time imagine that your client responds
positively.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #2{\i
: Start with a Check-In}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The check-in is an opportunity to get a general sense of how your client is doing,
find out if there have been any new developments in her life, and check on any
issues that were raised in the last session. That way, if there have been any major
events, or changes in your client\u8217?s life, you know about them right from the
beginning of the session.\par\pard\plain\hyphpar} {
Below is a review of the main components of the check-in that are covered in most
sessions. Depending on the flow of the session, you may not necessarily complete
the components in the order below.\par\pard\plain\hyphpar} {
Check whether there are any new developments in your client\u8217?s life and
generally how your client has been since the last session.\par\pard\plain\hyphpar}
{
Rate your client\u8217?s overall mood since the previous
session.\par\pard\plain\hyphpar} {
Bridge to the last session and ask about any issues you are concerned
about.\par\pard\plain\hyphpar} {
Review the homework from the last session.\par\pard\plain\hyphpar} {
Identify possible agenda items.\par\pard\plain\hyphpar} {
Let\u8217?s look at the different components.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Check how your client has been since the last session.} You want to know if there
have been any changes since the last session and generally how your client has been
feeling. If there has been a change in my client\u8217?s mood, either for better or
worse, I follow up with asking whether anything has changed or how my client
understands the change in her mood.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Ask your client to rate her mood.} I usually ask my clients to rate their overall
mood since the last session. Most non-CBT therapists are not used to rating
moods\u8212?try it and see whether you and your clients find it helpful. Use a
scale of 1 to 10, with 10 being the worst your client has ever felt, and 1 being
very happy. Rating helps your client engage in a process of self-reflection. It
also gives you a quick sense of how your client is doing and if she is better, the
same, or worse since the last session.\par\pard\plain\hyphpar} {
Let me give you a quick example of how rating your client\u8217?s mood can be
helpful. When I started working with Donald, his depression was at a 10 and we
wondered whether he should be hospitalized. After about six months of therapy,
Donald had significantly improved, and his moods were generally in the 4 to 5
range. He had been away and I had not seen him for over two weeks. He started his
session saying he had been very depressed for the past two weeks, and he was scared
that he would need to be hospitalized. He rated his overall mood at an 8. Realizing
he was at an 8 and not a 10 helped him feel less frightened and enabled him to
focus on the issues related to his increased depression.\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Bridge to the last session.} This is an opportunity to follow up on any issues from
the previous session, including asking about specific areas in your client\u8217?s
life that you are worried about. For example, if I have a client who has been
suicidal, during the check-in I ask about current suicidal thoughts and behavior.
If a client is working on a specific issue, such as reducing weekend binge drinking
or stopping cutting herself, even if the client doesn\u8217?t mention drinking or
cutting, I will ask as part of the check-in. This provides a sense of continuity to
the work of therapy.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Review the homework.} The check-in is a good time to review any homework, though
some therapists review homework as part of setting the agenda. A large meta-
analytic study (Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010) found that
homework completion was significantly related to a positive outcome in therapy.
This means we need to do everything we can to encourage our clients to complete
their homework. Asking about and reviewing homework tells your client that homework
is important and encourages completion.\par\pard\plain\hyphpar} {
If your client completed her homework, give positive feedback and indicate that it
is important. Check what she actually did as well as the outcome. Clients
don\u8217?t always understand the homework in the same way you intended it. You
then want to ask what your client learned from doing the
homework.\par\pard\plain\hyphpar} {
If your client did not complete the homework, explore what got in the way. I
usually ask my client what might help her complete homework in the future. If
possible, we spend some time completing the homework task in session. At the end of
the session, I spend extra time making sure the homework for the coming week makes
sense to my client. Later in this chapter we are going to talk about how to develop
effective homework.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Identify possible agenda items.} Issues raised in the check-in are often good
issues to put on the agenda for the therapy session. For example, if a client tells
you that she is thinking of breaking up with her boyfriend, or that she impulsively
spent too much money on clothes again, you can say, \u8220?I want to check if this
is something that you would like to talk about today\u8221? or, \u8220?Is this
something that we should put on the agenda?\u8221? It is important to check, as
sometimes when asked, clients realize that this is not really what they want to
talk about.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Keep the Check-In Focused\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The challenge with the check-in is to keep it short and focused. This means that
rather than immediately exploring an issue your client brings up, you need to
contain the client and make sure this is what she wants to address in the therapy
session. For example, imagine that during the check-in your client starts giving a
long and complicated example of a difficulty she is having with her child\u8217?s
teacher, and you have not yet set the agenda. You might say, \u8220?I think this is
an important topic. However, before we talk more about it, I want to make sure this
is what you want to focus on today and see whether there are any other
issues.\u8221? If you have explained to your client that she will set the agenda at
the beginning of the session, she will find it normal that you stop and check what
she wants to talk about. She may say, \u8220?Yes, this is the main issue.\u8221? In
that case, you have your agenda. The check-in is a balance between exploring issues
enough to have some understanding of the issue and make sure there is no immediate
crisis, and not letting the check-in take the whole
session.\par\pard\plain\hyphpar} {
Here are some phrases that I have found helpful in keeping my client focused during
the check-in:\par\pard\plain\hyphpar} {
That sounds like a really important issue. Before we talk more about it, I want to
check if there is anything else that happened this week or anything else you want
to bring up in therapy today.\par\pard\plain\hyphpar} {
That sounds pretty upsetting, and it would be important to talk more about it.
Before we go into more detail, I want to be sure I get an overall sense of how you
have been since our last session.\par\pard\plain\hyphpar} {
I can see how upsetting that would be. I want to write it down to be sure we get
back to it, but I also want to check up on what we talked about last
week.\par\pard\plain\hyphpar} {
When a client comes in and starts talking about an important situation in her life,
it can be hard not to get pulled into starting therapy and forget about finishing
the check-in or setting an agenda. You can be straightforward and simply say,
\u8220?I just realized that we started talking about this issue, and I never asked
if this is the main topic you want to talk about
today.\u8221?\par\pard\plain\hyphpar} {
A word of caution: while CBT sessions follow a set structure, it is important to be
flexible and sensitive to your client\u8217?s needs. For example, if a client
starts a session by sobbing as she tells me about an awful event that just
occurred, of course I would not rigidly keep to a structured session. I listen
empathically, assess her immediate needs, and help her deal with her overwhelming
emotions. However, after I have listened to what happened, if the client is calmer,
I might say, \u8220?I want to talk more about this. But I also want to double-check
whether there is anything else you want to talk about today.\u8221? I have often
been surprised that even if my client is in the middle of a crisis, there may be
additional issues she wants to address.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Suzanne\u8217?s Therapist Starts with a Check-
In\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s look at an example of how a check-in might work. This is Suzanne\u8217?
s fourth session and her therapist has already explained using a structured
session. Before reading the dialogue below, ask yourself: how would you start the
session?\par\pard\plain\hyphpar} {
{\i
Therapist:} Hello, good to see you. I would like to check in, see how your week has
been, make a list of what you would like to focus on today, and hear how the
homework went.\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
looking downcast}) Well, my week has been pretty much the same and pretty awful. I
did the homework and have it here.\par\pard\plain\hyphpar} {
{\i
Suzanne\u8217?s therapist wants to follow up on the homework but also wants her to
rate her mood and continue with the check-in.}\par\pard\plain\hyphpar} {
{\i
Therapist:} It\u8217?s great that you did the homework; I want to follow up on it,
but first I want to get an overall sense of your week and check what we need to
focus on today. Is that okay with you? ({\i
Suzanne nods}.) I was wondering\u8230?if you were to rate your mood over the past
week, where would you put it?\par\pard\plain\hyphpar} {
{\i
Note how the therapist redirects Suzanne to the tasks of the check-
in.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} Probably overall a 7; I just felt really down a lot of the
time.\par\pard\plain\hyphpar} {
{\i
Therapist:} So the same as last week. Were there any times that were particularly
hard, or any times when your mood was better?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I\u8217?m not sure, I was pretty down most of the week. Home is still the
same. I can\u8217?t stand the new school. I think the teachers are really awful. No
matter how hard I try, I just don\u8217?t fit in. ({\i
Sounding more upset and agitated.}) One of the teachers asked me what I do at
lunch, since she never sees me in the lunchroom. I didn\u8217?t know what to
say.\par\pard\plain\hyphpar} {
{\i
This could be a good issue to focus on in therapy as it relates to Suzanne\u8217?s
goal of \u8220?trying to fit into the new school.\u8221? However, it is also not a
crisis issue and other issues might be more important. Notice her therapist did not
respond, \u8220?How did you feel when she asked you what you do at lunch?\u8221? or
\u8220?Tell me more about that,\u8221? as these responses would encourage Suzanne
to keep talking about that incident.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Sounds like you were pretty upset by the teacher\u8217?s comment.
Before we talk more about it, I want to check if that was the main thing you wanted
to talk about or whether there were other issues.\par\pard\plain\hyphpar} {
{\i
Suzanne:} That just happened this morning. I don\u8217?t really want to spend time
on it; it\u8217?s not that important.\par\pard\plain\hyphpar} {
{\i
At this point in the check-in, Suzanne has indicated that there have not been any
changes in her life and she has rated her overall mood. There is nothing the
therapist wants to raise as a bridge from the last session. The next step is to
discuss the homework and set an agenda.}\par\pard\plain\hyphpar} {
{\qc
Your Turn! Help Raoul Stay Focused During the Check-
In\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s see how Raoul\u8217?s therapist uses the check-
in.\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Hello, good to see you. I would like to check in, see how your week has
been, see what you would like to focus on today, and go over your
homework.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Raoul:} ({\i
looking agitated}) I\u8217?ve been really anxious all week. I have a major deadline
on a project that\u8217?s due, and I am way behind. My boss must think I am a total
loser. My anxiety is through the roof. I don\u8217?t know what\u8217?s the matter
with me, I should just do the
project.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below. Choose the response that will help
Raoul stay focused on checking in.\par\pard\plain\hyphpar} {
{\ql
I can see why you would be anxious. You have done really good work in the past.
What makes you think that your boss thinks you are a
loser?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Let\u8217?s see if we can help you with your deadline. What do you need to do to
meet the deadline?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Sounds like it would be important for us to look at what is going on with the
project. Before we do that, I want to check whether anything else happened this
week that is important to you. {\i
Response #3 keeps Raoul focused on the check-in and structure of therapy. His
therapist is also demonstrating empathy about the urgency of the project. In
response #1, the therapist tries to be supportive but assumes that this issue with
the boss is the main agenda item and has not checked in or set an agenda. In
response #2, the therapist starts to problem solve without being sure this is the
topic Raoul wants to focus on.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist} Sounds like it would be important for us to look at what is going on
with the project. Before we do that, I want to check whether anything else happened
this week.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Raoul:} I\u8217?ve been so anxious, I haven\u8217?t been sleeping, but otherwise
nothing is really new. {\i
In this situation you have an agenda item that came from the check-in. Before you
start discussing the agenda item, you need to ask Raoul to rate his overall mood
during the week, and check if there are any other issues he would like to talk
about in therapy. All you need to say is, \u8220?Before we talk about your
difficulties with the project, I want to do a quick check on how your overall mood
has been this past week. How would you rate your mood, from 1 to 10?\u8221?}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 4.1\par\pard\plain\hyphpar} {
Practice keeping the check-in focused when the client has multiple
problems.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Collaboratively Set an Agenda}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Setting an agenda involves collaborating with your client to make a list of what
she wants to focus on in the session. Some therapists think that setting an agenda
sounds like a business meeting, but it is actually very client focused. When you
set an agenda you are saying, \u8220?I care that our therapy focuses on what is
important to you, so at the beginning of our session I want to spend a few minutes
checking on what you want to talk about.\u8221? The process involves the client
expressing her needs, and you, the therapist, hearing and responding to her needs.
This can be very empowering for your client.\par\pard\plain\hyphpar} {
Setting an agenda also sets the expectation that therapy is not just about coming
and talking; you expect your client to work on specific problems and to give some
thought to what she wants to talk about. You, the therapist, can also add issues to
the agenda. For example, if you talked with a teenager\u8217?s probation officer or
parent, this would be a good time to let the teen know and add it to the agenda. It
is helpful to write out the agenda and place it where you and your client can both
see it. Many therapists have a white board or flip chart in their office, but you
can also use a piece of paper.\par\pard\plain\hyphpar} {
Clear Agenda \u8594? Focused Therapy \u8594? Effective Therapy and Satisfied
Clients\par\pard\plain\hyphpar} {
One of the many things I like about setting agendas is that it helps with what I
call \u8220?doorknob therapy.\u8221? Doorknob therapy is when you have finished the
session and your client has a hand on the doorknob, ready to leave, and says,
\u8220?Oh I forgot, I wanted to talk to you about this really important
issue.\u8221? You can then say, \u8220?That sounds like an important issue. Can we
put it on the agenda for next time, and start with it?\u8221? If your client
regularly raises important issues at the end of therapy, you can start therapy by
saying, \u8220?The last couple of sessions it wasn\u8217?t until the end that you
remembered an important issue you wanted to talk about. I thought it might be
helpful to take a moment and think about what you want to talk about today.\u8221?
As your client learns to set an agenda for her therapy session, she is taking
responsibility not only for her therapy, but also for making changes in her
life.\par\pard\plain\hyphpar} {
Once you have a list of agenda items, the next step is to ask the client which
issue she would like to start with. If a client has a large number of issues on the
agenda, I simply say, \u8220?There are too many issues for us to talk about all of
them today. Let\u8217?s choose two or three and see if we can start to work on
them.\u8221? It can also be helpful to decide roughly on the amount of time you
will spend on each issue. At about the midpoint of the session I usually let my
client know the time and ask whether she wants to stay on the issue we are
discussing or move to the next issue on the agenda.\par\pard\plain\hyphpar} {
Below are some helpful questions for setting an agenda. You can download a
Questions to Help Set an Agenda{\i
handout} at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
What would you like to focus on today?\par\pard\plain\hyphpar} {
What shall we put on the agenda for today?\par\pard\plain\hyphpar} {
Should we make a list of what you would like to talk about today, and then choose
where you would like to start?\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Suzanne\u8217?s Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s look at how Suzanne\u8217?s therapist sets the agenda after they
finished the check-in. If you remember, in Suzanne\u8217?s case there were no
agenda items that came from the check-in.\par\pard\plain\hyphpar} {
{\i
Therapist:} I want to spend a few minutes making a list of what you would like to
focus on today. I also want to be sure we spend some time going over the homework,
but I want to check whether there is anything else you want to bring
up.\par\pard\plain\hyphpar} {
{\i
Suzanne:} Actually, the main issue I want to talk about is that I got an invitation
from the principal to a barbecue for new teachers at his home. I\u8217?m really
anxious, and not sure if I should go.\par\pard\plain\hyphpar} {
{\i
Therapist:} That sounds like an important issue. Anything else you want to talk
about?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Actually, yes, I have been really angry with my husband this past week.
He promised to take care of the kids on the weekend and ended up working. Those are
the two big ones I want to talk about.\par\pard\plain\hyphpar} {
{\i
Both issues relate to Suzanne\u8217?s goals. It is just a question of which is more
important to her.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Between the barbecue and being angry with your husband, where would you
like to start?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I think the barbecue, as I\u8217?ve been really worried about it. The
issue with my husband doesn\u8217?t feel as urgent.\par\pard\plain\hyphpar} {
{\i
Therapist:} Would it be okay if we start with looking at the homework, then spend
some time talking about the invitation to the barbecue, and if we have time, finish
with looking at how angry you have been with your husband?\par\pard\plain\hyphpar}
{
{\i
Suzanne:} That sounds good.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Raoul\u8217?s Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Raoul had identified an agenda item in the check-in. His therapist wants to check
whether there are additional issues he wants to talk about in
session.\par\pard\plain\hyphpar} {
{\i
Therapist:} I would like to make a list of what we want to focus on today. One
issue that you identified is the project that is due; is there anything else you
would like to talk about today?\par\pard\plain\hyphpar} {
{\i
Raoul:} Actually, my wife wants to invite her sister to stay with us for a month
while she looks for a new job. I\u8217?m really upset\u8212?what if it takes her
sister a really long time to find a job? We can\u8217?t just let her move in, but
we can\u8217?t say no, she\u8217?s family. Her sister is a very difficult woman who
talks all the time. She expects us to just take care of
her.\par\pard\plain\hyphpar} {
{\i
Therapist:} Sounds like it would be important to talk about your wife\u8217?s
sister maybe moving in, too. I just want to check if there is anything
else.\par\pard\plain\hyphpar} {
{\i
Notice how the therapist summarizes the problem to indicate she heard Raoul\u8217?s
concern, but then sticks to setting the agenda.}\par\pard\plain\hyphpar} {
{\i
Raoul:} Those are the two. I have to say, the idea of my sister-in-law living with
us is not great. She\u8217?s pretty critical, and I don\u8217?t think she really
likes me. She also puts my wife down all the time.\par\pard\plain\hyphpar} {
{\i
It is tempting to start talking about the sister-in-law; however, we have not asked
Raoul where} he{\i
would like to start.}\par\pard\plain\hyphpar} {
{\i
Therapist:} We have two big issues; which one would you like to start with, the
project at work or your sister-in-law?\par\pard\plain\hyphpar} {
{\i
Raoul:} I think the project, because if I don\u8217?t get this project done, I risk
another bad work evaluation! It\u8217?s just all so much.\par\pard\plain\hyphpar} {
{\i
Therapist:} It is a lot. How about if we started with the project? I\u8217?ll let
you know when we are halfway through the session and then we can talk about your
sister-in-law.\par\pard\plain\hyphpar} {
{\i
Notice how the therapist sticks to the structure but adds the empathic comment
\u8220?It is a lot\u8221? to indicate that she heard Raoul\u8217?s
distress.}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: Work the Agenda}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once you have set an agenda and decided on the first item, the next step is to
start working on that issue in therapy. One of the challenges is sticking to an
agenda item. In my experience, therapy drifts. For example, a client may start
talking about her anger toward her father, who criticized her parenting, and drift
to talking about her feelings toward her cousin who is moving away. It is easy to
stray from the agenda. When you talk with a friend, you drift from topic to topic;
however, in therapy you want to focus on a specific
problem.\par\pard\plain\hyphpar} {
The easiest way to keep your client focused is to point out that she has strayed
from the agenda and ask her what she would like to do. You can gently say, \u8220?
We were talking about your feelings toward your father, and we\u8217?ve moved to
talking about your cousin. I am wondering if you want to go back to discussing your
father, or if this issue with your cousin is more important.\u8221? That way, you
give your client a choice. However, it is important to be flexible. If your client
starts to talk about a painful issue that has been difficult for her to discuss or
discloses a traumatic or very distressing event, you follow your client\u8217?s
lead.\par\pard\plain\hyphpar} {
Exercise 4.2\par\pard\plain\hyphpar} {
Practice keeping to a structured session.\par\pard\plain\hyphpar} {
Video 4.1\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #5{\i
: Develop Helpful Homework for the Next
Session}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Homework is an opportunity for your client to practice in her everyday life what
she worked on in therapy. In a meta-analytic study, Kazantzis, Whittington, and
Dattilio (2010) found that overall, 62 percent of clients improved when therapy
included homework, compared with 38 percent of clients who improved when therapy
did not include homework. This seems to me like a pretty compelling reason to
include homework in your therapy.\par\pard\plain\hyphpar} {
Homework can take many forms. Some examples might be noticing the situations where
your client has specific difficulties, asking your client to complete a thought
record, or asking your client to try a new behavior.\par\pard\plain\hyphpar} {
Clients who complete homework tend to benefit more from therapy (Rees et al.,
2005). So, how do you increase the chances that your client will complete her
homework? First, be sure to leave between five and ten minutes at the end of the
session to plan the homework. Assignments given in a rushed manner tend not to get
done. Second, use the following four criteria to develop helpful homework. You can
download a Guidelines for Helpful Homework handout at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Developed collaboratively with your client\par\pard\plain\hyphpar} {
Specific and concrete\par\pard\plain\hyphpar} {
Related to the session\par\pard\plain\hyphpar} {
Doable\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Developed collaboratively.} Ideally, the homework comes out of a discussion with
your client. I often start with asking, \u8220?What do you think would be a good
way to practice what we have talked about today during the coming week?\u8221?
While your client may have some good suggestions, frequently it is the therapist
who suggests specific homework. It is important to check your client\u8217?s
reaction to any homework that you suggest. I usually say, \u8220?One idea I had was
for you to\u8230? What do you think?\u8221? My clients often have good ideas about
how to modify my suggestions.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Specific and concrete.} You and your client need to be clear on what she is going
to do for homework. To decide if the homework is specific and concrete, ask
yourself: Is there a specific behavior my client is going to try? How often will my
client do the homework? Where and when will my client do the homework? For example,
\u8220?Try to notice your negative thoughts\u8221? is not very specific or
concrete. A more specific assignment would be, \u8220?When you get angry at your
teacher in science class, write down the thoughts that go through your mind. Do you
think you can do this twice this coming week?\u8221? Your client then knows what
she will do, in what situation, and how often.\par\pard\plain\hyphpar} {
Unless homework is specific and concrete, it is impossible for your client to
accurately evaluate whether she completed the homework. For example, Raoul\u8217?s
homework was to start work on a group project he had been avoiding. The next
session Raoul reported that he contacted his colleagues and set up a meeting for
next Tuesday. Raoul added, \u8220?I wasn\u8217?t able to do the homework; I should
have already started the project.\u8221? If his homework had been to contact his
colleagues and set up a meeting, might Raoul have had a different
reaction?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Related to the session.} Clients are more likely to complete homework that flows
from the session. Let\u8217?s go back to Suzanne. One of her sessions focused on
identifying specific situations she found difficult at school. Listening to a
relaxation tape would not be an effective homework task. While she might find the
tape helpful, it is not related to what she talked about in session. A better
homework assignment would be an activity related to the situations she found
difficult at school. Effective homework is also related to a client\u8217?s overall
goals.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Doable.} Be sure to ask your client whether the homework seems doable and if she
foresees any obstacles. If your client does foresee obstacles, problem solve how to
overcome them.\par\pard\plain\hyphpar} {
{\qc
Your Turn! Evaluate Suzanne\u8217?s
Homework\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In session 6 Suzanne talked about how she has stopped doing almost all of the
activities she used to enjoy with her children. Suzanne had been very sad and self-
critical during the session and often teary. With only a few minutes left in the
session, Suzanne sighed sadly and said, \u8220?I have become a terrible mother. I
would so like to go back to doing fun things with my children again.\u8221?
Suzanne\u8217?s therapist responded with, \u8220?I would like to give you some
homework. I think it would be really helpful if you could try to do some fun things
with your children this coming week.\u8221? Does this homework meet the guidelines
for helpful homework? Complete the chart below. You can find my answers in the
appendix.\par\pard\plain\hyphpar} {\b
Helpful Homework Guidelines} {\b
Does Suzanne\u8217?s Homework Meet This Guideline?} {
The homework is developed collaboratively.\par\pard\plain\hyphpar} {
The homework is specific and concrete.\par\pard\plain\hyphpar} {
The homework is related to the session.\par\pard\plain\hyphpar} {
The homework is doable.\par\pard\plain\hyphpar} {
Before you look at the dialogue below, what questions could you ask Suzanne so that
together you could develop homework that fits the
guidelines?\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} We have about five minutes left in our session. You said you would like
to start doing some of the fun activities you used to enjoy with your children.
Does that give you any ideas for homework this coming week? {\i
It is important to start developing the homework when you have at least five
minutes left in the session. Notice that the therapist first asks Suzanne whether
she has any ideas.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} No, not really.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} I am wondering if you could think of one activity that you used to do
with your children that you would like to start doing again this week. {\i
If Suzanne could think of an activity, together they would make a specific plan
that included when the activity could happen and specifically what Suzanne would
do. The therapist would check that the plan felt doable and that Suzanne had
everything she needed to do the homework. Lastly, the therapist would check if
there were any obstacles.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne and her therapist decided she would sit with her children for ten minutes
on the couch and watch TV with them before starting dinner. Suzanne would do this
Monday and Wednesday evening this coming week. Is this homework collaborative,
specific and concrete, related to the session, and doable? I think it
is.\par\pard\plain\hyphpar} {
I don\u8217?t want my client to think that she failed if she does not do the
homework or it does not go well. I often end our discussion about homework by
saying, \u8220?If you do the homework, that is great and it will help us see how
you can start moving toward your goals. If you don\u8217?t do the homework, it is
important that we explore what happened, as this will give us some clues as to what
is keeping you stuck in your problems.\u8221?\par\pard\plain\hyphpar} {
Exercise 4.3\par\pard\plain\hyphpar} {
Practice using the homework guidelines.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #6{\i
: Review the Session and Ask for
Feedback}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The last section of a structured session involves reviewing the session and asking
for feedback. This section is often forgotten or rushed, but it is just as
important as the other components.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Review the Session\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
One of the best ways to help your clients remember what was covered in therapy is
to ask them to review. If they forgot to mention a point you think was important,
you can raise it and ask if it also seems important to your client. Many of my
clients keep notebooks and either during the session or at the end write down the
points they want to remember. In my clinical notes, I also write down the main
points from the review. Below are some helpful ways to introduce reviewing the
therapy session. You can download a Questions to Review the Therapy Session{\i
handout} at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Before we end, let\u8217?s take a moment to review. What was most important to you
from our session today?\par\pard\plain\hyphpar} {
Before our session is up, let\u8217?s take a moment to think over what we talked
about today. I think we talked about some very important things, and I want to be
sure that we don\u8217?t forget them. Could you write down anything you would like
to remember?\par\pard\plain\hyphpar} {
I was thinking it would be helpful to stop and just summarize what we talked about.
How could you put what we talked about into your own words?\par\pard\plain\hyphpar}
{
A few years ago I noticed that if I thought the session had not gone well, I
would \u8220?forget\u8221? to review, or else I conveniently ran out of time. When
I started reviewing even when I thought the session had not gone well, I discovered
that a good part of the time my client had found the session helpful. This was very
useful information. If my client had not found the session helpful, this was also
valuable information. We now had a problem we could discuss and potentially solve
rather than my worrying about the session.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Ask Your Client for Feedback\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After you review the session, it is a good time to ask for feedback. This is
especially important in the beginning of the therapy relationship. I simply say,
\u8220?I want to check if it feels that we are on the right track\u8221? or \u8220?
I want to check if there was anything that we did that was particularly helpful for
you. Was there anything that didn\u8217?t feel like a helpful use of our
time?\u8221?\par\pard\plain\hyphpar} {
{\qc
Your Turn! Practice in Your Imagination: Review a Session with Your
Client\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose a client you are currently seeing who you think would be open to reviewing
the session. Before we begin, rate from 1 to 10 how comfortable you are with asking
your client to review the session, with 1 being very comfortable and 10 being very
uncomfortable. At the end of the exercise, rate your level of comfort again to see
whether it has changed. Now, let\u8217?s try the exercise.\par\pard\plain\hyphpar}
{
Imagine you are at the end of a session and you want to ask your client to review
the session. Try to get a picture of him or her in your mind. Imagine yourself in
your office. Take a moment to look around, notice the sounds and smells in the
room. Read over Questions to Review the Therapy Session while imagining yourself
asking the questions. You can also use your own phrases. Really hear and feel
yourself introducing the idea of reviewing. Now imagine reviewing two more times
with the same client. Each time imagine that your client responds
positively.\par\pard\plain\hyphpar} {
Video 4.2\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Clinical
Examples\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 4.1:} Eulela Has a Very Bad Week\par\pard\plain\hyphpar} {
{\b
Exercise 4.2:} Dewei Uses Marijuana Again\par\pard\plain\hyphpar} {
{\b
Exercise 4.3:} (a) Renee Tries to Catch Up at School, and (b) Wilson Feels
Tense\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Most of us wake up every morning and there is a long list of what we have to do. We
have to prioritize and figure out what is most important to us, or we would never
get anything done. Setting agendas in therapy is similar to figuring out what is
most important to attend to in our own lives.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Use a Structure in Your
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
An agenda is a list to help your clients identify and prioritize what is most
important to them. Many people make lists to help them organize their lives and
figure out what needs to be done first. I thought it would be helpful for you to
reflect on your own experience of making lists and identifying your
priorities.\par\pard\plain\hyphpar} {
First, consider lists you\u8217?ve written in your life. Take a moment and think
about a time when it was helpful to make a list, and a time when it was not
helpful. Then identify factors that contributed to the list being helpful and
factors that contributed to the list not being helpful.\par\pard\plain\hyphpar} {
Second, think about the next couple of days. Make a list of things you need to
accomplish in the next few days that are not part of your normal routine. It can be
either at work or in your personal life. After you\u8217?ve made the list, pick
three items that are a priority to accomplish. Try to make them as concrete and
specific as possible.\par\pard\plain\hyphpar} {
Third, think about this exercise and if there are any implications for how you can
make agenda setting more helpful for your clients. Now take a moment to review what
you learned.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I want to explore your expectations and any concerns you have about using a
structured format.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Explore Your Attitudes about Using a Structured
Format\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose two clients whom you are currently working with. Imagine that with each
client you set an agenda and review at the end of the session. I am going to ask
you to write down your predictions.\par\pard\plain\hyphpar} {
Complete the following form for each client.\par\pard\plain\hyphpar} {
1. My client will:\par\pard\plain\hyphpar} {\b
1} {\b
2} {\b
3} {\b
4} {\b
5} {
Dislike using a structure\par\pard\plain\hyphpar} {
Have a neutral reaction\par\pard\plain\hyphpar} {
Like using a structure\par\pard\plain\hyphpar} {
2. I will:\par\pard\plain\hyphpar} {\b
1} {\b
2} {\b
3} {\b
4} {\b
5} {
Dislike using a structure\par\pard\plain\hyphpar} {
Have a neutral reaction\par\pard\plain\hyphpar} {
Like using a structure\par\pard\plain\hyphpar} {
3. What I imagined happening:\par\pard\plain\hyphpar} {
4. My main concern about using a structured format with this client
is:\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3 Structure a Session with a New and Current
Client\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose two clients with whom you are going to try and structure a session. If
possible, choose one new client and one current client with whom you are not using
a structured session. You are more likely to learn a new skill if you practice the
different components individually before you put it all together. I want you to
start by only practicing three components of a structured session: (1) explain the
structure of a therapy session, (2) set an agenda, and (3) choose an agenda item to
focus on. Here are the three steps:\par\pard\plain\hyphpar} {
{\ql
{\b
Explain the structure of a therapy session:} Explain to your client that you would
like to make a list of what she wants to talk about. You can look back through this
chapter to see how to introduce setting a structure with new and current clients.
Remember that to set an agenda all you have to do is say, \u8220?I would like to
make a list of what you would like to talk about today.\u8221? If it is the first
time you are trying to set an agenda, you may find it helpful to have a copy of the
handout Explain the Structure of a Therapy Session beside
you.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Set an agenda:} Once you and your client have set the agenda and identified the
issues he or she would like to focus on, write them down where you can both see
them.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Choose an agenda item:} Once you have your list of agenda items, ask your client
which item he or she would like to start
with.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If you are setting an agenda with a current client, at the end of the session ask
if your client liked setting an agenda. You can say, \u8220?I am curious whether
you liked the structure we used today where we made a list of what you wanted to
work on.\u8221? If your client had a positive reaction, ask if she would like to
continue using this structure in the future.\par\pard\plain\hyphpar} {
After you try setting an agenda for the first time, notice if your predictions
about your own and your client\u8217?s reactions were accurate. Take a moment to
think about what you learned. Have your predictions
changed?\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #4 Review the Session with Your
Client\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once you have tried setting an agenda with two clients, I would like you to include
one more component of a structured session.\par\pard\plain\hyphpar} {
At the end of the session, ask your client to review the session. Remember{\i
,} all you have to do is ask, \u8220?When you look over our work today, what would
you like to remember?\u8221? As you did in the last exercise, notice if your
predictions of your own and your client\u8217?s reactions were accurate{\i
.}\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under the agenda items.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} Organize your therapy sessions.\par\pard\plain\hyphpar} {
What are the main components of a structured therapy
session?\par\pard\plain\hyphpar} {
What is the importance of each component?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Start with a check-in.\par\pard\plain\hyphpar} {
What is included in a check-in?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Collaboratively set an agenda.\par\pard\plain\hyphpar} {
How could you introduce setting an agenda with a new
client?\par\pard\plain\hyphpar} {
How could you introduce setting an agenda with a current
client?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Work the agenda.\par\pard\plain\hyphpar} {
How could you respond when your client drifts off the agenda
topic?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #5:} Develop helpful homework for the next
session.\par\pard\plain\hyphpar} {
What are two guidelines for helpful homework?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #6:} Review the session and ask for feedback.\par\pard\plain\hyphpar} {
How could you ask your client to review?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Part 2\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Understand Your Clients\u8217?
Problems\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 5\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Identify Your Clients\u8217? Feelings, Physical Reactions, and
Behaviors\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the previous chapter we covered how to structure a session. Did you have a
chance to try setting an agenda with a new client or a current client? How did it
go? What about reviewing at the end of the session? How did using a structure make
a difference to your therapy sessions? I am hoping that you will keep using a
structured format. One of the best ways to maintain change is to assign yourself a
specific task that reinforces your new behavior. Would you be willing to pick four
clients and try setting an agenda and reviewing?\par\pard\plain\hyphpar} {
If you did not have a chance to try structuring a session, what got in the way? Did
you have negative predictions about structured sessions? Try to set an agenda with
just one client this coming week and notice how your client
responds.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this chapter we will cover how to identify situations that trigger your client
and then how to use the four-factor model to understand your client\u8217?s
reactions. We will focus on identifying your client\u8217?s feelings, physical
reactions, and behavior. I want to leave identifying thoughts for the next two
chapters.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} Use the four-factor model in therapy.\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Identify your clients\u8217? triggers.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Understand your clients\u8217? reactions.\par\pard\plain\hyphpar}
{
{\b
Agenda Item #4:} Help your clients identify their feelings.\par\pard\plain\hyphpar}
{
{\b
Agenda Item #5:} Help your clients identify their physical
reactions.\par\pard\plain\hyphpar} {
{\b
Agenda Item #6:} Help your clients identify their
behaviors.\par\pard\plain\hyphpar} {
{\b
Agenda Item #7:} Remain empathic.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Clients come to therapy with all kinds of problems. For example, Suzanne is too
anxious to talk to the other teachers and make friends, Raoul is procrastinating on
his project at work, some clients drink too much, and others feel panic when they
try to use an elevator. In this chapter we are going to start using the four-factor
model to understand your clients\u8217? problems.\par\pard\plain\hyphpar} {\s3
\afs28
{\b
Agenda Item #1{\i
: Use the Four-Factor Model in
Therapy}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Almost every client has specific situations that trigger him, and when triggered he
automatically zooms down a well-worn negative path. The path is strewn with a mix
of feelings, physical reactions, behaviors, and thoughts and ends in a big negative
jumbled black ball. It happens so quickly and automatically that your client never
pauses to notice or question his negative path. He is just aware of the big
negative ball at the end. The negative path feels like the only option. Take a look
at figure 5.1 to see how the negative path works.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

Figure 5.1. Your client\u8217?s negative

path.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
We are going to spend the next three chapters using the four-factor model to help
your clients hit the pause button on their negative automatic paths (see figure
5.2). This starts a process of self-reflection, and it is often the first time that
a client has fully acknowledged his own thoughts and feelings. As clients become
more aware of how the four factors are maintaining their problems, change becomes a
possibility.\par\pard\plain\hyphpar} {
{\i
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}}

Figure 5.2. Your client hits the pause

button.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The first step involves identifying a trigger situation and then identifying and
recording your client\u8217?s feelings, physical reactions, behaviors, and
thoughts. We are going to use the Understand Your Reaction worksheet (which is the
same as the first five columns of a thought record) as a tool to identify and
record your client\u8217?s reactions. You can download a copy at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
Understand Your Reaction}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Physical Reactions {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Behaviors} {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
How did my body react?\par\pard\plain\hyphpar} {
What did I do?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {
If you are not used to writing during therapy, you may initially find it awkward.
However, once you try it, I think you will find writing very useful. For most
clients, writing down thoughts and feelings creates a different experience from
saying them in their head; writing encourages pausing and reflecting. Using a
written worksheet helps organize the session. Plus, your clients can use the
Understand Your Reaction worksheet outside of therapy to slow down and identify
what is going on when they are upset.\par\pard\plain\hyphpar} {
While I think it is important to try a written worksheet, CBT is flexible;
identifying the four factors can also be done orally, as part of a therapy
dialogue.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #2{\i
: Identify Your Clients\u8217?
Triggers}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Each client has specific types of situations that set his automatic negative path
in motion; these are his triggers. To address your client\u8217?s problems, you
need to know which situations are difficult for him and trigger his negative
path.\par\pard\plain\hyphpar} {
While many clients are aware of their triggers, other clients have trouble
identifying their specific trigger situations. For example, a client may tell you
that he is \u8220?always\u8221? sad, or \u8220?always\u8221? drinks too much, and
can\u8217?t identify specific problematic situations. Identifying your
client\u8217?s triggers helps you start to see patterns and then know what to focus
on in therapy.\par\pard\plain\hyphpar} {
A helpful first step is to ask your client to monitor his problematic feelings or
behaviors and see if there are some situations where his feelings are stronger or
his behavior is more extreme. For example, a client of mine, Elsbeth, came to
therapy because she was {\i
always} angry. When I asked for examples of specific situations, she responded that
she was angry \u8220?all the time.\u8221? Her first homework assignment was to
monitor her angry feelings and see when they were strongest. She came back having
discovered that she was the most angry when her tee nage son didn\u8217?t do what
she wanted him to do, for example, when he did his homework at 2 a.m., broke
curfew, or did not do his chores. She discovered that her anger toward her son was
spilling over into the rest of her life.\par\pard\plain\hyphpar} {
I often use a simple monitoring worksheet like the one below. You can download a
copy of What Is Your Trigger? at http://www.newharbinger.com/38501. I ask my
clients to note situations that were the most difficult for them and to rate their
feelings from 1 to 10. We often start to see patterns. For example, Suzanne told
her therapist that she was very unhappy in her new school \u8220?all of the
time.\u8221? As homework, her therapist asked her to notice situations where she
was the most unhappy and rate her moods. Look at how Suzanne filled in the
worksheet below. Do you see a pattern?\par\pard\plain\hyphpar} {\b
{\qc
What Is Your Trigger?}} {\b
Situation} {\b
Feelings (Rate from 1\u8211?10; 1 = very happy; 10 = very unhappy)} {
Monday: Lunch, no one to eat with\par\pard\plain\hyphpar} {
Unhappy: 10\par\pard\plain\hyphpar} {
Tuesday: At the school assembly, the two teachers sitting next to me were talking
together and did not talk to me.\par\pard\plain\hyphpar} {
Unhappy: 8\par\pard\plain\hyphpar} {
Wednesday: I overheard a teacher talking about a party she was having, and she did
not invite me.\par\pard\plain\hyphpar} {
Unhappy: 10\par\pard\plain\hyphpar} {
Thursday: One of the teachers asked the person next to me at recess if she wanted
to work on the school play with her.\par\pard\plain\hyphpar} {
Unhappy: 10\par\pard\plain\hyphpar} {
Friday: I stood alone at recess.\par\pard\plain\hyphpar} {
Unhappy: 9\par\pard\plain\hyphpar} {
When Suzanne and her therapist looked at the worksheet, they discovered that she
was the most unhappy in social situations with other teachers. None of the
situations she identified involved students. Suzanne was surprised. Charting her
reactions helped her focus on the situations that were difficult for her, and it
also helped her realize that some aspects of school were going fairly
well.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Help Your Clients Identify Situations That Are Specific and
Concrete\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
You begin the session with a check-in, set the agenda, and then decide on the
agenda item you want to start with. What happens next? You want to identify a
specific situation that is problematic for your client and that you can work on in
therapy.\par\pard\plain\hyphpar} {
Frequently, your client will describe his trigger situation in vague terms, and you
don\u8217?t really understand what happened. You need to help your client become
more specific and concrete. A specific and concrete description includes what
happened, with whom, and the specific time and place it occurred. For example, a
vague description of a situation would be \u8220?My partner doesn\u8217?t respect
my work\u8221?; a more concrete and specific description would be \u8220?My partner
told me that she thought her work was more important than mine.\u8221? Below are
some additional examples of situations that are described vaguely, along with more
specific and concrete descriptions of the same situations.\par\pard\plain\hyphpar}
{\b
{\qc
Examples of Vague and Specific Situations}} {\b
Vague Description} {\b
Same Situation Described in a Specific and Concrete Manner} {
My child was rude to her stepmother.\par\pard\plain\hyphpar} {
My daughter swore at her stepmother and left the room when her stepmother asked her
to help with the dishes after dinner.\par\pard\plain\hyphpar} {
I have to walk on eggshells around my father; he gets angry at the smallest
thing.\par\pard\plain\hyphpar} {
I asked my father if I could have the car on Saturday night, and he yelled at me
that I should know he wanted it to go out with his friends.\par\pard\plain\hyphpar}
{
I had a few too many drinks over the weekend.\par\pard\plain\hyphpar} {
I was at a bar with my friends and probably drank over eight beers and at least
four shots.\par\pard\plain\hyphpar} {
The more specific and concrete your client\u8217?s description of the situation,
the more your client will be emotionally engaged with the situation, and the more
he will have access to his feelings and thoughts. Consider your own experience:
Think of someone you are a little annoyed with. Now, think of a specific situation
when you were annoyed with this person. Try to remember the situation in detail.
Chances are that as you thought about a specific situation, you became more annoyed
and your feelings and thoughts became more immediate. The same thing will happen
when your clients talk about specific situations.\par\pard\plain\hyphpar} {
Sometimes your client\u8217?s situation is a long, complicated story. In this case,
listen to the whole story and then ask what was the worst or most difficult part
for your client. It is helpful to identify a situation that lasts from a few
seconds to thirty minutes (Greenberger & Padesky, 2016)\u8212?any longer and your
client will probably have a large variety of feelings and thoughts, and it will be
hard to focus on the main ones.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Questions to help identify a specific situation.} I know I have a clear
understanding of the situation if I can form a picture in my mind. If not, I ask my
client the {\b
W} questions: {\b
What} happened? {\b
Who} was involved? {\b
Where} did it happen? and {\b
When} did it happen? I am looking for the facts of the situation. In some ways it
is similar to being a detective or a newspaper reporter on a fact-finding mission,
except rather than being a solo operator, you are a fact-finding team with your
client. I usually start with being sure I understand {\b
What} happened.\par\pard\plain\hyphpar} {
Let\u8217?s look at an example. One of my clients was upset with her boyfriend. I
asked for an example. She responded, \u8220?My boyfriend was really mean to me last
night.\u8221? Let\u8217?s see if we have the answers to the W questions. Do we know
What happened? No, we don\u8217?t. Do we know Who was involved? Yes, the boyfriend,
but we don\u8217?t know if anyone else was involved. Do we know Where it happened?
No, we don\u8217?t. Do we know When it happened? Yes, it happened last night.
Before we can start to explore my client\u8217?s feelings, physical reactions,
behaviors, and thoughts, we need a clearer idea of what
occurred.\par\pard\plain\hyphpar} {
Here is another example. If you remember from chapter 4, Suzanne\u8217?s main
agenda item was about being invited to a barbecue at the principal\u8217?s house.
She doesn\u8217?t feel like going and thinks she will just say no. Her therapist
wants to get a better understanding of the situation. Let\u8217?s look at what
happens when her therapist uses the four W questions.\par\pard\plain\hyphpar} {
{\i
Suzanne:} I was invited to a barbecue event at the principal\u8217?s
house.\par\pard\plain\hyphpar} {
{\i
Therapist:} I want to make sure that I understand. ({\i
Notice her therapist explains what she will do.}) {\b
What} is the event?\par\pard\plain\hyphpar} {
{\i
Suzanne:} The principal invited all the new teachers to her home for a
barbecue.\par\pard\plain\hyphpar} {
{\i
Her therapist doesn\u8217?t want to fire a volley of questions at Suzanne, but she
also wants more information. You can ask more than one of the W questions at the
same time}.\par\pard\plain\hyphpar} {
{\i
Therapist:} Can you give me a better sense of what\u8217?s involved with the
barbecue, for example, who was invited, where is it happening, and
when?\par\pard\plain\hyphpar} {
{\i
Suzanne\u8217?s therapist learns that Suzanne was invited to a barbecue at her
principal\u8217?s house along with the three other new teachers. It is taking place
after school in two weeks. Once you are clear on the situation, you and your client
can start to figure out why she is upset by using the four-factor
model.}\par\pard\plain\hyphpar} {
{\qc
Your Turn! Help Neale Identify a Specific
Situation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Neale, a thirty-six-year-old man, starts a session by saying he wants to focus on
his relationship with his mother. Try to help him specify a situation that he wants
to work on.\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} You said you wanted to focus on your relationship with your mother
today.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Neale:} Everything is going wrong; my relationship with my mother is worse than
ever.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help you get
a better understanding of the situation that is troubling
Neale.\par\pard\plain\hyphpar} {
{\ql
Can you tell me more about your relationship with your
mother?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I can see that your relationship with your mother is really upsetting you; it feels
as if everything is going wrong.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Could you give me an example of what is going wrong between your mother and you?
{\i
Response #3 is the most likely to help the client identify a specific situation.
Response #1 is too vague. If this was the first time you were hearing about
Neale\u8217?s difficulties with his mother, it could be a good question, but it
does not help you focus on a specific difficult situation. Response #2 is
supportive, but it also does not help identify a difficult situation.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Could you give me an example of what is going wrong between your mother
and you?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Neale:} We had a big family dinner on Sunday afternoon and it was just awful. My
mother and I just don\u8217?t get along. {\i
Before looking at the therapist\u8217?s response, ask yourself what the therapist
could ask to help Neale be more specific about what happened.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} You were saying that the family dinner was just awful last Sunday. Can
you tell me what happened?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Neale:} I am so upset because my mother was so critical of me. {\i
Ask yourself the W questions: Do you know What happened? Who was involved? Where it
happened? When it happened? You don\u8217?t know what happened; you know
Neale\u8217?s mother was involved and that the situation occurred at a family
dinner last Sunday. We need more information.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help you get
a better understanding of the situation.\par\pard\plain\hyphpar} {
{\ql
When you say your mother was critical of you, can you help me understand what your
mother did?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Can you tell me more about your mother being
critical?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
When your mother was critical, what did you
think?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\i
Response #1 is most likely to help Neale become more specific about the situation.
Response #2 is a good start, but it is too vague. Neale could react by talking
about his feelings or thoughts, or about the situation. In response #3 you
don\u8217?t know what the client means by critical, so it is too early to ask about
his thoughts.}\par\pard\plain\hyphpar} {
Exercise 5.1\par\pard\plain\hyphpar} {
Practice identifying a specific situation.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
The Facts About a Situation Are Different from the Meaning of a
Situation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Clients frequently include their thoughts or interpretation of what the situation
meant when describing the situation. When you start to separate the facts about the
situation from the thoughts and feelings about the situation, you and your client
begin to get a more objective idea of what occurred. Let\u8217?s look at an
example. A client identifies the following situation: \u8220?My wife doesn\u8217?t
care about my mother; she told my mother we were too busy to visit her.\u8221? The
facts of the situation are that his wife told his mother that they were too busy to
visit; the client\u8217?s thoughts or interpretation of the situation are, \u8220?
My wife doesn\u8217?t care about my mother.\u8221? Let\u8217?s look at another
example. A client says, \u8220?My new girlfriend asked me home to meet her parents.
She\u8217?s moving too fast; I don\u8217?t want to get serious.\u8221? In this
example, the facts of the situation are the girlfriend invited the client home to
meet her parents; the thoughts or what the situation meant to the client are,
\u8220?She is moving too fast; I don\u8217?t want to get
serious.\u8221?\par\pard\plain\hyphpar} {
Often a client will use an adjective to describe the other person in the situation;
the adjective is usually the client\u8217?s thought about the other person. For
example, a client says, \u8220?My child was very inconsiderate toward the
teacher.\u8221? \u8220?Inconsiderate\u8221? is an adjective. You know that the
client thought the child was inconsiderate, but you don\u8217?t know what the child
did. If you want to understand the facts of the situation, it is helpful to ask,
\u8220?What did your child do that made you think he was
inconsiderate?\u8221?\par\pard\plain\hyphpar} {
Sometimes a client will include his feelings as part of the situation; for example,
when describing a situation he will say, \u8220?I was so angry at my mother when
she was late.\u8221? The fact is that his mother was late; the feeling is anger. A
client can also include his behavior in the description of the situation, for
example, \u8220?When my boss yelled at another coworker, I just sat there and did
nothing.\u8221? The boss yelling at another coworker is the fact in the situation;
the client doing nothing is the client\u8217?s behavior.\par\pard\plain\hyphpar} {
{\qc
Your Turn! Separate the Facts about the Situation from the Thoughts about the
Situation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Below are examples of situations where clients mixed up the {\i
facts} about the situation and their {\i
thoughts} about the situation. In the examples below, separate the facts about the
situation from the client\u8217?s thoughts. Complete the worksheet below before
looking at my answers in the appendix.\par\pard\plain\hyphpar} {\b
Examples of Situations} {\b
Facts about the Situation} {\b
Client\u8217?s Thoughts about the Situation} {
Instead of doing homework, I was lazy and went out with
friends.\par\pard\plain\hyphpar} {
My boss told me I did a good job, but he didn\u8217?t really mean
it.\par\pard\plain\hyphpar} {
My child is not normal; he is not crawling at age five
months.\par\pard\plain\hyphpar} {
The huge mess my husband left in the kitchen\par\pard\plain\hyphpar} {
Exercise 5.2\par\pard\plain\hyphpar} {
Practice distinguishing the facts about a situation from the thoughts and feelings
about the situation.\par\pard\plain\hyphpar} {
Video 5.1\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Understand Your Clients\u8217?
Reactions}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Identifying trigger situations is an important first step. The next step is using
the four-factor model to understand your client\u8217?s reaction. It is important
to explain what you will be doing, both so that your client understands the process
and so that he learns a tool to use outside of therapy. I use the Understand Your
Reaction worksheet that we looked at in the beginning of the chapter as a
structure. I show the worksheet to my client and explain each column. I usually
say:\par\pard\plain\hyphpar} {
I think you did a really good job identifying the situation. What I would like to
do now is to see if we can understand your reaction by identifying your feelings,
physical reactions, behaviors, and thoughts\u8212?and then see how they all go
together. I call this using the four-factor model.\par\pard\plain\hyphpar} {
I want to complete this worksheet. {\i
(I get out the worksheet or draw one on a sheet of paper.)} You see there are five
columns. This first column says \u8220?Situation,\u8221? and we are going to write
down the situation we just identified. {\i
(I write it down or the client writes it down.)} We are then going to see if we can
identify your feelings, physical reactions, behaviors, and thoughts and write them
down in the next columns.\par\pard\plain\hyphpar} {
When clients see the five columns, they automatically become more organized, and
some of the jumble and distress starts to diminish. My own attitude is one of
engaged curiosity, as this models a helpful attitude my client can take toward his
own problems. Notice how I start by saying, \u8220?I think you did a really good
job identifying the situation.\u8221? Providing positive feedback for learning a
specific skill reinforces the skill and helps the therapy relationship. Many of our
clients rarely receive any positive feedback; to hear that they did something well
is important.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Practice in Your Imagination: Explain the Understand Your Reaction
Worksheet\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose a client who you think would benefit from identifying his or her feelings,
physical reactions, behaviors, and thoughts. Before you start, rate from 1 to 10
how comfortable you feel introducing and using the Understand Your Reaction
worksheet. At the end of the exercise, rate your level of comfort again to see if
it changed. Now, let\u8217?s try this exercise.\par\pard\plain\hyphpar} {
Imagine you want to introduce the Understand Your Reaction worksheet to your
client. Try to get a picture of him or her in your mind. Imagine yourself in your
office with your client. See your office; notice the sounds and smells in the room.
Read over how I suggest introducing the worksheet while imagining yourself saying
the words. You can also use your own phrases. Really hear and feel yourself taking
out the worksheet and explaining it to your client. Now, imagine explaining the
worksheet two more times with the same client. Each time, imagine that your client
responds positively.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: Help Your Clients Identify Their
Feelings}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this book, we are going to start with identifying feelings, then physical
reactions and behavior, and lastly thoughts. This is because most clients are more
aware of their feelings than their thoughts and tend to come in talking about
feelings. However, in practice, you could start with any of the four factors. I
often start with the factor that my client brings up first.\par\pard\plain\hyphpar}
{
The ability to label feelings is a part of {\i
affect regulation}, or managing one\u8217?s feelings in a healthy way. When you ask
your client, \u8220?What were you feeling?\u8221? you are asking him to pause and
reflect, which automatically interrupts his negative path. Labeling feelings helps
both client and therapist understand the client\u8217?s reactions. Asking your
client to label his feelings gives the message that you are interested in his
experience. Clients\u8217? feelings can also guide therapy. You may want to try
different interventions depending on your client\u8217?s dominant feelings. For
example, if your client tells you he feels \u8220?bad,\u8221? it is hard to know
where to start, but if he tells you he feels \u8220?anxious,\u8221? you can start
to explore his fears.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What Are Feelings?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s see if we can understand Suzanne\u8217?s feelings about going to the
principal\u8217?s barbecue. When Suzanne\u8217?s therapist asked her what she was
feeling, Suzanne answered, \u8220?I just don\u8217?t want to go.\u8221? Let\u8217?s
stop for a moment. Suzanne\u8217?s response is not a feeling, it is a thought about
the behavior Suzanne wants\u8212?or in this case, doesn\u8217?t want\u8212?to do
(she does not want to go to the barbecue).\par\pard\plain\hyphpar} {
If Suzanne\u8217?s response was not a feeling, then what is a feeling? As I
mentioned earlier, feelings are usually one word. There are generally six main
emotions that clients identify: happy, mad, sad, anxious, guilty, and ashamed.
While there are many other feelings, these are the basic ones. Take a moment to
look at the Identify Your Feelings handout, which is a more comprehensive list of
feelings; you can download it at http://www.newharbinger.com/38501. Reading over
this handout will help expand your own vocabulary. Clients find it helpful when you
find a word that exactly captures what they are feeling.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Strategies to Identify Your Client\u8217?s
Feelings\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
While some clients can give very accurate and detailed descriptions of what they
are feeling, others have difficulty. Remember my client Elsbeth, from earlier in
the chapter, who was angry with her son for not doing his homework or his chores?
Initially she was only aware of her anger, but when we started paying attention to
her feelings, she discovered that she was more anxious than
angry.\par\pard\plain\hyphpar} {
If your client has trouble identifying his feelings, here are some interventions
you can try:\par\pard\plain\hyphpar} {
Show your client the Identify Your Feelings handout and ask if one of these
feelings seems to fit.\par\pard\plain\hyphpar} {
Ask your client to notice his feelings during the coming week, and see if he can
start to identify his feelings. Often just paying attention to feelings can be
helpful. Some clients have never asked themselves the question, {\i
What am I feeling?}\par\pard\plain\hyphpar} {
Ask your client to notice when he becomes physically tense and to try and label his
feelings at that moment.\par\pard\plain\hyphpar} {
You can discuss feelings with your client and how to know whether someone is happy,
sad, mad, glad, anxious, guilty, or ashamed. Ask your client to identify physical
symptoms, behaviors, and thoughts that go with each
feeling.\par\pard\plain\hyphpar} {
Raoul generally found it hard to identify his feelings. In one of his therapy
sessions, he came in looking very agitated and said he was really upset about his
boss\u8217?s comment at a meeting. His boss had said that Raoul\u8217?s project
seemed to be going slowly, and he hoped Raoul would be able to meet the deadline.
When the therapist asked Raoul if he could describe his feelings a little more,
Raoul shrugged, looked down at the floor, and said he felt \u8220?awful.\u8221? His
therapist thought it would be helpful if Raoul could start to be more aware of his
feelings. She tried three interventions. First, they talked about feelings and how
you could know what you are feeling. Second, his therapist gave him the Identify
Your Feelings handout and discussed it with him. Third, for homework his therapist
asked him to record three situations when he felt awful, to note what was happening
in his body, and to look at the Identify Your Feelings handout and try to label his
feelings. When Raoul came back the next week, he had completed his homework and was
able to identify that he felt nervous and angry. This helped him and his therapist
start to address these feelings more specifically. His therapist also started
directly asking whether he was nervous or angry when he said he was feeling \u8220?
awful\u8221? or \u8220?upset.\u8221?\par\pard\plain\hyphpar} {
One of the difficulties in identifying feelings is that we often use \u8220?
feel\u8221? when we are making a judgment and are really describing what we \u8220?
think.\u8221? For example, you might say, \u8220?I {\i
feel} that the movie was too slow\u8221? when what you really mean is \u8220?I {\i
think} the movie was too slow.\u8221? It is even more difficult to differentiate
thoughts and feelings in statements like \u8220?I feel stupid\u8221? or \u8220?I
feel incompetent.\u8221? Even though these statements start with \u8220?I
feel,\u8221? they are really judgmental thoughts about ourselves. We say, \u8220?I
feel stupid\u8221? when we mean, \u8220?I think I am stupid.\u8221? Thoughts are so
closely connected to feelings that it can be hard at first to see the difference,
but the more you use the four-factor model, the easier it will
get.\par\pard\plain\hyphpar} {
Now, let\u8217?s go back to Suzanne and see how her therapist helps her identify
her feelings about the invitation to the principal\u8217?s
barbecue.\par\pard\plain\hyphpar} {
{\i
Therapist:} I hear you don\u8217?t want to go, but I am wondering what your
feelings are when you think of the invitation.\par\pard\plain\hyphpar} {
{\i
Suzanne:} What do you mean? I just don\u8217?t want to go.\par\pard\plain\hyphpar}
{
{\i
Often when you ask clients what they were feeling, they answer with a feeling word.
However, Suzanne repeated her initial response. Her therapist thought that Suzanne
needed more guidance.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Well, feelings are usually expressed in one word. While there are many
feelings, it would be helpful to ask yourself whether you were feeling happy, mad,
sad, anxious, guilty, ashamed, or any other feeling.\par\pard\plain\hyphpar} {
{\i
Suzanne:} Oh that\u8217?s easy, I was really nervous and worried, and I think also
embarrassed.\par\pard\plain\hyphpar} {
{\i
Giving Suzanne the basic list of feelings helped her start to identify her own
feelings.}\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Help Your Clients Rate Their
Feelings\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In CBT, we often ask our clients to rate the intensity of their feelings. At first
it can feel strange to ask your client to rate his feelings; however, it is very
helpful. You are asking your client to reflect on his feelings rather than
automatically respond to them. Here is an example of how rating his feelings helped
one of my clients. He was a man in his late forties who had intense anxiety attacks
at work and would subsequently become immobilized for the whole day. A few weeks
after we had started working together, he came in smiling and said, \u8220?I had
one of my anxiety attacks at work last week, but I rated my anxiety, and I realized
it was only a 7. So I kept on working and it went away.\u8221? Rating his feelings
helped my client get a different perspective on his
feelings.\par\pard\plain\hyphpar} {
I usually ask clients to first identify and label their feelings and then to rate
their feelings. I say,\par\pard\plain\hyphpar} {
You did a good job identifying your feelings. ({\i
Notice I am reinforcing my client for a specific task.}) Before we move on, I would
like to ask you to look at each feeling you identified and rate how strongly you
had this feeling from 1 to 10. Ten would be the strongest you have ever felt this
feeling and 1 would be not having the feeling at all. Rating your feelings can help
us get a better understanding of how you are feeling. Would you be willing to
try?\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Help Suzanne Rate Her
Feelings\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s go back to the situation where Suzanne was invited to the
principal\u8217?s barbecue. Imagine that Suzanne has just identified her feelings.
You now want to help Suzanne rate the intensity of her
feelings.\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} When you received the invitation to the barbecue, what were your
feelings?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} Oh that\u8217?s easy, I was really nervous and worried, and I think also
embarrassed.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} You just did a really good job of identifying your feelings. ({\i
Note how the therapist is giving specific feedback on a
task.})\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Suzanne
rate her feelings.\par\pard\plain\hyphpar} {
{\ql
Can you tell me what you are nervous
about?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I think it would be helpful if you could look at each feeling and rate how strongly
you felt, from 1 to 10. Ten is the strongest you have ever felt this feeling, and 1
is not at all. Would you be willing to
try?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Lots of people are nervous when they are invited to a party. It\u8217?s a very
normal reaction. {\i
Response #2 is the most likely to help Suzanne rate her feelings. It clearly
explains what the therapist would like her to do. Response #1 starts to explore the
thoughts that go with the feeling of being} {\i
nervous. It is too early in therapy to identify thoughts, as you have not finished
identifying and rating feelings. Response #3 is a supportive comment, but it does
not help Suzanne rate her feelings.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} I think it would be helpful if you could look at each feeling and rate
how strongly you feel it, from 1 to 10. Ten is the strongest you have ever felt
this feeling, and 1 is not at all. Would you be willing to
try?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} Well sure. Where do I
start?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one you think will help
Suzanne start to rate her feelings.\par\pard\plain\hyphpar} {
{\ql
Where would you like to start?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I can tell you really want to get better, which is very important. Learning about
our feelings is a key part to getting
better.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Why don\u8217?t we start with the first feeling you listed, which was \u8220?
nervous.\u8221? When you think of the invitation, 1 to 10, how nervous are you? {\i
Suzanne is asking for guidance on how to rate her feelings. Response #3 is the most
likely to help Suzanne start to rate her feelings. It clearly explains what the
therapist would like Suzanne to do. Responses #1 and #2 don\u8217?t address
Suzanne\u8217?s question, \u8220?Where do I start?\u8221?}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne and her therapist rate all of her feelings. Before filling in the
Understand Your Reaction worksheet, her therapist says, \u8220?You did a good job
of rating your feelings. Just to summarize, you were nervous at a 7, and worried at
an 8, and embarrassed at a 6. Is that right? Can we write it down?\u8221? Notice
that the therapist makes a summary statement and then explains that she wants to
fill in the worksheet. This keeps therapy organized. Below is how Suzanne recorded
her responses on the Understand Your Reaction worksheet.\par\pard\plain\hyphpar}
{\b
{\qc
Understand Your Reaction}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Physical Reactions {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Behaviors} {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
How did my body react?\par\pard\plain\hyphpar} {
What did I do?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {
Principal invited me to barbecue with the other new
teachers\par\pard\plain\hyphpar} {
Nervous (7)\par\pard\plain\hyphpar} {
Worried (8)\par\pard\plain\hyphpar} {
Embarrassed (6)\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #5{\i
: Help Your Clients Identify Their Physical
Reactions}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Physical reactions are often clues to our feelings. Plus, a client can misinterpret
his physical symptoms, leading to emotional distress or dysfunctional behaviors.
For example, a client may assume that if his heart is pounding he is having a heart
attack or it is dangerous for his health. He becomes very anxious and starts to
avoid situations where his heart pounds. In reality, his pounding heart is related
to too much coffee or another issue and is not dangerous. Unless your client is
able to identify his physical reactions, you can\u8217?t explore what these
physical reactions mean to him.\par\pard\plain\hyphpar} {
While some clients are very aware of their physical reactions, other clients are
unaware. The easiest way to identify your client\u8217?s physical reactions is to
simply ask, \u8220?How did your body react?\u8221? or, \u8220?What were you feeling
in your body?\u8221?\par\pard\plain\hyphpar} {
If you are working with a client who has difficulty identifying his feelings, it
can be helpful to start with identifying his physical reactions, and then move on
to identifying feelings. Often specific physical reactions go with specific
feelings. For example, Raoul discovered that when he felt angry he was hot, when he
felt anxious he was shaky, and when he felt sad he had a lump in his throat. As he
learned to relate his physical symptoms to his feelings, it became easier for Raoul
to identify his feelings. When your client identifies his physical reactions, it
encourages self-reflection and helps him hit the pause button and stop zooming down
the path of his automatic negative reaction.\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist asked her to identify the physical reactions that went
with her feelings about being invited to the barbecue. Suzanne indicated that she
got a clenched stomach and felt tense in her shoulders. She rated her clenched
stomach at about a 4 and her tense shoulders at about a 5. She was surprised at how
low her ratings were. Often when my clients rate their physical reactions, they
realize that they are not as strong as they had thought. If, on the other hand, the
physical reactions are very strong, this suggests you may want to teach your client
specific skills to manage his physical symptoms.\par\pard\plain\hyphpar} {
This coming week, try to notice any increase in your own physical tension. Ask
yourself what you were feeling and what you were thinking. See if you learn
anything.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #6{\i
: Help Your Clients Identify Their
Behavior}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Next you want to identify your client\u8217?s behavior. I usually simply ask,
\u8220?What did you do?\u8221? I am looking for behaviors that indicate that my
client is avoiding a situation, acting impulsively, or behaving in a way that is
likely to make the situation worse. For some clients, when you slow down and help
them specify what they did, it is a first step in acknowledging their problematic
behavior and taking responsibility for their actions. A client of mine, Connor, had
difficulty controlling his anger and tended to minimize his angry outbursts. He was
describing how angry he was at his friend for not repaying a minor debt. He
initially described his behavior as \u8220?letting off some steam.\u8221? When I
asked what he had done, he sheepishly told me that he kicked a door so hard that he
smashed the glass insert. Connor went on to blame his friend for not paying the
debt and making him so angry that he kicked the door. When we looked at his
behavior, Connor could see that his friend had not \u8220?made\u8221? him kick the
door, and that kicking a door so hard that he broke the glass insert was not
just \u8220?letting off steam.\u8221?\par\pard\plain\hyphpar} {
To really understand your client\u8217?s behavior, you want a description of his
behavior that is specific and concrete, like Connor\u8217?s. This way, you can
examine the consequences of the behavior and the appropriateness of the response.
Clients often initially use a vague descriptor, such as \u8220?I just gave
up\u8221? or \u8220?I freaked out.\u8221? It is important to ask what your client
actually did.\par\pard\plain\hyphpar} {
Here are some examples of vague descriptions of behavior and specific descriptions
of the same behavior. You want to know what your client did, whom he did the
behavior with or to, where he was, and when it happened.\par\pard\plain\hyphpar}
{\b
{\qc
Examples of Vague and Specific Behaviors}} {\b
Situation} {\b
Vague Behavior} {\b
Specific Behavior} {
My father told me I should not have dropped out of school.\par\pard\plain\hyphpar}
{
I withdrew.\par\pard\plain\hyphpar} {
I sat at the dining room table completely silent for the rest of the
meal.\par\pard\plain\hyphpar} {
My husband came home so drunk he could barely stand.\par\pard\plain\hyphpar} {
I got angry.\par\pard\plain\hyphpar} {
I stood in the kitchen and yelled at my husband that I was tired of him drinking
all the time.\par\pard\plain\hyphpar} {
My boss at the restaurant told me I had made a mistake on two customers\u8217?
orders, and he wanted me to double-check all orders.\par\pard\plain\hyphpar} {
I did what my boss asked.\par\pard\plain\hyphpar} {
I returned to serving tables and double-checked the orders.\par\pard\plain\hyphpar}
{
Exercise 5.3\par\pard\plain\hyphpar} {
Practice helping clients provide a specific description of their
behavior.\par\pard\plain\hyphpar} {
I often ask my clients about the consequences of their behaviors. This is a
question many of my clients have never asked themselves. It is important to look at
both short-term and long-term consequences. Often, avoiding dealing with a
situation or having angry outbursts has relatively positive short-term consequences
but very negative long-term consequences, which many clients have never
considered.\par\pard\plain\hyphpar} {
Let\u8217?s return to Suzanne\u8217?s invitation. Her therapist wants to identify
her behavior and asks Suzanne how she had responded to the invitation. Suzanne
said, \u8220?I just got it three days ago and I\u8217?m not sure what to
do.\u8221?\par\pard\plain\hyphpar} {
Ask yourself if you know what her behavior is. You don\u8217?t really know. It
seems that her behavior is that she has not responded to the invitation, but you
need to check. Given that it has been three days, I would guess that Suzanne is
avoiding dealing with the invitation. Is her statement \u8220?I\u8217?m not sure
what to do\u8221? a behavior, feeling, physical reaction, or thought? (Try to
answer before reading on.) It is a thought. At this point I would notice the
thought but not comment on it, as we are concentrating on her behavior. Remember,
you want to stay organized. I put that thought in my back pocket, so when I ask
Suzanne to identify her thoughts, if she does not mention \u8220?I\u8217?m not sure
what to do,\u8221? I have it in reserve and can take it out at the right
moment.\par\pard\plain\hyphpar} {
Below is a summary of what we know about Suzanne\u8217?s reaction to the invitation
from the principal. We don\u8217?t yet know Suzanne\u8217?s thoughts, but we will
cover that in the next chapter.\par\pard\plain\hyphpar} {\b
{\qc
Understand Your Reaction}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Physical Reactions {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Behaviors} {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
How did my body react?\par\pard\plain\hyphpar} {
What did I do?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {
Principal invited me to barbecue with the other new
teachers\par\pard\plain\hyphpar} {
Nervous (7)\par\pard\plain\hyphpar} {
Worried (8)\par\pard\plain\hyphpar} {
Embarrassed (6)\par\pard\plain\hyphpar} {
Clenched stomach (4)\par\pard\plain\hyphpar} {
Tense shoulders (5)\par\pard\plain\hyphpar} {
Has not responded\par\pard\plain\hyphpar} {
Video 5.2\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #7{\i
: Remain Empathic}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Although CBT is structured, it is not rigid, and the therapeutic relationship is
critically important. Using summary statements and asking open questions are key
counseling skills for maintaining an empathic relationship while adhering to the
structure of CBT.\par\pard\plain\hyphpar} {
Summary statements help your clients pause and reflect on what they just said. A
good summary statement can be very simple. It\u8217?s as if you are holding up a
mirror that helps your clients look at themselves. When you summarize, you also let
your clients know that you heard them. Let\u8217?s try one. Your client starts a
session saying, \u8220?I am not sure which situation I want to focus on. First, the
whole party was a disaster. My three-year-old child screamed and cried most of the
night; at the end of the evening, my husband told me he never wants to have another
party. Second, work has been awful this week, once again my boss ignored my
comments at a meeting; and third, to top it all off, my husband got really drunk
again.\u8221? How could you summarize what your client just said? One way is to
simply say, \u8220?It is hard to know what to focus on, since so much happened.
Should we talk about the party, what\u8217?s been happening at work with your boss
ignoring your comments, or your husband getting drunk again?\u8221? The summary
helps your client pause and think about where she would like to
start.\par\pard\plain\hyphpar} {
Earlier we talked about open and closed questions. If you remember, closed
questions can be answered with either a single word or a short phrase. Examples of
closed questions are \u8220?Did you ask your boss for a year-end evaluation?\u8221?
and \u8220?Did you use cocaine over the weekend?\u8221? Closed questions can
usually be answered with a yes or no, or with facts. Open questions ask people to
think and talk about their thoughts and feelings. Examples of open questions are
\u8220?How did you feel after you asked your boss for a raise?\u8221? and \u8220?
When your friend offered you cocaine, what were your thoughts?\u8221? As you use
the four-factor model as a structure to explore your client\u8217?s reactions,
remember to use summary statements and open questions.\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to a Clinical
Example\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 5.1:} Raoul\u8217?s Boss Is Difficult\par\pard\plain\hyphpar} {
{\b
Exercise 5.2:} Find the Facts\par\pard\plain\hyphpar} {
{\b
Exercise 5.3:} Mary Treats Her Son Badly\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After you have completed the homework assignments below, pause and take a moment to
think about what you learned about yourself. Then, think about the implications of
your experience with these exercises for your therapy with
clients.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Describe a Specific and Concrete
Situation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Think of a situation in your own life where you would describe someone in a
general, vague manner, such as, \u8220?My partner is self-centered,\u8221? \u8220?
My boss is unreasonable,\u8221? or \u8220?My father is very frail.\u8221? Now try
to make the situation more concrete and specific. Think of a specific example and
ask yourself, {\i
What happened?} {\i
Who was in the situation? Where did it happen?} and {\i
When did it happen?}\par\pard\plain\hyphpar} {
What did you learn from specifying the situation? Did it make a
difference?\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Describe a Specific and Concrete
Behavior\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Think of a behavior that you either like or dislike about yourself and that is a
vague description. For example, are you messy, kind, organized, thoughtful,
ambitious, easygoing, or easily distracted? Now try to think of a specific example
of this behavior and describe your behavior in a more specific and concrete manner.
What was the impact of giving a specific description of your
behavior?\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3 Rate Your Own
Feelings\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Often my students are skeptical about the benefit of rating feelings until they try
it for themselves. This coming week, pick three different situations. At least one
should be a situation that upset you. Try to first identify your feelings. You may
have only one feeling, but you may have many. Remember: if you have trouble
identifying your feelings, ask yourself if you felt happy, mad, sad, anxious,
guilty, or ashamed. You may also have lots of other feelings. Once you have
identified your feelings, rate each one. Complete the chart below. Did rating your
feelings make a difference? What did you learn?\par\pard\plain\hyphpar} {\b
Identify Three Situations} {\b
Identify Your Feelings in Each Situation and Rate Each Feeling from 1\u8211?10 (1 =
not at all, 10 = the strongest you have ever had this feeling)} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It is now time to start using the Understand Your Reaction worksheet. Don\u8217?t
worry if it feels awkward at first; it is important to try.\par\pard\plain\hyphpar}
{
{\qc
Homework Assignment #4 Use the Understand Your Reaction Worksheet with a
Client\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose a current client you think would benefit from and like using the Understand
Your Reaction worksheet. Then complete the steps below.\par\pard\plain\hyphpar} {
{\b
Step 1:} Ask your client to identify a specific situation that he wants to work on.
Be sure to ask {\b
What} happened? {\b
Who} was involved? {\b
Where} did it happen? and {\b
When} did it happen?\par\pard\plain\hyphpar} {
{\b
Step 2:} Explain that you want to understand the situation using the four-factor
model, and show your client the Understand Your Reaction
worksheet.\par\pard\plain\hyphpar} {
{\b
Step 3:} Ask about your client\u8217?s feelings and have your client rate their
intensity from 1 to 10.\par\pard\plain\hyphpar} {
{\b
Step 4:} Ask about your client\u8217?s physical reactions and have your client rate
their intensity from 1 to 10.\par\pard\plain\hyphpar} {
{\b
Step 5:} Ask about your client\u8217?s behavior.\par\pard\plain\hyphpar} {
Complete the worksheet with your client. If it is the first time you are trying to
use the four-factor model with a client, you may feel awkward, and it may not go
smoothly. But that\u8217?s okay! Think of the first time you rode a bike, drove a
car, tried to swim, or cooked a turkey. If you are like most people, you were
unsure how to do it. The more you practiced, the better you got. Think of me
cheering you on. Remember that the goal of homework is not to do it well, but to
try.\par\pard\plain\hyphpar} {\b
{\qc
Understand Your Reaction}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Physical Reactions {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Behaviors} {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
How did my body react?\par\pard\plain\hyphpar} {
What did I do?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under the agenda items.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} Use the four-factor model in therapy.\par\pard\plain\hyphpar} {
How can you use the four-factor model in therapy?\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Agenda Item #2:} Identify your clients\u8217? triggers.\par\pard\plain\hyphpar} {
What are four questions you could use to specify your client\u8217?s trigger
situation?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Understand your clients\u8217? reactions.\par\pard\plain\hyphpar}
{
How could you introduce using the four factors to understand your client\u8217?s
reaction?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Help your clients identify their feelings.\par\pard\plain\hyphpar}
{
How could you explain a feeling?\par\pard\plain\hyphpar} {
Is \u8220?I feel like a failure\u8221? a feeling or a
thought?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #5:} Help your clients identify their physical
reactions.\par\pard\plain\hyphpar} {
What is a good question to identify your clients\u8217? physical
reactions?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item#6:} Help your clients identify their behaviors.\par\pard\plain\hyphpar}
{
Your client says, \u8220?I want to punch him in the face.\u8221? Is this a
behavior? If not, is it a feeling, physical reaction, or
thought?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #7:} Remain empathic.\par\pard\plain\hyphpar} {
What is the purpose of summarizing your client\u8217?s
response?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 6\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
My Clients Have So Many Thoughts\u8212?Which Do I Focus
On?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the previous chapter we covered identifying a trigger situation and how to
understand your client\u8217?s reactions using the four-factor model. Did you have
a chance to try the homework? Did you try asking your client about his or her
feelings, physical reactions, or behaviors? Take a moment to reflect on what you
learned from completing the homework.\par\pard\plain\hyphpar} {
If you did not do the homework, can you identify the obstacles that got in the way?
Before you read this chapter, take a moment to think about an upsetting experience
that happened last week. Then identify your feelings, physical reactions, and
behaviors.\par\pard\plain\hyphpar} {
Don\u8217?t forget about structuring your sessions. Are you setting agendas and
reviewing at the end? If you have not been using a structured session, try setting
an agenda with just one client this coming week.\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The next two chapters focus on how to help your clients identify their thoughts. In
this chapter we will cover how to decide which thoughts are worth working on. We
will call these thoughts hot thoughts. In the next chapter we will cover how to
identify hot thoughts.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} Identify hot thoughts.\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Is this thought an unrealistic evaluation of self, others, or the
future?\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Does this thought explain your client\u8217?s
feelings?\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} Does this thought contain a cognitive
distortion?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In CBT you are going to spend a lot of time and effort helping your clients
identify and examine their thoughts. You want to be sure that time is well spent.
We all have a continual stream of thoughts that go through our head every day, and
not every thought is worth working on. You want to target thoughts that are central
to your client\u8217?s distress and which, when targeted, will lead to meaningful
change.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: Identify Hot Thoughts}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Thoughts that are worth working on explain the meaning of the situation and are
strongly connected to intense feelings. We call these {\i
hot thoughts} (Safran, Vallis, Segal, & Shaw, 1986) because they carry emotion, and
when we work with them in therapy there is meaningful
change.\par\pard\plain\hyphpar} {
Here is an example. Jaylen\u8217?s father lives six hours away. He calls Jaylen
once a week and always starts the conversation by sighing and saying, \u8220?I
never see you. When will you come visit? I miss you.\u8221? Every week his
father\u8217?s phone call triggers the same negative automatic thoughts: {\i
My father has called every week for the past two years. He is always critical. He
does not appreciate what I do for him.} Let\u8217?s look at Jaylen\u8217?s thoughts
and identify which ones are hot thoughts. The thought {\i
My father has called every week for the past two years} is a fact; it does not
explain what his father\u8217?s phone call means to Jaylen or the reason for
Jaylen\u8217?s emotional distress. It is not a hot thought. The thoughts {\i
He is always critical} and {\i
He does not appreciate what I do for him} are hot thoughts because they capture
what his father\u8217?s words mean to him and explain Jaylen\u8217?s emotional
reaction.\par\pard\plain\hyphpar} {
When you are first learning CBT, it can be hard to know which thoughts are hot
thoughts and worth focusing on. In this chapter we are going to look at three
guidelines to help you identify a hot thought. Remember, a hot thought has to
capture the meaning of the situation and is related to intense feelings. Below are
the three guidelines.\par\pard\plain\hyphpar} {
Is this thought an unrealistic evaluation of self, others, or the
future?\par\pard\plain\hyphpar} {
Does this thought explain your client\u8217?s feelings?\par\pard\plain\hyphpar} {
Does this thought contain a cognitive distortion?\par\pard\plain\hyphpar} {\s3
\afs28
{\b
Agenda Item #2{\i
: Is This Thought an Unrealistic Evaluation of Self, Others, or the
Future?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It is your client\u8217?s unrealistic thoughts about self, others, or the future
that capture the meaning of a situation and help you understand her
distress.\par\pard\plain\hyphpar} {
Sometimes it is easier to understand a concept if we start with an example. A
client of mine, Regina, was recently fired from a job and was feeling very
depressed and anxious. When I asked what she was thinking, she responded, \u8220?I
can\u8217?t believe I was fired\u8221? and \u8220?I wish I hadn\u8217?t been
fired.\u8221? These thoughts do not explain what being fired means to Regina, so
they are not hot thoughts. I asked additional questions and we identified the
following thoughts:\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Evaluation of self} (thoughts that are a judgment about
yourself)\par\pard\plain\hyphpar} {
I am too old to learn another skill.\par\pard\plain\hyphpar} {
Something is wrong with me.\par\pard\plain\hyphpar} {
I am stupid.\par\pard\plain\hyphpar} {
{\i
Try to think of a negative evaluation that you have of yourself, or that one of
your clients has of herself.}\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Evaluation of others} (thoughts that are a judgment about other people or an
expectation about how other people will treat you)\par\pard\plain\hyphpar} {
My boss is unfair.\par\pard\plain\hyphpar} {
My father will be disappointed.\par\pard\plain\hyphpar} {
None of my colleagues cares about me.\par\pard\plain\hyphpar} {
{\i
Try to think of a negative evaluation that you have of other people, or that one of
your clients has of others.}\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Evaluation of the future} (thoughts that are a judgment of the future or an
expectation of what the future will be like)\par\pard\plain\hyphpar} {
My friends and partner will no longer respect me ({\i
this is both about others and the future}).\par\pard\plain\hyphpar} {
I will be poor and lose my house.\par\pard\plain\hyphpar} {
I will never get another job that is as good.\par\pard\plain\hyphpar} {
{\i
Try to think of a negative evaluation that you have of the future, or that one of
your clients has of the future.}\par\pard\plain\hyphpar} {
When you look at the thoughts that Regina identified about self, others, and the
future, can you see how they explain what getting fired meant to Regina and why
these thoughts would lead to her feeling depressed and
anxious?\par\pard\plain\hyphpar} {
Let\u8217?s look more closely at how to identify thoughts about self, as they can
sometimes be hard to identify. Some thoughts are clearly about the self, for
example, {\i
I made a serious mistake}, or {\i
I am disorganized}. However, sometimes negative thoughts about self are hidden in
thoughts about others and in particular thoughts about how others treat you.
Let\u8217?s take the thought {\i
My colleague never asks my opinion}. You could believe this is the case because
your colleague is unpleasant and bossy (thought about others), but you believe that
you have good ideas (thought about self). In this case, the negative judgment is
about your colleague and there are no negative judgments about yourself. However,
you could believe that your colleague never asks your opinion because she thinks
you do not have good ideas, and you think this as well. In this case, you have a
negative judgment about your colleague, but you also have a negative judgment about
yourself.\par\pard\plain\hyphpar} {
Here are some more examples of thoughts about others where there may be hidden
negative beliefs about self: {\i
None of my new colleagues would want to be my friend}, {\i
No one would want to help me}, and {\i
No one will ever want to stay married to me}. In all these situations, your client
may believe that there is something about her that causes the other person\u8217?s
negative behavior. For example, a client might think, {\i
None of my new colleagues would want to be my friend because I am too shy and
boring}. \u8220?I am too shy and boring\u8221? is a negative thought about self. A
client could also think none of her new colleagues wants to be her friend because
they are all close to retirement and are not interested in making new friends at
work. In this case, there is no underlying negative evaluation of self. You can
check whether there is an underlying negative evaluation of self by asking your
client, \u8220?Is there something about you that would cause the other person to
treat you this way?\u8221?\par\pard\plain\hyphpar} {
{\qc
Your Turn! Identify Suzanne\u8217?s Thoughts about Self, Others, and the
Future\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In their fourth session, Suzanne wanted to talk about how upset she was with her
husband. She describes a recent fight. A few nights ago her husband was watching TV
when she asked him if he had bathed Andrew, their four-year-old son. He responded
by saying, \u8220?I\u8217?m exhausted, can you do it?\u8221? Suzanne blew up at
him, yelled that he had promised to give their son a bath and that he was selfish,
and then stomped out of the room. She is feeling depressed and hopeless. Her
therapist wants to understand the thoughts that caused her to become so upset.
Another way of thinking about it is, what did it mean to Suzanne that her husband
did not give Andrew a bath and said, \u8220?Can you do
it?\u8221?\par\pard\plain\hyphpar} {
Look over the dialogue and list Suzanne\u8217?s thoughts. Then decide if the
thought is a fact or an evaluation of self, others, or the future. You can find my
answers in the appendix.\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} What were you thinking when you realized your husband did not give
Andrew his bath and said, \u8220?I\u8217?m exhausted, can you do
it?\u8221?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} I just keep thinking that he didn\u8217?t give Andrew his bath; no matter
what I do, it won\u8217?t make a
difference.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Any other thoughts?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} He doesn\u8217?t care about the kids or me. Besides, you can\u8217?t
count on men.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Can you tell me more about those
thoughts?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} I keep thinking that I\u8217?m a completely inadequate mother; I keep
asking myself, Why do I have to do everything in the
house?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} A lot of thoughts, any
others?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} No, that\u8217?s probably all; it\u8217?s
enough!\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 6.1\par\pard\plain\hyphpar} {
Practice identifying thoughts about self, others, or the
future.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Does This Thought Explain Your Client\u8217?s
Feelings?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The second guideline for evaluating whether your client has identified her hot
thoughts is examining whether her thoughts explain her feelings, and in particular
her strong negative feelings. What do I mean by this? Given your client\u8217?s
thoughts, the feelings have to make sense, and the intensity of the feeling has to
make sense. Let\u8217?s look at an example.\par\pard\plain\hyphpar} {
A client of mine, Angela, was concerned about her new babysitting arrangements.
When her therapist asks about the situation, Angela explains that when she left her
daughter with the new babysitter, her daughter cried and begged Angela not to
leave. This is unusual behavior for her daughter, who loved her previous sitter and
usually played happily when Angela left her with the sitter in the morning. Angela
is feeling very guilty (8) and anxious (8\u8211?9). When asked about her thoughts,
Angela responded, \u8220?My daughter is probably upset because it is a new sitter.
She will just have to get used to her. It will take
time.\u8221?\par\pard\plain\hyphpar} {
These are very good coping thoughts; however, they don\u8217?t help us understand
Angela\u8217?s feelings. If she really believed these thoughts, and she had no
others, would she feel guilty at 8 and anxious at 8 to 9? Probably not. Given the
strength of her anxiety and guilt, there are probably some other thoughts that
Angela is not aware of. Had Angela\u8217?s feelings been \u8220?slightly
sad,\u8221? these thoughts would have made sense.\par\pard\plain\hyphpar} {
When your client\u8217?s thoughts don\u8217?t match her feelings, this is a sign
that you need to keep exploring to identify the underlying thoughts. We will get to
{\i
how} you can help your clients identify their underlying thoughts in the next
chapter.\par\pard\plain\hyphpar} {
Different feelings have different types of accompanying thoughts. In CBT we call
this {\i
content specificity} (Beck et al., 1979). Let\u8217?s look at the kind of thoughts
that go with anxiety, depression, anger, guilt, and shame. Take a moment and think
of the last time that you were anxious, and then focus on the feeling. What
thoughts accompany this feeling of anxiety? Jot down your thoughts. Now do the same
for depression, anger, guilt, and shame. See whether your own thoughts fit with the
descriptions below.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
How to Understand Anxiety\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Thoughts that accompany anxiety are about a future threat that you think will have
awful consequences, is likely to occur, and you don\u8217?t think you can handle.
Figure 6.1 shows how you can think of anxiety as an
equation.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

Figure 6.1. Understand

anxiety.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If you think you can handle the threat, it becomes a challenge. Kendall et al.
(2002), in their treatment program for anxious adolescents, describe anxiety as
\u8220?expecting bad things to happen.\u8221? I find this a very helpful way to
think about anxiety. If your client is feeling anxious, nervous, or worried, make
sure you understand what \u8220?bad thing\u8221? your client is expecting to
happen. For example, in the case of Angela leaving her child with the sitter, you
could say, \u8220?I hear even though you are worried, you tell yourself it will be
all right, but I wonder, what are you worried will
happen?\u8221?\par\pard\plain\hyphpar} {\s4 \afs23
{\b
How to Understand Depression\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Depression is about loss and hopelessness. Usually when your clients are depressed,
they have negative thoughts about themselves, others, and the future. Below are the
kinds of thoughts you would expect someone who is depressed to
have.\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Thoughts about Self\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I am inadequate.\par\pard\plain\hyphpar} {
I am ugly.\par\pard\plain\hyphpar} {
I am a bad friend.\par\pard\plain\hyphpar} {
I am a bad parent.\par\pard\plain\hyphpar} {
I am bad at sports (or work or school).\par\pard\plain\hyphpar} {
Nothing I do is any good.\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Thoughts about Others\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
No one likes me.\par\pard\plain\hyphpar} {
My kids don\u8217?t care about me.\par\pard\plain\hyphpar} {
My colleagues think my work is no good.\par\pard\plain\hyphpar} {
My partner thinks I am a burden.\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Thoughts about the Future\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Nothing will ever change.\par\pard\plain\hyphpar} {
I will never have any friends.\par\pard\plain\hyphpar} {
I will never get another job.\par\pard\plain\hyphpar} {
Often depression is precipitated by a loss. It could be the loss of a relationship,
the loss of health, the loss of a job, or another loss. Clients who are depressed
believe that the future without what they have lost is bleak and
hopeless.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
How to Understand Anger\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Thoughts that accompany anger usually have to do with the belief that the client or
someone he cares about has been treated unfairly. Angry thoughts are usually
directed at other people. Generally, the person who is angry feels disempowered,
disrespected, or put down and reacts with anger. Thoughts that include \u8220?
should statements\u8221? are very common. With anger there is a belief that the
rules of how the world should be have been broken to the client\u8217?s
disadvantage.\par\pard\plain\hyphpar} {
Anger is a complex feeling. Sometimes people have only angry feelings, especially
if they believe that they have been unjustly wronged. However, anger is closely
related to depression and hopelessness. If you believe you have been unjustly
wronged and you believe that there is nothing you can do, you can easily become
depressed. Some clients label all feelings as anger, and it can be very useful to
help them recognize their other feelings.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
How to Understand Guilt and Shame\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Guilt and shame often go together. When we feel guilty, we believe that we have
done something wrong and broken an important moral rule. Guilt is often related to
believing that we have hurt someone. When we feel guilty, we feel responsible, and
we tell ourselves that we should have behaved differently. Shame is closely
related, as it is also connected to believing that we have broken an important
rule, but we believe that because we have broken that rule, we are somehow flawed
or awful. When we are ashamed, we often hide what we are ashamed about and believe
we would be rejected if people knew the \u8220?real
me.\u8221?\par\pard\plain\hyphpar} {
It is helpful to ask your client to specify what he did that is so terrible that he
feels guilty or ashamed. Often, this is the first time that a client has
articulated what it is he did. Once you have a clear idea what your client did, you
can start to examine how terrible it really was.\par\pard\plain\hyphpar} {\s4
\afs23
{\b
How Intense Is the Feeling?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
We have talked about the types of thoughts that you would expect to accompany
specific feelings. We also expect thoughts to match the intensity of the feeling.
For example, a client rates her anger at a 2 out of 10, and her thought was, {\i
I can\u8217?t stand my boss; he humiliates me every chance he gets}. Given her
thoughts, would you expect her anger to be stronger than a 2? I would. What if a
client rates her disappointment at an 8 and her thought is, {\i
I wish I had not sprained my ankle, but even if I can\u8217?t play I can still} {\i
enjoy watching the basketball game}. Do you think the thought and rating go
together? I don\u8217?t. Either the rating is too strong, or the client has
additional thoughts that you need to identify.\par\pard\plain\hyphpar} {
{\qc
Your Turn! What Thoughts Go with These
Feelings?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Below are three situations. For each situation there are three possible thoughts
the client might have. Choose the thought that is most likely to go with the
feeling. You can find my answers in the appendix.\par\pard\plain\hyphpar} {
{\ql
Cameron\u8217?s college hockey team was in the state semi-final. The score was
tied. Cameron had the puck and was sure he would score, when another player knocked
him over. Cameron is feeling {\i
furious}. What might he be thinking? \u8226? Our team will never have another
chance to play in the semi-finals. \u8226? That guy is an animal; he should be
punished; it\u8217?s unfair. \u8226? If we lose, it is all my fault.
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Annette just heard that she was the second-choice candidate for a job she had
applied for. Annette is feeling {\i
disappointed}. What might she be thinking? \u8226? I will never get a decent job;
my life is over. \u8226? They should have hired me; what idiots! \u8226? I had
hoped to get the job, but at least I was second choice.
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Orly did not visit his best friend, Roy, when Roy was in the hospital for two
weeks. Orly is feeling {\i
guilty}. What might he be thinking? \u8226? I am a bad friend; I should have gone;
I bet I hurt Roy\u8217?s feelings. \u8226? My friend is probably furious at me.
\u8226? I bet Roy will not want to be my friend anymore.
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: Does This Thought Contain a Cognitive
Distortion?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The term {\i
cognitive distortion} is commonly used in the CBT literature and is familiar to
many therapists. However, I don\u8217?t really like it. I think the term {\i
distorted} suggests that the therapist is negatively judging the client\u8217?s
thoughts. McKay, Davis, and Fanning (2011) have used the term {\i
patterns of limited thinking}, which I prefer. In my own clinical practice, I often
use the term {\i
thinking traps} because there is an inherent assumption that you can avoid a trap.
I also like the term {\i
thinking style}. However, for the purpose of this discussion, I\u8217?ll stick to
the common term {\i
cognitive distortions.}\par\pard\plain\hyphpar} {
Cognitive distortions are how your clients typically respond to situations that
trigger them. You can think of cognitive distortions as a label for your
clients\u8217? negative thinking patterns. Initially, psychologists identified only
a few specific distortions. Over time, the list of cognitive distortions has
expanded to the point that many therapists and clients find them confusing and hard
to use. It is important not to get lost in a long list. The purpose of identifying
a client\u8217?s cognitive distortions is to have a label that a client feels
captures his experience. Labeling a negative thinking pattern is another way of
hitting the pause button on automatic negative reactions. When a client labels a
thought as a cognitive distortion, he is also questioning the accuracy of his
thoughts.\par\pard\plain\hyphpar} {
Below is a list of the most common cognitive distortions. I also have included in
italics a number of shorthand ways of describing the cognitive distortions, which
were inspired by Kendall and his colleagues (2002) and Stallard (2005). For each
cognitive distortion, I have included an example from one of my clients. (Full
disclosure\u8212?I snuck in one or two examples from my own life!) A Thinking Traps
handout can be downloaded at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Thinking Traps}\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Filtering:} Focusing on the negative details of the situation while other positive
aspects are ignored.\par\pard\plain\hyphpar} {
{\i
Negative glasses or walking with blinders: You only see negative
things.}\par\pard\plain\hyphpar} {
Example: A student has consistently received A\u8217?s in a course. On a small
quiz, the student receives a C+ and immediately assumes she\u8217?s {\i
doing poorly in the course}.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Overgeneralizing:} You make a broad generalization, which is based on only one
piece of usually negative evidence.\par\pard\plain\hyphpar} {
{\i
The repetitor: It happened once; it will always be that
way.}\par\pard\plain\hyphpar} {
Example: Since I found out that my last boyfriend cheated on me, I can never trust
another man again.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
All-or-Nothing Thinking or Black-and-White Thinking:} You or others are either
right or wrong, good or bad, perfect or a failure. There is no room for grays or
middle ground in evaluating yourself or others.\par\pard\plain\hyphpar} {
Examples: The world is made up of winners and losers, and I sure don\u8217?t want
to be one of those losers. If it is not done perfectly, it is not worth doing at
all. My employee missed a small deadline\u8212?he\u8217?s completely useless!
\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Mind Reading/Making Assumptions:} You assume that you know what people are feeling
and thinking and why they are acting that way.\par\pard\plain\hyphpar} {
{\i
Mind readers and fortune tellers: Knowing that things will go
wrong.}\par\pard\plain\hyphpar} {
Examples: My boss didn\u8217?t say anything about my last report; I know he thought
it was terrible. My partner gave me a funny look; I know she disapproved of what I
said. \par\pard\plain\hyphpar} {\s5 \afs23
{\b
Personalizing:} You assume that what people are saying or doing is about you, even
though there is no indication of that. Another aspect is that you often compare
yourself to others, trying to determine how you measure up in a variety of
attributes, such as intelligence, competence, or
appearance.\par\pard\plain\hyphpar} {
Example: In the meeting when Mary said that some people have not been pulling their
weight on this project, I know that she was talking about
me.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Catastrophizing:} You assume disaster will occur. Sometimes it is related to an
initial difficulty. Catastrophic thoughts often start with \u8220?what if.\u8221?
For example, your child borrowed the car to go to a party and comes home fifteen
minutes late. You think, {\i
What if he had an accident? What if the car broke down?}\par\pard\plain\hyphpar} {
{\i
Blowing things up: Negative things become bigger than they really
are.}\par\pard\plain\hyphpar} {
Examples: Since my son came home slightly drunk the other night, I\u8217?m sure
he\u8217?s on his way to becoming an alcoholic like his uncle; it will ruin his
life. I lost my job; we will have to sell the house; I destroyed my whole
family. \par\pard\plain\hyphpar} {\s5 \afs23
{\b
Predicting the Future:} In many ways, predicting the future is similar to
catastrophizing, if the prediction is negative. However, individuals who engage in
dysfunctional behavior, or who avoid completing necessary responsibilities, often
falsely predict a positive or benign future.\par\pard\plain\hyphpar} {
Example: I can handle my alcohol; seven beers a night is not too much for
me.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Magnifying and Minimizing:} The degree or intensity of the problem is exaggerated
so that anything difficult is deemed overwhelming, and anything positive is ignored
or minimized.\par\pard\plain\hyphpar} {
{\i
Positive doesn\u8217?t count: Throwing out the good things that
happen.}\par\pard\plain\hyphpar} {
Example: A mother discovers that her son, who has schizophrenia, occasionally
smokes marijuana. She says, \u8220?My child is a failure; nothing he does works
out.\u8221? She ignores that he is also regularly taking his medication, is no
longer paranoid, and has a part-time job.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Shoulds:} Individuals have a list of rules about how they and other people are
expected to act, and they experience it as terrible if these rules are broken. They
feel angry if other people break the rules, and guilty if they themselves break the
rules.\par\pard\plain\hyphpar} {
Examples: I should always be available to my children and husband. I should always
try my hardest. I should be perfect at everything I do. \par\pard\plain\hyphpar} {
If a thought contains words that indicate extremes, such as \u8220?
always,\u8221? \u8220?never,\u8221? \u8220?everyone,\u8221? or \u8220?no
one,\u8221? it is most likely a cognitive distortion, as the real world is not so
absolute. When people use these terms, they are usually focusing only on the
negative aspects of a situation and ignoring other information. This is especially
true if the thought is accompanied by a strong emotional reaction. Let\u8217?s look
at some examples:\par\pard\plain\hyphpar} {
I {\i
always} fail at everything I do.\par\pard\plain\hyphpar} {
{\i
No one} will ever want to be my friend.\par\pard\plain\hyphpar} {
{\i
Everyone} hates me.\par\pard\plain\hyphpar} {
I {\i
never} do anything right.\par\pard\plain\hyphpar} {
My partner {\i
never} helps me.\par\pard\plain\hyphpar} {
In the coming week, see if you can listen to your clients\u8217? thoughts and
identify when they use terms such as \u8220?always,\u8221? \u8220?never,\u8221?
\u8220?everyone,\u8221? or \u8220?no one.\u8221?\par\pard\plain\hyphpar} {
{\qc
Your Turn! Identify the Cognitive
Distortion\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Below is a list of thoughts. See if you can identify the cognitive distortions. You
will find my answers in the appendix.\par\pard\plain\hyphpar} {
{\ql
If I don\u8217?t get this job, my life will be over. Cognitive distortion:
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
To be a good therapist, you have to give it your all and be there for your clients
100 percent of the time. Cognitive distortion:
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I\u8217?m sure that no one will ever want to hire me after this last fiasco of a
job interview. Cognitive distortion:
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
If I don\u8217?t help all of my clients, I am an inadequate therapist. Cognitive
distortion: \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I know that my last client canceled because she thinks I\u8217?m a bad therapist.
Cognitive distortion: \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
A colleague told me he wondered if the group check-in should be a bit shorter next
time. That was a terrible mistake I made in the first group. Cognitive
distortion: \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 6.2\par\pard\plain\hyphpar} {
Practice listening for cognitive distortions as your client describes a
problem.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Help Your Clients Identify Their Cognitive
Distortions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After your client has identified her thoughts, it is helpful to explain cognitive
distortions. I sometimes give my client the Thinking Traps handout with the
definitions of the cognitive distortions. I explain that these are common thinking
styles that get people into trouble. I then ask my client to indicate whether she
thinks any apply to her, and if so, to give me some examples from her own life. I
make sure to tell her that identifying her cognitive distortions is an important
first step.\par\pard\plain\hyphpar} {
If my client is able to identify a cognitive distortion that she commonly uses, and
if the exercise seems helpful to her, I then incorporate noticing cognitive
distortions into her homework. I usually ask my clients to record three situations
where they caught themselves in a cognitive distortion and to record their response
on the What Are My Thinking Traps? worksheet that follows, which you can download
at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
What Are My Thinking Traps?}} {\b
Situation} {\b
Thoughts} {\b
Thinking Trap (filtering; overgeneralizing; all-or-nothing thinking; mind reading;
personalizing; catastrophizing; predicting the future; magnifying and minimizing;
shoulds)} {\s4 \afs23
{\b
Identify Your Clients\u8217? Cognitive Distortions Before, During, and After a
Dysfunctional Behavior\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I often examine my client\u8217?s cognitive distortions before, during, and after a
dysfunctional behavior in order to understand what is maintaining the behavior. For
example, Shula is diabetic. Despite having difficulty controlling her blood sugar
levels, she frequently eats sugary desserts. She tells her therapist, \u8220?I
don\u8217?t know what is wrong with me; I have no willpower. I just end up having
dessert.\u8221? Let\u8217?s see what we discover when we examine her thoughts
before, during, and after eating a dessert.\par\pard\plain\hyphpar} {\b
{\qc
Shula Eats Dessert}} {\b
Before/During/After} {\b
Shula\u8217?s Thoughts} {\b
Cognitive Distortion} {\b
Before Shula Eats Dessert} {
I will just have one small bite.\par\pard\plain\hyphpar} {
I had a hard day; I deserve it.\par\pard\plain\hyphpar} {
If I say no I will insult my host, who made the dessert.\par\pard\plain\hyphpar} {
Minimizing and predicting the future\par\pard\plain\hyphpar} {
Magnifying\par\pard\plain\hyphpar} {
Mind reading and catastrophizing\par\pard\plain\hyphpar} {\b
While Shula Eats Dessert} {
As long as I have eaten a little sugar, I might as well have the whole
dessert.\par\pard\plain\hyphpar} {
It is too hard to keep to my eating plan.\par\pard\plain\hyphpar} {
It doesn\u8217?t matter if I eat some dessert.\par\pard\plain\hyphpar} {
All-or-nothing thinking\par\pard\plain\hyphpar} {
Magnifying\par\pard\plain\hyphpar} {
Minimizing\par\pard\plain\hyphpar} {\b
After Shula Eats Dessert} {
I am a loser.\par\pard\plain\hyphpar} {
I will never get my diabetes under control.\par\pard\plain\hyphpar} {
Black-and-white thinking\par\pard\plain\hyphpar} {
Predicting the future\par\pard\plain\hyphpar} {
Once we examined Shula\u8217?s thoughts before, during, and after she ate dessert,
it made sense that she was having so much trouble keeping to a healthy eating plan.
Shula had been aware of her self-critical thoughts {\i
after} she ate the dessert, but she had not been aware of her thoughts {\i
before} and {\i
during}, and the role they played in maintaining her dessert
eating.\par\pard\plain\hyphpar} {
I have had clients who tell me they \u8220?end up\u8221? drinking until they black
out, having unprotected sex, or not studying for exams. The reality is people
don\u8217?t \u8220?end up\u8221? doing these things. Even if it is fleeting, there
is almost always a thought before the behavior that enables or justifies the
dysfunctional behavior. Helping your client identify her cognitive distortions
before, during, and after dysfunctional behavior is an important step in helping
her feel more in control and starting a change process.\par\pard\plain\hyphpar} {
Exercise 6.3\par\pard\plain\hyphpar} {
Practice identifying cognitive distortions that occur before, during, and after
your client\u8217?s problematic behavior.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to a Clinical
Example\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Exercise 6.1:} (a) Jim Forgets His Wallet, and (b) Richard\u8217?s Boyfriend Wants
to End the Relationship\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Exercise 6.2:} Julie Has a Terrible
Week\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\b
Exercise 6.3:} Raymond Drinks Too
Much\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look over the Thinking Traps handout for this homework
assignment.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Identify Your Own Cognitive
Distortions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose one or two thinking traps that resonate with you and think of a recent
example from your own life for each one. This coming week, see whether you can
catch any thinking traps you are currently doing and try to complete the What Are
My Thinking Traps? worksheet.\par\pard\plain\hyphpar} {\b
{\qc
What Are My Thinking Traps?}} {\b
Situation} {\b
Thoughts} {\b
Thinking Trap (filtering; overgeneralizing; all-or-nothing thinking; mind reading;
personalizing; catastrophizing; predicting the future; magnifying and minimizing;
shoulds)} {
{\qc
Homework Assignment #2 Identify Your Own Cognitive Distortions Before You Either
Avoid or Act Impulsively\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The guided audio file available for this exercise also gives an example from my own
life of my forever failing attempts to drink less coffee.\par\pard\plain\hyphpar} {
Think of a situation where you would like to change your behavior and where you are
either avoiding or acting impulsively. For example, most of us would like to
exercise more, eat less junk food, or be more organized. Choose one of these issues
or a similar one. Next, think of a specific situation where you had planned to
exercise but didn\u8217?t, or you ate the whole pack of potato chips when you had
decided no more junk food, or instead of neatly filing your bills or reports you
just left them in a pile on your desk. Once you have chosen a specific situation,
think back and try to identify what your thoughts were that enabled you to not
exercise, to eat the junk food, or to stick the paper onto the already messy pile
of papers. Once you have identified your thought, try to identify the cognitive
distortion.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Now that you\u8217?ve had a chance to practice with your own thoughts, let\u8217?s
turn to your clients\u8217? thoughts.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3 Try Identifying Your Client\u8217?s Thoughts about Self,
Others, or the Future\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
During your next few therapy sessions, when a client spontaneously mentions a
thought, ask yourself if the thought is about self, others, or the future. Try to
complete the worksheet below for three thoughts that a client spontaneously
mentions.\par\pard\plain\hyphpar} {\b
{\qc
Are My Client\u8217?s Thoughts about Self, Others, or the Future?}} {\b
Client} {\b
Thought} {\b
Self, Others, or Future?} {
{\qc
Homework Assignment #4 Help Your Clients Identify Their Thinking
Traps\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose a client who often discloses his or her thoughts and who you think would
find the idea of thinking traps helpful. Give him or her the Thinking Traps
handout, which is available at http://www.newharbinger.com/38501, and ask if any of
the thinking traps apply. If this part of the exercise goes well, ask your client
to identify and write down three thoughts that are thinking traps this coming week.
You can use the What Are My Thinking Traps? worksheet.\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under the agenda items.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} Identify hot thoughts.\par\pard\plain\hyphpar} {
What are two characteristics of hot thoughts?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Is this thought an unrealistic evaluation of self, others, or the
future?\par\pard\plain\hyphpar} {
Why is it important to identify thoughts about self, others, or the
future?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Does this thought explain your client\u8217?s
feelings?\par\pard\plain\hyphpar} {
What type of thoughts would you expect to go with depression, anxiety, anger, and
guilt?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Does this thought contain a cognitive
distortion?\par\pard\plain\hyphpar} {
Explain three cognitive distortions.\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 7\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Identify Your Clients\u8217?
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Did you have a chance to do the homework from the last chapter? Here is one of my
catastrophizing cognitive distortions that I caught. I am in the car, driving to a
meeting with colleagues I don\u8217?t know very well. I pick up coffee, and within
five minutes I manage to spill a good part of it on my new white shirt. Can you
guess my thoughts? {\i
I will look like a complete idiot; everyone will think I am totally incompetent}.
However, the truth is I simply pulled my jacket over my shirt\u8212?and it
wasn\u8217?t great, but it certainly wasn\u8217?t a catastrophe. Were you able to
catch any of your own cognitive distortions? Were you able to identify your
clients\u8217? thoughts about self, others, or the future?\par\pard\plain\hyphpar}
{
If you did the homework, take a moment to reflect on what you learned. If you did
not do the homework, think about an upsetting experience that happened last week.
Identify your thoughts and then ask yourself, {\i
Do my thoughts contain unrealistic judgments about self, others, or the future? Are
they a cognitive distortion?}\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the last chapter we focused on how to decide which thoughts are worth working
on. Now that we know {\i
what} to look for, it\u8217?s time to get our hands dirty and learn {\i
how} to look.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} Identify automatic thoughts.\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Helpful questions.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Your clients\u8217? images.\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} Additional strategies to identify
thoughts.\par\pard\plain\hyphpar} {
{\b
Agenda Item #5:} How do you know which questions to use?\par\pard\plain\hyphpar} {
{\b
Agenda Item #6:} Link thoughts to feelings, physical reactions, and
behavior.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Remember that the purpose of identifying your client\u8217?s thoughts is to
understand what a situation means to your client, or how he interpreted the
situation. We want to help our clients identify their hot thoughts. To recap, a hot
thought explains your client\u8217?s feelings and behavior and is an
unrealistically negative evaluation of self, others, or the
future.\par\pard\plain\hyphpar} {
Clients can have a variety of reactions when they start to identify their negative
thoughts. Many clients feel more in control when they understand what is
maintaining their difficulties and can identify the relationship between their
thoughts, feelings, physical reactions, and behaviors. Other clients become more
distressed when they realize how negative their thoughts really are. It is
important to explain that even though it can be hard to look at negative thoughts,
it is a first step to feeling better.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: Identify Automatic Thoughts}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It sounds simple, but if you want to know what your client is thinking, just ask.
The following \u8220?Just Ask\u8221? questions are often all that you
need.\par\pard\plain\hyphpar} {\b
{\qc
\u8220?Just Ask\u8221? Questions}} {\b
General Probing Questions} {
What were you thinking?\par\pard\plain\hyphpar} {
What were you saying to yourself at the time?\par\pard\plain\hyphpar} {
What was running through your mind?\par\pard\plain\hyphpar} {\b
Prompting Questions} {
Any other thoughts?\par\pard\plain\hyphpar} {
Anything else?\par\pard\plain\hyphpar} {\b
Reflective Statements} {
So you were thinking\u8230?(repeat last thought)\par\pard\plain\hyphpar} {
{\i
Often just repeating the last thought or statement will encourage the client to
elaborate on more thoughts. You can then choose to add a prompting
question.}\par\pard\plain\hyphpar} {\b
Clarifying Questions} {
Can you tell me more about that thought?\par\pard\plain\hyphpar} {
When you ask your client, \u8220?What were you thinking?\u8221? use a gentle,
curious tone that encourages self-reflection. It is often helpful to refer to the
situation you are exploring. For example, Suzanne\u8217?s therapist asked, \u8220?
When you received the invitation to the barbecue, what were your thoughts?\u8221?
Don\u8217?t forget to go slowly and give your client time. It can take a couple of
questions before your client can identify his thoughts.\par\pard\plain\hyphpar} {
Let\u8217?s look at the example we started working on with Suzanne in chapter 5. If
you remember, the principal of her new school invited her to a barbecue with the
other new teachers. You know about the situation (invitation to the barbecue), you
already know her feelings (nervous, worried, and embarrassed), you know her
physical reaction (clenched stomach and tense shoulders), and you know her behavior
(put the invitation aside and did not respond). You now want to identify
Suzanne\u8217?s thoughts, and in particular you want to help her identify her hot
thoughts. Let\u8217?s see what happens if her therapist uses the \u8220?Just
Ask\u8221? questions.\par\pard\plain\hyphpar} {
{\i
Therapist:} Suzanne, you have done a good job identifying your feelings, physical
reactions, and behavior. Let\u8217?s see if we can also identify your thoughts.
When you were invited to the party, what thoughts went through your
mind?\par\pard\plain\hyphpar} {
{\i
Notice her therapist starts by positively reinforcing Suzanne for identifying her
feelings, physical reactions, and behavior. She then refers to the situation before
asking a general probing question.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
pausing}) I don\u8217?t know, just that I don\u8217?t want to go; the other new
teachers will all be there.\par\pard\plain\hyphpar} {
{\i
The thought} I don\u8217?t want to go{\i
is the behavior Suzanne wants to do. It is a fact. The thought} All the other new
teachers will be there{\i
is also a fact. These thoughts do not contain unrealistic judgments about self,
others, or the future; they do not explain her feelings; and they do not contain a
cognitive distortion. Suzanne has not yet identified a hot
thought.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Any other thoughts?\par\pard\plain\hyphpar} {
{\i
The therapist uses a prompting question.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, just that I won\u8217?t fit in.\par\pard\plain\hyphpar} {
{\i
Suzanne is starting to identify her hot thoughts.} I won\u8217?t fit in {\i
is a thought about self. Her therapist wants to keep
exploring.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Are there other thoughts that go with {\i
I won\u8217?t fit in}?\par\pard\plain\hyphpar} {
{\i
The therapist uses another prompting question.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} I feel that I will just stand there looking awkward, and no one will talk
to me. I will be so anxious, and I will probably get all
sweaty.\par\pard\plain\hyphpar} {
{\i
This is an example of a client using \u8220?I feel,\u8221? when what Suzanne really
means is \u8220?I think.\u8221? When this happens, simply repeat the sentence
saying, \u8220?You were thinking,\u8230?\u8221?}\par\pard\plain\hyphpar} {
{\i
Therapist:} You were thinking, {\i
I will just stand there looking awkward, no one will talk to me, and I will
probably get all sweaty}.\par\pard\plain\hyphpar} {
{\i
Suzanne:} That\u8217?s right, it\u8217?s not just that they won\u8217?t talk to me,
it\u8217?s that no one will {\i
want} to talk to me.\par\pard\plain\hyphpar} {
{\i
At this point Suzanne has identified a thought about herself:} I won\u8217?t fit
in{\i
; thoughts about herself and the future:} I will stand there looking awkward, and I
will probably get all sweaty{\i
; and a thought about others and the future:} no one will want to talk to me{\i
.}\par\pard\plain\hyphpar} {
Her therapist then asked Suzanne if she would like to write down her thoughts on
the Understand Your Reaction worksheet. Sometimes clients like to write, and
sometimes they like me to write. I don\u8217?t think it matters. If I am writing, I
repeat my client\u8217?s thoughts out loud as I write. I find that this encourages
my client to start thinking about his thoughts, rather than just experiencing
them.\par\pard\plain\hyphpar} {
Let\u8217?s see what Suzanne\u8217?s worksheet looks like.\par\pard\plain\hyphpar}
{\b
{\qc
Understand Your Reaction}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Physical Reactions {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Behaviors} {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
How did my body react?\par\pard\plain\hyphpar} {
What did I do?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {
Principal invited me to barbecue with the three other new
teachers\par\pard\plain\hyphpar} {
Nervous (7)\par\pard\plain\hyphpar} {
Worried (8)\par\pard\plain\hyphpar} {
Embarrassed (6)\par\pard\plain\hyphpar} {
Clenched stomach (4)\par\pard\plain\hyphpar} {
Tense shoulders (5)\par\pard\plain\hyphpar} {
Has not responded\par\pard\plain\hyphpar} {
I don\u8217?t want to go.\par\pard\plain\hyphpar} {
The other new teachers will be there.\par\pard\plain\hyphpar} {
I won\u8217?t fit in.\par\pard\plain\hyphpar} {
I will just stand there looking awkward.\par\pard\plain\hyphpar} {
No one will want to talk to me.\par\pard\plain\hyphpar} {
I will probably get all sweaty.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #2{\i
: Helpful Questions}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Sometimes when you ask your clients what they are thinking, they respond with
thoughts that are not hot thoughts. For example, Raoul felt very awkward going to
the lunchroom. When his therapist asked what he was thinking, he responded, \u8220?
I don\u8217?t know, I just feel awkward.\u8221? His therapist needs to ask
additional questions to help Raoul identify his thoughts.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
What Does the Situation Mean to Your
Client?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
One way to discover what a situation means to your client is to ask him directly.
You can use any of the following questions:\par\pard\plain\hyphpar} {
What does this situation mean to you?\par\pard\plain\hyphpar} {
What does this situation mean about you, other people, or the
future?\par\pard\plain\hyphpar} {
What is it about this situation that is so distressing for
you?\par\pard\plain\hyphpar} {
How is this situation a problem for you?\par\pard\plain\hyphpar} {
Initially, I felt very awkward using these questions. My clients had just told me
about an emotionally difficult situation, and I was asking what it meant to them or
why it was a problem. However, I have consistently found these questions to be very
helpful. Like all questions, it is important that you use a gentle, curious tone
that conveys your desire to understand your client\u8217?s
experiences.\par\pard\plain\hyphpar} {
Let\u8217?s go back to Suzanne. Her therapist decided to keep exploring, using the
additional questions identified above, in order to be sure she fully understood why
Suzanne found the invitation to the barbecue so
distressing.\par\pard\plain\hyphpar} {
{\i
Therapist:} I want to be sure I understand what it is about the invitation to the
barbecue that is so distressing for you.\par\pard\plain\hyphpar} {
{\i
Suzanne:} It\u8217?s not the invitation, it\u8217?s going there with all the other
new teachers.\par\pard\plain\hyphpar} {
{\i
Therapist:} What is it about being there with all the other new teachers that is so
distressing for you?\par\pard\plain\hyphpar} {
{\i
Her therapist uses one of the questions to keep probing what the situation means to
Suzanne.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} It\u8217?s hard to figure out. I guess that I won\u8217?t fit in; ({\i
pausing}) I think my biggest fear is that they won\u8217?t want to be my
friend.\par\pard\plain\hyphpar} {
{\i
Therapist:} Sounds like the big fear is \u8220?they won\u8217?t want to be my
friend\u8221??\par\pard\plain\hyphpar} {
{\i
Suzanne:} That\u8217?s right, that no one will want to be my friend, and I will be
there all alone.\par\pard\plain\hyphpar} {
In the example above, the question \u8220?What is it about this situation that is
so distressing for you?\u8221? helped Suzanne figure out her underlying thought.
Let\u8217?s look at another example and see how you can use these
questions.\par\pard\plain\hyphpar} {
{\qc
Your Turn! What Does This Situation Mean to
Suzanne?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In her fifth session, Suzanne wanted to focus on her feelings at recess. She was
increasingly anxious and uncomfortable during recess duty and had been trying
unsuccessfully to avoid it completely. Her therapist asked if Suzanne could give an
example of what happens. Suzanne explained that she stands alone in the schoolyard,
does not talk to anyone, and tries to look as if she is supervising the children.
She feels very lonely and wishes the other teachers would talk to her. Suzanne adds
that this exact situation happened yesterday. Her therapist believes this is a good
situation to work with. She knows Suzanne\u8217?s feelings (anxious) and her
behavior (she stands alone). She wants to understand Suzanne\u8217?s
thoughts.\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} When you are standing in the schoolyard at recess, what are you
thinking?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} ({\i
looking sad}) None of the other teachers are talking to me. {\i
Suzanne\u8217?s thought is a fact. It does not indicate what the situation means to
Suzanne.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Suzanne
identify what the situation means to her.\par\pard\plain\hyphpar} {
{\ql
Help me understand what it is about the other teachers not talking to you that is a
problem for you.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Have you tried talking to them?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What do you feel when the other teachers don\u8217?t talk to you? {\i
Response #1 is the best answer to help Suzanne identify what the situation means to
her and to help Suzanne identify her hot thoughts. Response #2 starts problem
solving, and response #3 takes therapy into a different direction.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Help me understand what it is about the other teachers not talking to
you that is a problem for you.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} The main problem is that I stand alone, while all the other teachers
stand with a friend and talk to each
other.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below. Choose the response that will help
Suzanne explore what the situation means to her.\par\pard\plain\hyphpar} {
{\ql
When the other teachers don\u8217?t talk to you, how do you
feel?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What does it mean to you that you are standing alone, and the other teachers are
standing with a friend and talking to each
other?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
When you say the other teachers don\u8217?t talk to you, how many other teachers
are outside at recess? {\i
Response #2 is the best response to explore what the situation means to Suzanne.
Response #1 would be a good response if you wanted to identify her feelings, and
response #3 would be a good response if you wanted to understand the situation.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} What does it mean to you that you are standing alone, and the other
teachers are standing with a friend and talking to each
other?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\i
Suzanne:} It means that the other teachers don\u8217?t want to talk to me, because
none of them approaches me.\par\pard\plain\hyphpar} {
At this point, Suzanne has identified a hot thought that explains her distress at
recess. Her hot thought {\i
The other teachers don\u8217?t want to talk to me} is a thought about others. Her
therapist could continue using the \u8220?Just Ask\u8221? questions and the
questions about the meaning of the situation to explore whether there were other
hot thoughts.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
When the Situation Involves Another
Person\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Many difficult situations involve other people besides your client. It can be
helpful to ask what your client thinks the other person\u8217?s behavior means
about how he or she thinks or feels about your client. For example, in
Suzanne\u8217?s situation, her therapist asked, \u8220?What do you think the other
teachers not talking to you means about how they feel toward you?\u8221? Suzanne
responded that she thought it meant that they did not want to get to know her and
liked to stay in their own little cliques.\par\pard\plain\hyphpar} {
A good follow-up question is whether there is anything about your client that
causes the other person to behave in this manner. For example, Suzanne\u8217?s
therapist asked if there was anything about her that would cause the other teachers
not to include her. Suzanne responded that she was shy and awkward and would not
fit in.\par\pard\plain\hyphpar} {
Exercise 7.1\par\pard\plain\hyphpar} {
Practice identifying what situations mean to your clients.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Focus on Feelings\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Another approach to exploring your client\u8217?s thoughts is to ask what thoughts
go with specific feelings. I often use this approach when my client is very aware
of his feelings but is having trouble identifying his
thoughts.\par\pard\plain\hyphpar} {
There are a number of ways I ask what thoughts go with my client\u8217?s feelings.
I have used these questions to explore a great variety of feelings, including sad,
hurt, annoyed, disappointed, angry, and anxious. I often ask my client to take a
moment, go back to the situation in his mind, and focus on the feeling. I then ask
one of the following questions:\par\pard\plain\hyphpar} {
What thoughts go with this feeling?\par\pard\plain\hyphpar} {
Help me understand, when you have this feeling, what thoughts go through your
mind?\par\pard\plain\hyphpar} {
Just before you started to have this feeling, what went through your mind, or what
were your thoughts?\par\pard\plain\hyphpar} {
Let\u8217?s look at an example of how you could use these questions. Jasmine just
found out that her grandfather, who lives out of town, was not feeling well. She
has been feeling overwhelming guilt that she had not visited him in a few
months.\par\pard\plain\hyphpar} {
{\i
Therapist:} When you found out that your grandfather was not feeling well, what
were your thoughts?\par\pard\plain\hyphpar} {
{\i
Jasmine:} I just felt so guilty.\par\pard\plain\hyphpar} {
{\i
Therapist:} Any other thoughts?\par\pard\plain\hyphpar} {
{\i
The therapist starts by using one of the \u8220?Just Ask\u8221? questions. When
Jasmine was unable to identify a hot thought but kept repeating her feelings, the
therapist decided to try and identify the thoughts that went with Jasmine\u8217?s
feelings.}\par\pard\plain\hyphpar} {
{\i
Jasmine:} No, just this really strong, overwhelming feeling of
guilt.\par\pard\plain\hyphpar} {
{\i
Therapist:} Can you go back in your mind to when your mother told you that your
grandfather was not well?\par\pard\plain\hyphpar} {
{\i
Jasmine:} Sure, I can remember it really clearly.\par\pard\plain\hyphpar} {
{\i
Therapist:} Can you focus on your feeling of guilt? Really let yourself feel the
guilty feeling. ({\i
pausing}) I am wondering what thoughts go with this guilty
feeling.\par\pard\plain\hyphpar} {
{\i
Jasmine:} I just think that a good granddaughter would visit more regularly; now he
is sick and old.\par\pard\plain\hyphpar} {
Video 7.1\par\pard\plain\hyphpar} {\s4 \afs23
{\b
List Worries\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Often when clients are in emotional distress, they worry. Worry is a big component
of anxiety, but clients who feel depressed, guilty, ashamed, and angry also often
worry. Worry is about expecting bad things to happen. When my client is anxious or
worried, I start by making a list of all the \u8220?bad things\u8221? he is worried
will happen. The more concrete the list, the more useful it is. Remember, I am
looking for what my client is expecting to happen, not what he is expecting to
feel. For example, \u8220?I am worried I will be anxious when giving a
presentation,\u8221? or \u8220?I am worried that my presentation will not go
well\u8221? are less concrete worries than \u8220?I am worried I will forget my
talk.\u8221?\par\pard\plain\hyphpar} {
Below are some good questions to explore what specifically your client is worried
or anxious will happen:\par\pard\plain\hyphpar} {
What are you anxious or worried is going to happen?\par\pard\plain\hyphpar} {
Is there anything you are specifically worried about
happening?\par\pard\plain\hyphpar} {
What is the worst that could happen? Or what is your worst-case
scenario?\par\pard\plain\hyphpar} {
What do you imagine happening?\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist realized that she did not fully understand what Suzanne
was worried would happen at the barbecue. The therapist said, \u8220?I can tell
that you are pretty anxious about the barbecue. I thought it would be helpful if we
could make a list of what you are worried will happen, including your worst-case
scenario.\u8221? Together they made the following list:\par\pard\plain\hyphpar} {
When I get there, everyone will be talking to each other, and no one will say hi to
me.\par\pard\plain\hyphpar} {
If I approach one of the new teachers, she will turn her back on
me.\par\pard\plain\hyphpar} {
I will stand there alone, with no one to talk to.\par\pard\plain\hyphpar} {
If I go up to one of the other teachers and say hi, I will have nothing to
say.\par\pard\plain\hyphpar} {
Clear image of standing next to the barbecue, looking very awkward, holding a glass
in my hand. I see myself standing there all alone as everyone else is talking
together.\par\pard\plain\hyphpar} {
Making a specific list of worries can be a very helpful tool to manage anxiety.
Often, when clients see their worries written out, they realize that some are
unrealistic.\par\pard\plain\hyphpar} {
I want you to try a quick exercise. Think of an upcoming event that you are
somewhat anxious or worried about. Now, write down every bad thing you are worried
might happen, and look at the list. Try to make your worry list as specific and
concrete as possible. Do your worries seem more manageable? Maybe some of your
worries are reasonable, in which case you can start to problem solve. Making a list
takes anxiety from a big ball of bad feelings to specific worries you can start to
address. It is one more way to hit the pause button on your automatic negative
path.\par\pard\plain\hyphpar} {
Exercise 7.2\par\pard\plain\hyphpar} {
Practice helping your clients list their worries.\par\pard\plain\hyphpar} {\s3
\afs28
{\b
Agenda Item #3{\i
: Your Clients\u8217? Images}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Some of the most exciting work in CBT involves working with clients\u8217? images
(Hackmann, Bennett-Levy, & Holmes, 2011). Imagery can be a very useful tool to help
clients identify their hot thoughts.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Use Imagery to Recreate the
Situation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Sometimes when you ask your client, \u8220?What were you thinking?\u8221? he will
respond with, \u8220?I don\u8217?t know.\u8221? I usually follow up with one of the
\u8220?Just Ask\u8221? questions. I might say, \u8220?Was anything going through
your mind?\u8221? Often that is enough to prompt my client to start talking about
his thoughts, but sometimes my client still says, \u8220?I don\u8217?t know,\u8221?
or tells me a thought that is not a hot thought. In that case, one way to help your
client identify his thoughts is to ask him to take a moment and imagine himself
back in the situation. When a client imagines being back in the situation, some of
the feelings he had at the time come back and he has better access to his
thoughts.\par\pard\plain\hyphpar} {
When you recreate a situation using imagery, you can use all of the five senses;
however, asking clients to imagine {\i
seeing} the situation and {\i
hearing} anything that was said or any other sounds in the environment is often the
most effective way to recreate the situation (Richardson,
1999).\par\pard\plain\hyphpar} {
Here is an example of how recreating the situation in imagery helped Charles
identify his thoughts. Charles is newly married and has a two-month-old baby. He
has had trouble with alcohol in the past and is trying to drink moderately. He
comes to therapy saying he \u8220?blew it.\u8221? He tells his therapist that a few
nights ago he went out with his buddies to a bar for a drink. When he got home he
was very depressed and had three glasses of scotch.\par\pard\plain\hyphpar} {
{\i
Charles:} I was so depressed when I got home, I just thought if I had a drink I
would feel better.\par\pard\plain\hyphpar} {
{\i
There is no one right way to respond. Before she addressed the drinking,
Charles\u8217?s therapist wanted to understand what had happened at the bar that he
became so depressed.}\par\pard\plain\hyphpar} {
{\i
Therapist:} When you were out with your buddies, do you remember what you were
feeling?\par\pard\plain\hyphpar} {
{\i
Charles:} Just normal, sort of down.\par\pard\plain\hyphpar} {
{\i
Therapist:} And your thoughts?\par\pard\plain\hyphpar} {
{\i
Charles:} Nothing, just hanging out with the guys.\par\pard\plain\hyphpar} {
{\i
CBT theory tells us that if a client becomes distressed, there was a thought that
fueled the distress. Charles\u8217?s therapist wanted to discover what Charles was
thinking that led to his feeling so depressed.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I am wondering if we could go back to the situation in the bar and try
and figure out what was going on with you, in particular your thoughts and
feelings. Before you started feeling down, can you remember any particular
incident?\par\pard\plain\hyphpar} {
{\i
Charles:} My buddies were all talking about the baseball game, and I hadn\u8217?t
gone with them as I had to stay home with my kid that night. They were drinking and
talking about all these plans that I knew I couldn\u8217?t do, \u8217?cause I now
spend weekends with my wife and son.\par\pard\plain\hyphpar} {
{\i
Therapist:} Can you go back to the night in your mind? Take a moment to see the
bar, look around. ({\i
pauses}) See your buddies\u8217? faces. Can you hear them talking about the game
they went to? Now hear them talking about the other plans. Take a moment to really
go back to the bar in your mind. See if you can remember what is going through your
mind as your buddies were talking.\par\pard\plain\hyphpar} {
{\i
The therapist uses both visual and auditory imagery.}\par\pard\plain\hyphpar} {
{\i
Charles:} I guess I started thinking what a great time they were having, and that
now all I do is change diapers and work. Feels like my life is at a dead end. My
wife never wants sex anymore; she just complains about how tired she
is.\par\pard\plain\hyphpar} {
{\i
Once Charles can identify his thoughts, his depression and drinking make a lot more
sense.}\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Explore Images\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Strong negative feelings are often accompanied by intense affect-provoking images.
For example, clients who are scared of spiders tend to have images of huge horrible
spiders (Pratt, Cooper, & Hackmann, 2004), and clients who are socially anxious
tend to have negative images of themselves in social situations. A socially anxious
client may have an image of himself stuttering, sweating, or behaving in an
extremely awkward manner (Hirsch, Clark, Mathews, & Williams, 2003). Images can
also be about the past. It has long been known that clients with post-traumatic
stress disorder (PTSD) frequently have intrusive images in the form of flashbacks
of the traumatic event. What researchers and clinicians are discovering is that
clients with a variety of problems can have intrusive images that contribute to
their distress. For example, often clients who are depressed have intrusive images
of negative events that occurred in the past (Wheatley & Hackmann,
2011).\par\pard\plain\hyphpar} {
Some clients can easily identify their images; however, many clients become aware
of their images only when specifically asked whether images accompany their
emotional reaction (Brewin, Christodoulides, & Hutchinson, 1996). In my article
\u8220?Incorporating Imagery into Thought Records\u8221? (Josefowitz, 2017), I
describe different types of questions that can help clients identify their images.
You can find a Questions to Identify Your Client\u8217?s Images handout at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Start with a general question.} Do you have any images or memories connected with
this situation? When you think of this situation, does it bring up any images or
memories?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Explore worries.} Many clients who are anxious have very clear images of their
feared event occurring. If your client has a worst-case scenario, be sure to ask
whether he actually sees the worst case happening in his
mind.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Ask about images that accompany your client\u8217?s feelings.} Do you have any
images or memories that accompany your feelings? When you have this feeling, do you
ever see pictures or images in your mind of yourself or other
people?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Ask about images that accompany your client\u8217?s verbal thoughts.} Clients often
have thoughts about themselves ({\i
I don\u8217?t fit in}); thoughts about others ({\i
my father is always critical of me}); and thoughts about the future ({\i
my boss will refuse to pay me overtime}). You can ask, \u8220?When you have this
thought, do you see or imagine this happening? Do you get a picture in your mind of
yourself or the other person? What do you see yourself or the other person doing or
saying?\u8221?\par\pard\plain\hyphpar} {
Some clients\u8217? images are very detailed and elaborate. Many clients tell
themselves long, complex stories; others have very brief, fleeting images. Try to
notice your own images.\par\pard\plain\hyphpar} {
Suzanne had a very clear image of herself standing in the principal\u8217?s
backyard, looking very awkward. She is holding a drink in her hand and is slightly
sweaty. She is all alone and everyone else is happily talking together. Her
therapist asked if there were any sounds in her image or if she heard anything.
Suzanne said she could hear the other teachers talking and laughing, and she was
outside the group with nothing to say.\par\pard\plain\hyphpar} {
Images hold encapsulated meanings. Once you have identified your client\u8217?s
images, you can ask what these images mean about himself, other people, or the
future. Often images hold the same meaning as\u8212?and reinforce\u8212?the hot
thought (Josefowitz, 2017). In Suzanne\u8217?s case, her images reinforced her hot
thoughts that no one would want to talk to her and that she would not fit
in.\par\pard\plain\hyphpar} {
Exercise 7.3\par\pard\plain\hyphpar} {
Practice helping your clients identify their images.\par\pard\plain\hyphpar} {
Video 7.2\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: Additional Strategies to Identify
Thoughts}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Clients\u8217? hopes, questions, and mood shifts can also provide glimpses into
their thoughts.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
When Thoughts Are Hopes or
Questions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Thoughts that are hopes or questions pose unique challenges because they do not
clearly explain the meaning of the situation. This means that you need to continue
to explore these thoughts in order to identify a hot thought. Let me give you some
examples.\par\pard\plain\hyphpar} {
Karl is very depressed. When his therapist asks about his thoughts, he sighs sadly
and says he really hopes one day he will have children. This hope is not a thought
that captures what his depression is about. If Karl were truly hopeful, he would
not be feeling depressed. When clients are depressed or anxious, they sometimes
express as {\i
hopes} the very things they feel {\i
hopeless} or {\i
worried} about. Karl\u8217?s therapist follows up and asked, \u8220?I hear you {\i
hope} that you will have children; are you worried that will not happen?\u8221?
Karl became teary and responded, \u8220?Yes I think that for me having children is
pretty hopeless, and it is the most important thing to me.\u8221? Karl\u8217?s
thought, {\i
It is hopeless that I will have children}, starts to explain his
sadness.\par\pard\plain\hyphpar} {
Karen is also depressed. When her therapist asks about her thoughts, she becomes
teary and says she keeps thinking, {\i
Will my husband leave me?} The problem is you can\u8217?t look for evidence for a
question\u8212?you need a statement to look for evidence. You can turn the question
into a statement by either rephrasing it or exploring how your client would answer
the question. For example, Karen\u8217?s therapist rephrased her question by asking
Karen, \u8220?Are you thinking, {\i
My husband will leave me?}\u8221?\par\pard\plain\hyphpar} {
Let\u8217?s see how Raoul\u8217?s therapist helped him further explore a thought
that was in the form of a question. About a week ago, Raoul\u8217?s boss asked him
to work on a new project with some of his junior colleagues. He had been
procrastinating over contacting them. Raoul was able to identify his feelings and
told his therapist he was embarrassed (8) and anxious (8). His therapist then asked
him what he was thinking.\par\pard\plain\hyphpar} {
{\i
Raoul:} I keep wondering, {\i
Why didn\u8217?t I get the promotion?}\par\pard\plain\hyphpar} {
{\i
Therapist:} When you think, {\i
Why didn\u8217?t I get the promotion}, how do you answer the question in your
head?\par\pard\plain\hyphpar} {
{\i
Raoul:} I guess I think I just wasn\u8217?t competent
enough.\par\pard\plain\hyphpar} {
{\i
Therapist:} So one answer you give yourself is, {\i
I just wasn\u8217?t competent enough}. Do you give yourself any other
answers?\par\pard\plain\hyphpar} {
{\i
Raoul:} Well, I also think my colleagues and boss don\u8217?t respect me, and
don\u8217?t respect my work.\par\pard\plain\hyphpar} {
{\i
When Raoul\u8217?s therapist starts to explore how he answers the question, he
starts to identify thoughts about himself}, I wasn\u8217?t competent enough{\i
, and thoughts about others,} My colleagues and boss don\u8217?t respect me and
don\u8217?t respect my work.\par\pard\plain\hyphpar} {
Exercise 7.4\par\pard\plain\hyphpar} {
Practice exploring thoughts that are facts, hopes, or
questions.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Use Shifts in Your Client\u8217?s
Mood\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
When clients talk about a difficult situation, they often become emotional. A shift
in your client\u8217?s mood usually goes with an important thought about self,
others, or the future. For example, if a client looks sad, blushes, or becomes
agitated, it is an opportunity to \u8220?catch\u8221? important thoughts. I usually
say, \u8220?I noticed you looked sad [or I noticed you looked upset]; what were you
thinking?\u8221?\par\pard\plain\hyphpar} {
Let\u8217?s look at an example that Suzanne brought up in the sixth session.
Suzanne came into the session saying she wanted to talk about her relationship with
her husband. She started in a very calm manner, saying that last night, she said
she was tired and wanted to go to bed early. Her husband became annoyed and angry
and told her that she was always tired and never wanted to do anything fun anymore.
Suzanne started to become teary as she described her husband\u8217?s response. Her
therapist wanted to identify what thoughts went with her change in
mood.\par\pard\plain\hyphpar} {
{\i
Therapist:} You looked teary as you remembered what your husband
said.\par\pard\plain\hyphpar} {
{\i
Suzanne:} Yes, it was pretty awful to hear him say that I never want to go out
anymore.\par\pard\plain\hyphpar} {
{\i
Therapist:} I am wondering what was going through your mind just now, as you got
teary.\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
looking very sad and more teary}) I thought that if I don\u8217?t start being more
fun, that he will leave me, and I will be all alone.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Notice Raoul\u8217?s Change in
Mood\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Up to now Raoul has mainly focused on work issues. In session 7 he comes in and
tells his therapist that his youngest niece may have a serious illness. He explains
in a calm voice, \u8220?When I think of the possibility of my niece being sick, I
know the whole family will just have to find a way to cope, as hard as it will
be.\u8221? He then goes on:\par\pard\plain\hyphpar} {
{\ql
{\i
Raoul:} We will know for sure whether my niece has the illness on Monday, when we
get the results of the lab tests. ({\i
His voice cracks, he takes a deep breath, and looks very
upset.})\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
How could his therapist use the shift in Raoul\u8217?s mood to help him identify
his thoughts about the lab results?\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Raoul
identify his thoughts:\par\pard\plain\hyphpar} {
{\ql
What a hard situation. I hope that you are taking care of
yourself.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
You just looked so upset, I am wondering what was going through your mind when you
thought of getting the lab results?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\ql
I can see how upset you are, but I also hear how important it is to you to cope.
How are you coping? {\i
Response #2 is the most likely to lead Raoul to identify the thoughts that
accompany his change in mood. In response #1, the therapist tries to be supportive
but does not ask about Raoul\u8217?s thoughts and is giving advice that Raoul did
not ask for. In response #3, the therapist tries to be empathic and then moves to
problem solving without having a good definition of the problem.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #5{\i
: How Do You Know Which Questions to
Use?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It can be hard to know which question to use, and there is no right answer. Here is
a summary of the questions I use, in the general order in which I use them. You may
initially find it helpful to keep this list by your side during therapy. (You can
download a Questions to Identify Your Client\u8217?s Thoughts handout at
http://www.newharbinger.com/38501.) The more you use these questions, the more they
will start to feel natural.\par\pard\plain\hyphpar} {
What were you thinking? Any other thoughts?\par\pard\plain\hyphpar} {
When a client\u8217?s mood shifts, ask about thoughts.\par\pard\plain\hyphpar} {
What does the situation mean to you? OR What does the situation mean about
yourself, others, or your future?\par\pard\plain\hyphpar} {
How is this situation a problem for you?\par\pard\plain\hyphpar} {
What are some of the thoughts that go with your feelings?\par\pard\plain\hyphpar} {
Let\u8217?s make a list of your worries. Do you have a worst-case
scenario?\par\pard\plain\hyphpar} {
Do you have any images?\par\pard\plain\hyphpar} {
If the thought is a question: How do you answer this question in your
mind?\par\pard\plain\hyphpar} {
If the thought is a hope: What are you worried about?\par\pard\plain\hyphpar} {
Let\u8217?s use some of these questions to help Michael, a twenty-eight-year-old
client of mine, to identify his thoughts. Michael\u8217?s main agenda was
addressing his anxiety about his relationship with a new girlfriend. He didn\u8217?
t understand why he was so anxious. We began with identifying situations where he
felt anxious. Michael told me that his girlfriend was rarely verbally affectionate
toward him; she almost never said she missed him or that she was happy to see him.
He described a text message he just received where she said, \u8220?See you tonight
for dinner.\u8221? As he talked about her behavior, he became almost teary. Below
is how I explored his thoughts; however, there are many other possible helpful
responses. As you read through the dialogue, consider what you would have
said.\par\pard\plain\hyphpar} {
{\i
Therapist:} When you received the text, what were your thoughts at the
time?\par\pard\plain\hyphpar} {
{\i
Michael:} I don\u8217?t know, it just doesn\u8217?t feel good to get a text like
that ({\i
eyes well up with tears}).\par\pard\plain\hyphpar} {
{\i
I started with using one of the \u8220?Just Ask\u8221? questions. However, Michael
responded with a thought that was not a hot thought, so I wanted to try another
approach.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I can see you\u8217?re becoming almost teary. What thoughts are going
through your mind?\par\pard\plain\hyphpar} {
{\i
I noticed the shift in his mood and thought it probably signaled an important
thought.}\par\pard\plain\hyphpar} {
{\i
Michael:} I know she had a relationship with another man for two years before me. I
keep wondering, {\i
Did she treat him the same way?}\par\pard\plain\hyphpar} {
{\i
Michael\u8217?s first thought is a fact:} She had a relationship for two years
before me{\i
. His second thought is a question:} Did she treat him the same way? {\i
I chose to explore how he answered the question, as there seemed to be more emotion
attached to that thought.}\par\pard\plain\hyphpar} {
{\i
Therapist:} And how do you answer the question, \u8220?Did she treat her past
boyfriend in the same way\u8221??\par\pard\plain\hyphpar} {
{\i
Michael:} I think she treated him differently, or the relationship wouldn\u8217?t
have lasted.\par\pard\plain\hyphpar} {
{\i
I wanted to explore what it meant to Michael that he thought his girlfriend had
treated her previous boyfriend differently.}\par\pard\plain\hyphpar} {
{\i
Therapist:} If she did treat her previous boyfriend differently, what would it mean
to you?\par\pard\plain\hyphpar} {
{\i
Michael:} That she doesn\u8217?t care about me as much as her previous boyfriend,
maybe that she doesn\u8217?t really care about me at all.\par\pard\plain\hyphpar} {
{\i
At this point, Michael started to talk with more emotion about his fears that his
girlfriend was not committed to the relationship and that he was not very important
to her.}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #6{\i
: Link Thoughts to Feelings, Physical Reactions, and
Behavior}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
At this point in therapy, you have identified a specific situation that is
problematic for your client, and you\u8217?ve explored your client\u8217?s reaction
using the four-factor model. Identifying the relationships among the four factors
provides your client with a structure for understanding what is maintaining his
problems, and provides you with a way of organizing your client\u8217?s treatment.
Here\u8217?s where the written worksheet Understand Your Reaction comes in handy:
you and your client have a document you can look at when developing a model to
understand the factors that are maintaining his problem.\par\pard\plain\hyphpar} {
I start with asking my client to look over the Understand Your Reaction worksheet
and ask if he sees a connection among the four factors. Often a client will
spontaneously comment that his reaction makes more sense, or that given his
thoughts, it makes sense how he is feeling or behaving. If a client does not see
the link between his thoughts and his feelings, physical reactions, and behaviors,
I point it out to him. For example, I might say, \u8220?When I look at your
thoughts, it makes sense to me that you would be [a feeling, for example
depressed], or do [a behavior, for example procrastinate]. Does this make sense to
you?\u8221? If my client agrees with me, I ask him to explain the link among the
four factors in his own words.\par\pard\plain\hyphpar} {
Let\u8217?s look at the Understand Your Reaction worksheet that Suzanne completed
to see how we can help her understand her difficulties.\par\pard\plain\hyphpar} {\b
{\qc
Understand Your Reaction}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Physical Reactions {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Behaviors} {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
How did my body react?\par\pard\plain\hyphpar} {
What did I do?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {
Principal invited me to barbecue with the three other new
teachers\par\pard\plain\hyphpar} {
Nervous (7)\par\pard\plain\hyphpar} {
Worried (8)\par\pard\plain\hyphpar} {
Embarrassed (6)\par\pard\plain\hyphpar} {
Clenched stomach (4)\par\pard\plain\hyphpar} {
Tense shoulders (5)\par\pard\plain\hyphpar} {
Has not responded\par\pard\plain\hyphpar} {
I don\u8217?t want to go.\par\pard\plain\hyphpar} {
The other new teachers will be there.\par\pard\plain\hyphpar} {
I won\u8217?t fit in.\par\pard\plain\hyphpar} {
I will just stand there looking awkward.\par\pard\plain\hyphpar} {
No one will want to talk to me.\par\pard\plain\hyphpar} {
I will probably get all sweaty.\par\pard\plain\hyphpar} {
{\i
Therapist:} Let\u8217?s look at what you wrote down. ({\i
Suzanne and her therapist look at the worksheet}.) When you look at it, do you
notice any connection among the four factors?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Sort of\u8230?I wasn\u8217?t aware that I had all of those
thoughts.\par\pard\plain\hyphpar} {
{\i
Suzanne\u8217?s therapist wants to positively reinforce Suzanne for identifying her
thoughts. Rather than telling her, she wants Suzanne to make the link between her
thoughts and how she was feeling and behaving.}\par\pard\plain\hyphpar} {
{\i
Therapist:} You did a really good job of identifying your thoughts. Do you see a
connection between your thoughts and your feelings, physical reactions, and
behaviors?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I do. It makes sense to me that if all these thoughts were going through
my head, I would feel anxious.\par\pard\plain\hyphpar} {
{\i
Therapist:} I think you are right, and you said it very well. The thoughts really
explain your feelings.\par\pard\plain\hyphpar} {
{\i
Notice how Suzanne\u8217?s therapist reinforces Suzanne\u8217?s understanding of
the relationship between her thoughts and her feelings; she tells Suzanne that she
articulated the relationship well, and repeats the
connection.}\par\pard\plain\hyphpar} {
At this point Suzanne\u8217?s therapist would introduce the idea of examining her
thoughts, to see if there is any evidence for her beliefs. In the next chapter, we
are going to cover how to look for evidence for your clients\u8217?
thoughts.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Do I Always Explore All Four
Factors?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
For most clients I use the Understand Your Reaction worksheet. However, you can
start with just focusing on one aspect of a client\u8217?s problem. For example,
remember my client Elsbeth, in chapter 5, who was angry at her son for not doing
his homework and chores? We started with just monitoring situations where she was
angry. With other clients, if behavior is not part of the presenting problem, I
start with exploring feelings, physical reactions, and thoughts. Once my client
understands the feeling\u8211?thought connection, we add exploring his
behaviors.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Evaluating Your Client\u8217?s
Worksheet\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Below are five criteria I use to evaluate whether I need to spend more time
exploring any aspect of a client\u8217?s Understand Your Reaction worksheet. If a
client did not find completing the worksheet helpful, I check that it was done
well; if it was not done well, I keep working with my client. You can download
Understand Your Reaction Checklist at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Is the {\b
situation} a factual description of what occurred or does it include feelings,
physical reactions, behaviors, or thoughts?\par\pard\plain\hyphpar} {
Is the {\b
feeling} really a feeling or is it a thought or behavior?\par\pard\plain\hyphpar} {
Did the client rate his or her feelings and physical
reactions?\par\pard\plain\hyphpar} {
Is the {\b
behavior} a factual description or does it include feelings, physical reactions, or
thoughts?\par\pard\plain\hyphpar} {
Are the {\b
thoughts} hot thoughts? Are the thoughts about self, others, or the future? Are the
thoughts related to the client\u8217?s feelings? \par\pard\plain\hyphpar} {
Exercise 7.5\par\pard\plain\hyphpar} {
Practice evaluating the Understand Your Reaction worksheet.\par\pard\plain\hyphpar}
{\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to a Clinical
Example\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 7.1:} (a) Yonas Asks a Question, and (b) Diana Wants to Go to
College\par\pard\plain\hyphpar} {
{\b
Exercise 7.2:} Isabella Lists Her Worries\par\pard\plain\hyphpar} {
{\b
Exercise 7.3:} Aabir Explores His Images\par\pard\plain\hyphpar} {
{\b
Exercise 7.4:} Carol Wants to Apply for a Job\par\pard\plain\hyphpar} {
{\b
Exercise 7.5:} Sophia Completes the Understand Your Reaction
Worksheet\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before you try completing the whole Understand Your Reaction worksheet, it is
helpful to practice identifying just your thoughts and
feelings.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Identify Your Own Feelings and
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
This coming week, choose two situations when you had at least a moderately strong
negative reaction. Describe the situation, identify and rate your feelings, then
identify your thoughts using Questions to Identify Your Client\u8217?s Thoughts.
Record your responses on the What Are My Feelings and Thoughts? worksheet, which
you can download at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
What Are My Feelings and Thoughts?}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Complete the Understand Your Reaction
Worksheet\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once you have practiced the What Are My Feelings and Thoughts? worksheet, you are
ready to try completing the entire Understand Your Reaction worksheet. There is a
copy below, and you can also download it at http://www.newharbinger.com/38501. Once
you have identified your thoughts, ask yourself if they are about self, others, or
the future.\par\pard\plain\hyphpar} {\b
{\qc
Understand Your Reaction}} {\b
Situation} {\b
Feelings {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Physical Reactions {
(Rate 1\u8211?10)\par\pard\plain\hyphpar} } {\b
Behaviors} {\b
Thoughts} {
What? Who? Where? When?\par\pard\plain\hyphpar} {
What did I feel?\par\pard\plain\hyphpar} {
How did my body react?\par\pard\plain\hyphpar} {
What did I do?\par\pard\plain\hyphpar} {
What did I think?\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It\u8217?s time to try the same exercise that you just did, but this time with a
client.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3 Identify Your Client\u8217?s Feelings and
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose a client who is easy to work with and follow these
steps:\par\pard\plain\hyphpar} {
{\ql
Identify a situation that is
problematic.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Introduce the What Are My Feelings and Thoughts? worksheet, which you completed in
Homework Assignment #1, and explain that you want to use it to help identify your
client\u8217?s feelings and
thoughts.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Identify and rate your client\u8217?s
feelings.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Use Questions to Identify Your Client\u8217?s
Thoughts.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Help your client link his or her thoughts to his or her
feelings.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #4 Complete the Understand Your Reaction Worksheet with a
Client\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If the last exercise went well, try the Understand Your Reaction worksheet with a
client. The first time you try this you may feel awkward and worry about your
client\u8217?s reaction. This is a normal response to trying something new.
However, try to put your worries aside and focus on the
task.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under the agenda items.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} Identify automatic thoughts.\par\pard\plain\hyphpar} {
What is the most straightforward way to identify negative automatic
thoughts?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Helpful questions.\par\pard\plain\hyphpar} {
How can you ask what a situation means to your client?\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Agenda Item #3:} Your clients\u8217? images.\par\pard\plain\hyphpar} {
What are two good questions you could use to ask about your client\u8217?s
images?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Additional strategies to identifying
thoughts.\par\pard\plain\hyphpar} {
If a thought is a question or a hope, how can you explore it
further?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #5:} How do you know which questions to use?\par\pard\plain\hyphpar} {
What are some of the questions you could use to help your clients identify their
thoughts?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #6:} Link thoughts to feelings, physical reactions, and
behavior.\par\pard\plain\hyphpar} {
Why is it helpful to look at the relationship among the four
factors?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Part 3\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Cognitive and Behavioral
Interventions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }
{\page } {\s1 \afs32
{\qc
Chapter 8\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Look for Evidence and Create Balanced
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In chapter 7 we covered how to help your clients identify their thoughts. Did you
have a chance to notice your own thoughts? Did you ask your clients about their
thoughts and feelings? What did you discover?\par\pard\plain\hyphpar} {
If you did not do the homework, think about an upsetting experience that happened
last week. Try to identify your feelings and thoughts. What did the situation mean
to you? What was your worst-case scenario? Did you have any
images?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this chapter we are going to build on the Understand Your Reaction worksheet and
learn how to work with thought records. You will ask your clients to examine the
evidence for their negative thoughts and develop a balanced thought that takes into
consideration all of the evidence. The whole process is called {\i
cognitive restructuring}.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} What are thought records?\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Explain looking for evidence.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Find evidence that supports negative
thoughts.\par\pard\plain\hyphpar} {
{\b
Agenda Item #4: Find e}vidence against negative thoughts.\par\pard\plain\hyphpar} {
{\b
Agenda Item #5:} Develop balanced thoughts.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In chapter 5 we talked about how your client has a well-worn automatic negative
path that she zooms down, ending up in a big black jumbled ball of feelings,
physical reactions, behaviors, and thoughts. One way to hit the pause button on
your client\u8217?s automatic negative reaction is to use the four-factor model to
help your client understand her reaction. Once your client has identified her
feelings, physical reactions, behaviors, and thoughts, she is ready to actively
change her negative path. One way to help your client change her negative path is
to ask her to step back and examine the evidence for her thoughts. Negative
thoughts are like thinking habits; we assume they are true and don\u8217?t stop to
question whether they make sense. However, habits can be changed. Looking for
evidence starts a process of developing new and more positive thought habits that
are based on reality.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: What Are Thought Records?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
A thought record is essentially a structure for helping your client look for the
evidence for her hot thoughts. In its simplest form, a thought record is a
worksheet where a client identifies a problematic situation and then records her
feelings and thoughts about the situation. The client then choses one thought to
focus on. For a thought record to be effective, the thought the client chooses
needs to be a hot thought. Once your client has identified the hot thought she
wants to explore, she then looks for the evidence for and against her thought.
After the client has examined the evidence, she develops a new more balanced or
alternative thought. Many thought records also include space to record physical
reactions and behavior. The Understand Your Reaction worksheet can be used as the
first five columns of a thought record. Thought records also frequently involve
having clients rate how much they believe their new balanced thought and rerate
their feelings after completing the thought record; however, this is not essential.
Below are the steps to complete a thought record. The steps in italics are common
but not essential to the process.\par\pard\plain\hyphpar} {
Identify a problematic situation.\par\pard\plain\hyphpar} {
Identify and rate feelings.\par\pard\plain\hyphpar} {
{\i
Identify physical reactions.}\par\pard\plain\hyphpar} {
{\i
Identify behaviors.}\par\pard\plain\hyphpar} {
Identify thoughts.\par\pard\plain\hyphpar} {
Choose a hot thought (a thought that is related to a negative feeling and a
negative evaluation of self, other, or the future).\par\pard\plain\hyphpar} {
Look for evidence for and against the hot thought.\par\pard\plain\hyphpar} {
Create a balanced or alternative thought based on all of the
evidence.\par\pard\plain\hyphpar} {
{\i
Rate the extent to which you believe the new balanced
thought.}\par\pard\plain\hyphpar} {
{\i
Rate your feelings now that you have examined the
evidence.}\par\pard\plain\hyphpar} {
I use the Examine the Reality of Your Thoughts worksheet, which follows, to help
clients complete the rest of the thought record process.\par\pard\plain\hyphpar}
{\b
{\qc
Examine the Reality of Your Thoughts}} {\b
Thought I want to examine:} {\b
Evidence for My Thought} {\b
Evidence Against My Thought} {\b
Conclusion or thoughts that consider all the evidence:} {
The theory behind thought records is that clients assume their negative thoughts
are true. Asking clients to examine the evidence for their thoughts stops their
automatic reaction and starts a process of self-reflection. When clients examine
the evidence for their thoughts and create their own balanced thought, they develop
new ways of thinking and less extreme attitudes toward the world and themselves.
New ways of thinking open up the possibility of behavioral change. Evidence clearly
shows that this process of cognitive restructuring is related to alleviating
depression and anxiety (Beck & Dozois, 2011).\par\pard\plain\hyphpar} {
A written thought record is not essential. Looking for the evidence for a thought
can be done as part of a therapy conversation. However, I would encourage you to
use the Understand Your Reaction and Examine the Reality of Your Thoughts
worksheets as written tools. A written thought record provides a structure and
makes the process of identifying thoughts and looking for evidence very concrete.
Some therapists like to use a seven-column thought record with space for
identifying the four factors, looking for evidence, and developing a balanced
thought. Dennis Greenberger and Christine Padesky use this type of thought record
in their book {\i
Mind Over Mood} (2016). Personally, however, I like to break the thought record
down into two stages, first using the Understand Your Reaction worksheet and then
the Examine the Reality of Your Thoughts worksheet. You can download both at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Although looking for evidence is a powerful intervention, looking for evidence once
will not shift a longstanding negative thought. Your clients will need to complete
many thought records, over a period of time, to change their negative thoughts.
However, while a client\u8217?s thoughts vary somewhat from situation to situation,
most clients have recurring negative thinking patterns. If you identify a
client\u8217?s thoughts in one situation, most likely these thoughts will recur in
other situations. This means that the thought record you complete for one situation
will often be relevant to other situations.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Choose a Hot Thought\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If your client has one central negative hot thought that is closely related to her
emotional distress, that is the thought you will focus on. However, your client may
have more than one hot thought, for example, {\i
I am an inadequate mother} and {\i
My partner does not love me}. In this case, your client needs to choose which
thought to work with, as you can only examine the evidence for one thought at a
time. If a client has more than one hot thought, I ask, \u8220?Which thought do you
think is the most central, or the most important for us to examine?\u8221? Another
question I have found helpful is, \u8220?Which thought do you think is most closely
related to your strongest negative emotion?\u8221? Clients usually know which
thought they need to focus on. Most of our negative thoughts are repetitive. If
your client chooses to examine {\i
I am an inadequate mother}, she will have another chance to examine {\i
My partner does not love me}.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What Is Socratic Questioning?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
All CBT books talk about the importance of Socratic questioning. The term comes
from the Greek philosopher, Socrates. Socratic questioning is the idea that
skillful questioning can help your clients examine the assumptions behind their
thoughts, consider aspects of the situation they had ignored, or understand their
situation from a different perspective. Your role is to ask questions that help
your client understand her problems in a new light.\par\pard\plain\hyphpar} {
The basic idea is that it is more effective to ask questions that help clients
reach their own conclusions than to tell a client what to think. If I could post
one sticky note on all my readers\u8217? heads, it would
say:\par\pard\plain\hyphpar} {
{\ql
Conclusions you reach yourself are more convincing than conclusions someone tells
you.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #2{\i
: Explain Looking for Evidence}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once your client has identified a hot thought, you need to explain the idea of
looking for evidence. Essentially, you are going to teach your client to examine
her thoughts for their validity rather than treating thoughts as facts. Your client
needs to learn to take a step back and put some distance between herself and her
thoughts.\par\pard\plain\hyphpar} {
My clients almost always immediately grasp the idea of looking for evidence, though
sometimes they assure me that they know their negative thoughts are accurate. Here
is how I usually explain looking for evidence (you can find a copy at
http://www.newharbinger.com/38501):\par\pard\plain\hyphpar} {
You did a really good job of identifying your thoughts and catching the negative
thoughts that cause you to feel bad. I am wondering if you would be willing to
examine your thoughts. I would like to look at the evidence that supports your
negative thoughts, and also at evidence that doesn\u8217?t support your negative
thoughts. Negative thoughts are like thought habits. By that I mean they are ways
of thinking that you are used to, but you have not examined whether they are
accurate. When we look for evidence, I want us to focus on facts. That way, we can
evaluate the accuracy of your thoughts. Would that be okay with
you?\par\pard\plain\hyphpar} {
We need to pick one thought that we want to examine. I want to look over the
thoughts you identified that go with your negative feelings and see if we can pick
one that feels the most central to you, or is the most related to your strongest
negative emotional reaction.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Practice in Your Imagination: Explain Looking for
Evidence\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I want to ask you to imagine explaining looking for the evidence for a hot thought.
Before you start, rate from 1 to 10 how comfortable you feel explaining looking for
evidence for and against a hot thought. At the end of the exercise, rate your level
of comfort again to see if it changed. Now, let\u8217?s try this
exercise.\par\pard\plain\hyphpar} {
Choose a client who you think would benefit from looking for evidence for his or
her thoughts. Try to get a picture of him or her in your mind. Imagine yourself in
your office with your client. See your office; notice the sounds and smells in the
room. Imagine that your client has identified a negative thought and you want to
explain how to examine the evidence for his thought. Read over how I suggest
explaining the process of looking for evidence while imagining yourself saying the
words. You can also use your own phrases. Really hear and feel yourself explaining
how to examine the evidence. Now, imagine explaining looking for evidence two more
times with the same client. Each time, imagine that your client responds
positively.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Find Evidence That Supports Negative
Thoughts}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If you are going to help your client reevaluate her negative thoughts, you need to
understand the evidence she uses to support them. Many clients find that writing
down the evidence, or saying the evidence out loud, makes it more manageable. It
becomes a fact that you can talk about, rather than something that sits in your
head. Sometimes when a client starts to look for facts that support her negative
thoughts, she realizes that there aren\u8217?t any, or not as many as she thought.
Sometimes a client discovers that her negative thoughts are fairly accurate. This
can also be helpful, as it highlights the need to problem solve and cope with a
real problem.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Suzanne Examines the Evidence\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s look at how we could help Suzanne with her anxiety about the invitation
to the principal\u8217?s barbecue. She identified her hot thought as {\i
No one will want to talk to me}. Suzanne\u8217?s therapist explained the process of
looking at the evidence, and Suzanne was willing to try.\par\pard\plain\hyphpar} {
{\i
Therapist:} I want to start with looking for the evidence that supports your
thought, {\i
No one will want to talk to me}. What makes you think that it might be
true?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I know that I will feel anxious when I go to the
barbecue.\par\pard\plain\hyphpar} {
{\i
Suzanne\u8217?s thought,} I will feel anxious when I go to the barbecue, {\i
is not a fact. It is a} prediction{\i
about how she will feel. Suzanne\u8217?s therapist wants to explore whether there
are any facts that support her hot thought.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I hear you will feel anxious, but I wonder if there are any facts that
support your belief that no one will want to talk to you.\par\pard\plain\hyphpar} {
{\i
Suzanne:} What do you mean?\par\pard\plain\hyphpar} {
{\i
Therapist:} If I wanted to prove that no one would want to talk to you, I would
have to back up my opinion with facts. For example, if you were in a court of law,
the judge would look only at the facts. Does that make sense to
you?\par\pard\plain\hyphpar} {
{\i
The therapist wants to be sure that Suzanne understands the idea of facts.
Sometimes using the analogy of a court of law can be
helpful.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} What about the fact that I hardly know any of the other teachers, does
that count?\par\pard\plain\hyphpar} {
{\i
Therapist:} Of course, that is a fact. I wonder\u8230?how is it related to no one
wanting to talk to you?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, none of them have made an effort to talk to me. I usually stand
alone at recess and I eat lunch by myself also.\par\pard\plain\hyphpar} {
{\i
Therapist:} Okay, so let\u8217?s write down what you just said, to be sure we
don\u8217?t forget. How would you put that in your own words? ({\i
Either Suzanne or her therapist writes.}) Other evidence that makes you think, {\i
No one will want to talk to me}?\par\pard\plain\hyphpar} {
{\i
Notice that Suzanne\u8217?s therapist is gathering data; she is not refuting or
problem solving.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} I think it\u8217?s mainly at lunch and recess. Maybe also when I arrive
in the morning, no one says hi to me, or smiles.\par\pard\plain\hyphpar} {\s4
\afs23
{\b
Use the Past to Understand the
Present\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It can be helpful to ask your client if she had any experiences in her childhood or
past that support, or that are related to, her negative thoughts. Making the link
between her history and her current thinking can help your client start to see that
what was true in her past is not necessarily true in her current
life.\par\pard\plain\hyphpar} {
Take a moment to think about how you could ask Suzanne about the relationship
between any past events and her hot thought.\par\pard\plain\hyphpar} {
{\i
Therapist:} Suzanne, is there anything in your past that would cause you to think,
{\i
No one will want to be my friend}?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Actually, when I was in high school, in my last year, there was a group
of really awful girls who made my life miserable. They wanted to use my house for a
drinking party when my parents were away for the weekend, and I said no. They
spread awful rumors about me, and I lost almost all my friends. It was a horrible,
lonely time in my life. I felt then that no one wanted to be my
friend.\par\pard\plain\hyphpar} {
{\i
When a client discloses painful memories from her past, you need to decide if you
want to focus on the memory or continue with the thought record. Generally, if it
is the first time a client discloses a traumatic memory, I ask my client if she
would like to focus on the memory. Suzanne disclosed a painful memory from high
school that was upsetting, but not traumatic. Her therapist thought it was more
important to continue with the thought record than to explore the high school
memory.}\par\pard\plain\hyphpar} {
{\i
Therapist:} It must have been very upsetting to have this happen. Is that when the
thought {\i
No one wants to be my friend} started?\par\pard\plain\hyphpar} {
{\i
Suzanne:} It was pretty awful. Yeah, that\u8217?s when I became more self-conscious
and started worrying about people liking me. Before that, I just had a bunch of
friends whom I hung out with.\par\pard\plain\hyphpar} {
{\i
Therapist:} It sounds like it really changed your outlook. In another session, it
might be important for us to talk about what happened in high school. For now,
could we just put it down in the \u8220?Evidence for\u8221?
column?\par\pard\plain\hyphpar} {
Let\u8217?s see how Suzanne filled in the \u8220?Evidence for My Thought\u8221?
column of her Examine the Reality of Your Thoughts
worksheet.\par\pard\plain\hyphpar} {\b
Thought I want to examine: No one will want to be my friend.} {\b
Evidence for My Thought} {\b
Evidence Against My Thought} {
No one has made an effort to talk to me.\par\pard\plain\hyphpar} {
I am alone at recess and lunch.\par\pard\plain\hyphpar} {
Other teachers do not say hi when I get to school in the
morning.\par\pard\plain\hyphpar} {
In high school, some girls started rumors and I lost almost all my
friends.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4: Find Evidence Against Negative
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Clients tend to focus on information that confirms their negative thoughts. Your
job is to help your client focus on information she usually ignores and that
challenges her negative thoughts. You can think of your client as living in a room
filled with information, but only the information that supports her negative
thoughts is lit; the rest of the room is in the dark. Your job is to use questions
so that the whole room is in the light. Once the whole room is lit and your client
sees all of the evidence, she can decide if her previous belief still makes
sense.\par\pard\plain\hyphpar} {
Figure 8.1 shows how a therapist used a drawing of lighting up a room to help her
client Paula, who is a doctor, understand that she was only looking at information
that confirmed her hot thought. In one of Paula\u8217?s therapy sessions she was
very distressed and told her therapist she thought that she was not a good doctor.
Her evidence for her belief was that this past week she had misdiagnosed a patient
and another patient had been very angry because she had kept him waiting half an
hour. Paula and her therapist looked at the evidence against her belief. Paula
noted that she had been a successful doctor for twenty years, almost all her
patients are happy, and she rarely keeps patients waiting; she also gave examples
of many complicated diagnoses she made over the years.\par\pard\plain\hyphpar} {
Her therapist drew figure 8.2 to help Paula understand that she only sees
information that confirms her belief that she is a bad doctor, and that all of the
information that suggests she is a good doctor is ignored or kept in the dark. Her
therapist told Paula they had to shine a light on all of the
information.\par\pard\plain\hyphpar} {
{\i
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}}

Figure 8.1. Paula\u8217?s therapist shines some light on ignored

information.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar
} {
There are three types of questions you can use to examine the evidence against a
hot thought:\par\pard\plain\hyphpar} {
Is there evidence that contradicts my negative thoughts?\par\pard\plain\hyphpar} {
How probable is my negative prediction?\par\pard\plain\hyphpar} {
Is there another perspective?\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Evidence That Contradicts Your Client\u8217?s Negative
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I generally start by directly asking my client if she has any experiences that
suggest that her hot thought is not true, or not true all of the time. When
Suzanne\u8217?s therapist asked, \u8220?Have you had any experiences that suggest
that people may want to be your friend?\u8221? Suzanne responded quietly, \u8220?I
had some friends in my previous school.\u8221?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Evidence needs to be concrete and detailed.} Examining the evidence for and against
a negative automatic thought is similar to weighing evidence on a scale. On one
side is the evidence for the negative thought and on the other side is the evidence
against the negative thought. The evidence for the negative thought is usually very
heavy and full of details. The evidence against the negative thought is often more
abstract and lacking in details. It can feel light compared to the heavy evidence
for the thought. The more your client can provide detailed examples of evidence
against the negative thought, the more she will be emotionally engaged, and the
more the evidence against the negative thought will weigh compared with the
evidence for it.\par\pard\plain\hyphpar} {
Suzanne\u8217?s evidence against her hot thought is that she had \u8220?some
friends.\u8221? This is not very strong or emotionally compelling evidence. To make
the evidence more compelling, her therapist started by asking for specific
examples, and then asked for details about the examples. Below are some of the
questions her therapist asked.\par\pard\plain\hyphpar} {
Can you give me examples of some of your friends?\par\pard\plain\hyphpar} {
When you say you had \u8220?some friends,\u8221? can you tell me about
them?\par\pard\plain\hyphpar} {
What kinds of things did you do with your friends, both at school and outside of
school?\par\pard\plain\hyphpar} {
How did you know that they wanted to be your friend?\par\pard\plain\hyphpar} {
Her therapist discovers that Suzanne was friendly with many of the teachers at her
previous school, but she had two good friends, Rita and Faiza. They generally ate
lunch together and worked on the school play together. They often saw each other on
weekends, and sometimes they would get together with their children and spouses.
Suzanne thought they were funny, nice, warm people whom she had a good time with.
Since she moved to her new school, she has seen less of them. They have often
called to see if she wanted to do something on the weekend, but she\u8217?s been
too tired. Faiza dropped by the other day with a cake she had made to cheer Suzanne
up.\par\pard\plain\hyphpar} {
What was the effect of making the evidence more concrete and detailed? Did it
become more emotionally compelling? When her therapist explores the details of her
friendship with Rita and Faiza, Suzanne\u8217?s mood lifts. When her mood lifts,
she is also more likely to remember other situations that challenge her negative
automatic thoughts. Figure 8.3 captures the idea of making the evidence heavier:
when Suzanne\u8217?s evidence against her hot thought {\i
No one will want to be my friend} becomes more detailed and concrete, it becomes
more compelling.\par\pard\plain\hyphpar} {
{\i
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}}

Figure 8.3. Weighing Suzanne\u8217?s

evidence.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 8.1\par\pard\plain\hyphpar} {
Practice making evidence concrete and detailed.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Additional Questions to Challenge Your Client\u8217?s Hot
Thought\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Clients may need additional help to think of evidence against their hot thoughts.
The following questions are inspired by a number of wonderful CBT therapists,
including Judy Beck (2011), Dennis Greenberger and Christine Padesky (2016), and
Jackie Persons and colleagues (2001). You can download a Questions to Identify
Evidence Against Negative Thoughts handout at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
What would you say to someone who thought this way?\par\pard\plain\hyphpar} {
What do you think a friend or someone who cared for you would say if he or she knew
you had this thought?\par\pard\plain\hyphpar} {
If you were in a better mood, what would you think?\par\pard\plain\hyphpar} {
Five years from now, looking back, what might you think?\par\pard\plain\hyphpar} {
Is there any information that contradicts your interpretation? Even small pieces of
information?\par\pard\plain\hyphpar} {
Is there any positive information that you are ignoring?\par\pard\plain\hyphpar} {
Let\u8217?s see how Suzanne\u8217?s therapist uses some of these
questions.\par\pard\plain\hyphpar} {
{\i
Therapist:} It sounds as if Faiza and Rita are really good friends. What do you
think they would say if they knew you were thinking, {\i
No one will want to be my friend}?\par\pard\plain\hyphpar} {
{\i
Suzanne:} They would say it was ridiculous. That of course people would want to be
my friend.\par\pard\plain\hyphpar} {
{\ql
{\i
Her therapist wants to expand this
evidence.}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\i
Therapist:} And if they really wanted to convince you, what might be some evidence
they would tell you?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, they would probably remind me of all the friends I had at my
previous school; they would also remind me that they like
me.\par\pard\plain\hyphpar} {
{\i
Therapist:} So they would remind you of your friends from your previous school and
that they like you. And how is the fact that Rita and Faiza like you evidence
against {\i
No one will want to be my friend}?\par\pard\plain\hyphpar} {
{\i
The therapist starts with a summary statement and then relates the evidence to the
hot thought.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
tentatively}) Well I guess, if they like me, other people might like
me?\par\pard\plain\hyphpar} {
{\i
Therapist:} ({\i
smiling}) Do you think that might be true?\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
smiling}) Yeah, I guess so.\par\pard\plain\hyphpar} {
{\i
Given that Suzanne\u8217?s mood has lifted a bit, she is more likely to remember
other positive information.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I am wondering if there is any positive information that you are
ignoring.\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
smiling}) When I think of it, there is actually quite a bit. In college I had lots
of good friends whom I still see, at least I saw them until I got depressed. I also
have a bunch of friends from my neighborhood that I see on weekends, at the
park.\par\pard\plain\hyphpar} {
{\i
How could you expand the evidence that Suzanne just discussed? Remember, ask for an
example and then ask for details.}\par\pard\plain\hyphpar} {
Suzanne\u8217?s evidence is starting to look very
different!\par\pard\plain\hyphpar} {\b
Thought I want to examine: No one will want to be my friend.} {\b
Evidence for My Thought} {\b
Evidence Against My Thought} {
No one has made an effort to talk to me.\par\pard\plain\hyphpar} {
I am alone at recess and lunch.\par\pard\plain\hyphpar} {
Other teachers do not say hi when I get to school in the
morning.\par\pard\plain\hyphpar} {
In high school, some girls started rumors and I lost almost all my
friends.\par\pard\plain\hyphpar} {
I had some friends in my previous school.\par\pard\plain\hyphpar} {
Rita and Faiza are good friends; ate lunch together; worked on the school play;
hung out on weekends; went out as couples; still call to see if I want to do
something; Faiza brought a cake.\par\pard\plain\hyphpar} {
Friends from college whom I still see\par\pard\plain\hyphpar} {
Friends from neighborhood\par\pard\plain\hyphpar} {
Video 8.1\par\pard\plain\hyphpar} {\s4 \afs23
{\b
How Probable Are My Predictions?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Clients\u8217? thoughts are often about the future and include negative
predictions. Some examples might be {\i
No one will like me}, {\i
I will fail the test}, {\i
I will not get the job}, or {\i
No one will like my Facebook post}. When thoughts are about the future, you want to
look for evidence about how likely it is that the negative event will occur. Below
are the steps I usually use.\par\pard\plain\hyphpar} {
Identify what your client fears will happen, and make the list as concrete as
possible.\par\pard\plain\hyphpar} {
Rate the probability that each feared event will occur.\par\pard\plain\hyphpar} {
Examine the evidence for the probability that each feared event will
occur.\par\pard\plain\hyphpar} {
Rerate the probability that each feared event will occur.\par\pard\plain\hyphpar} {
I often use the following worksheet, How Probable Are My Predictions?, which you
can download a full-scale version of at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
How Probable Are My Predictions?}} {\b
What I Fear Will Happen} {\b
Probability That Feared Event Will Occur {
(0\u8211?100%)\par\pard\plain\hyphpar} } {\b
Evidence That Supports the Probability} {\b
Evidence Against the Probability} {\b
Rerate the Probability That Feared Event Will Occur} {
Here is Suzanne\u8217?s list of what she feared would happen at the
barbecue:\par\pard\plain\hyphpar} {
When I get there, everyone will be talking to each other, and no one will say hi to
me.\par\pard\plain\hyphpar} {
If I approach one of the new teachers, she will turn her back on
me.\par\pard\plain\hyphpar} {
I will stand there alone, with no one to talk to.\par\pard\plain\hyphpar} {
If I go up to one of the other teachers, I will have nothing to
say.\par\pard\plain\hyphpar} {
Clear image of standing next to the barbecue grill, looking very awkward, holding a
glass in my hand, and being all alone as everyone else talks
together.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Rate the probability of each event occurring.} Suzanne\u8217?s therapist asked her
to rate from 0 to 100 percent how likely it was that each of these events would
occur. Suzanne thought that the first three events, as well as her image, were very
unlikely and rated them at 20 percent. Her therapist asked Suzanne to explain what
made them unlikely. Suzanne laughed and said that it was a small group, and the
principal would make sure everyone was talking to someone. She rated \u8220?having
nothing to say\u8221? as probable, at 80 percent.\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Examine the evidence.} Suzanne and her therapist looked at the evidence for \u8220?
If I go up to one of the other teachers, I will have nothing to say.\u8221? Suzanne
explained that when she was anxious, she sometimes had difficulty finding something
to talk about. This had happened at her husband\u8217?s holiday party. When Suzanne
and her therapist examined the evidence against her prediction, she was able to
think of many examples when she had been able to find something to say at social
events, even if it had been difficult. Even at her husband\u8217?s holiday party
she had found something to talk about with her husband\u8217?s
colleagues.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Rerate the probability.} After looking at the evidence, Suzanne rated the
probability of having nothing to say at about 50 percent. Before and after
probability ratings allow your client to see that there has been a decrease, even
if the probability is not a 0.\par\pard\plain\hyphpar} {
You can see how Suzanne and her therapist completed the How Probable Are My
Predictions? worksheet at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Real and false alarms.} Friedberg, Friedberg, and Friedberg (2001) have a wonderful
exercise that helps clients look at whether their negative predictions actually
occur. The therapist asks the client to list all of her worries for the coming
week. The next week they check which worries actually happened. Most of the time,
the majority of worries are \u8220?false alarms.\u8221?\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Tolerance of uncertainty.} Unless your client\u8217?s negative predictions are
totally bizarre, no one can guarantee that they will not occur. Clients need to
learn to tolerate uncertainty (Dugas & Robichaud, 2007). This can be hard, but a
first step is talking honestly with your clients about accepting that life is
uncertain, and that while not impossible, the probability of the feared events
occurring is small.\par\pard\plain\hyphpar} {
Video 8.2\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Is There Another Perspective?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Sometimes a client\u8217?s negative thought is based on an overly negative
interpretation of an event; you want to help your client find a more benign
interpretation. Let\u8217?s look at an example. Raoul was upset because a colleague
walked past him in the hall without saying hello. Raoul thought this meant that his
colleague was avoiding him. Another possible interpretation is that his colleague
was in a hurry or preoccupied.\par\pard\plain\hyphpar} {
Sometimes simply asking your client whether she can think of a different
perspective is enough to start her thinking in a different way. However, sometimes
you need to be more active. The following two approaches can help clients reach a
more benign interpretation: (1) taking a close look at the facts of the situation
and (2) exploring whether your client is blaming herself for something she has
little or no control over.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Take a close look at the facts.} Clients tend to focus on narrow information that
reinforces their thoughts; your job is to help your clients broaden their
perspective and look at all of the facts of a situation to see whether there is a
more balanced interpretation.\par\pard\plain\hyphpar} {
Do you remember in the last chapter Raoul was extremely upset that he had been
assigned to work with junior colleagues on a report? He was sure this meant that
his boss did not respect him. Below are questions you can use to help your client
examine her interpretation of a situation. You can download a Questions to Gather
More Information about the Situation{\i
handout} at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
How did this situation come about?\par\pard\plain\hyphpar} {
Who are the other people you will be working/interacting
with?\par\pard\plain\hyphpar} {
Is there any information that contradicts your interpretation? Even small pieces of
information?\par\pard\plain\hyphpar} {
Is there any positive information that you are ignoring?\par\pard\plain\hyphpar} {
Have you ever behaved in a similar way? What was your
motivation?\par\pard\plain\hyphpar} {
Let\u8217?s see what happens when Raoul\u8217?s therapist uses these questions to
explore Raoul\u8217?s interpretation of the situation.\par\pard\plain\hyphpar} {\b
{\qc
Questions to Gather More Information about the Situation}} {\b
Questions} {\b
Raoul\u8217?s Response} {
How did this situation come about?\par\pard\plain\hyphpar} {
My boss approached me and said he would like me to work on this report, as he
thought I had the needed expertise and had done this kind of work
before.\par\pard\plain\hyphpar} {
Who are the other people you will be working/interacting
with?\par\pard\plain\hyphpar} {
Two junior colleagues, who have been hired in the past two
years.\par\pard\plain\hyphpar} {
Is there any information that contradicts your interpretation? Even small pieces of
information?\par\pard\plain\hyphpar} {
Often senior people are asked to work with more junior people on reports. It is
pretty common in the firm.\par\pard\plain\hyphpar} {
Is there any positive information that you are ignoring?\par\pard\plain\hyphpar} {
One of the junior people told me she was really glad to have me on the team, that
she had heard great things about me.\par\pard\plain\hyphpar} {
Have you ever behaved in a similar way? What was your
motivation?\par\pard\plain\hyphpar} {
In the past, I assigned a senior person to work on a project, to be sure that there
was someone with the needed expertise on the project.\par\pard\plain\hyphpar} {
Raoul\u8217?s therapist asked him whether this additional information had any
implications for his thought that being assigned to the project meant that his boss
did not respect him. Raoul replied that it {\i
might} mean they wanted a senior person on this project. I am looking for a crack
in my client\u8217?s beliefs. Just like water seeping through a stone, if you can
get a small crack, it can spread.\par\pard\plain\hyphpar} {
{\qc
Your Turn! Help Suzanne Take a Close Look at the
Facts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne was very distressed that none of the teachers talked to her at recess. This
was a key piece of evidence in her belief that no one would want to be her friend.
Her therapist thought it would be worthwhile to see if there was a more benign
interpretation.\par\pard\plain\hyphpar} {
{\i
Therapist:} One of the pieces of evidence you use to support your belief that none
of the teachers would want to be your friend is that no one talks to you at
recess.\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Suzanne
start to gather facts about the situation.\par\pard\plain\hyphpar} {
{\ql
It seems strange to me that they don\u8217?t talk to you; they sound like horrible
people.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
How could you join one of the groups of
teachers?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Can you describe to me what happens at recess, what the other teachers do, and what
you do? {\i
Response #3 is the best question to help collect information on what occurs at
recess. Depending on the answer, the therapist can follow up in different ways.
Response #1 supports Suzanne\u8217?s interpretation of the situation. Response #2
starts a problem-solving process before the problem is clarified.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Can you describe to me what happens at recess and what the other
teachers do?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} We each have an area we are responsible for. Actually, when I think of
it, only the two teachers who are assigned to the jungle gym stand together. The
rest of us stand alone in the school yard. Some of the other teachers might
approach each other and say a few words. I just stand in the back of the school
yard next to the swings.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Suzanne
start to gain a different perspective.\par\pard\plain\hyphpar} {
{\ql
I hear that everyone is assigned to an area and that most of the teachers are
standing alone; do I have it right?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\ql
How much of a discipline problem are the children? What kinds of things do you find
help with maintaining order?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
It seems to me that everyone is alone, and it doesn\u8217?t mean they don\u8217?t
want to talk to you. {\i
Response #1 is the best response. It is a summary of what Suzanne has told her
therapist and is most likely to encourage her to consider a different perspective
on what standing alone at recess means. In response #2, the therapist is gathering
data about the situation, but the data is not relevant to Suzanne\u8217?s thought,}
No one wants to be my friend{\i
. In response #3, the therapist is telling Suzanne what to think.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Video 8.3\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Is your client blaming herself for something she has little or no control over?}
Many clients feel responsible for situations they have no control over or believe
that the situation is a reflection of themselves, when it is at least partially due
to external factors. Two of the questions I find most helpful
are:\par\pard\plain\hyphpar} {
Are there other factors that could contribute to this
situation?\par\pard\plain\hyphpar} {
Am I blaming myself for something I have little or no control
over?\par\pard\plain\hyphpar} {
Let\u8217?s look at some examples of clients\u8217? thoughts and see if there are
other ways of looking at the situation. You can download a Other Ways of
Understanding the Situation worksheet at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
Other Ways of Understanding the Situation}} {\b
Situation} {\b
Client\u8217?s Thought} {\b
Are there other factors that could contribute to this situation? {
List all of the factors.\par\pard\plain\hyphpar} } {\b
What can I control? {
Am I blaming myself for something I have little or no control
over?\par\pard\plain\hyphpar} } {
Client\u8217?s 16-year-old son is using marijuana\par\pard\plain\hyphpar} {
I am a bad mother.\par\pard\plain\hyphpar} {
Many factors contribute to a child using marijuana, including availability, peer
group, and laws.\par\pard\plain\hyphpar} {
I can control telling my child not to use marijuana, but there are many other
factors that contribute to marijuana use.\par\pard\plain\hyphpar} {
Yes, I am blaming myself for something I do not have complete control
over.\par\pard\plain\hyphpar} {
Only 15 people came to my talk at the confer-ence; many people had over 25 at their
talks.\par\pard\plain\hyphpar} {
My work is not interesting or important.\par\pard\plain\hyphpar} {
My talk was at the end of the day; it was a beautiful day outside; there were other
similar talks at the same time.\par\pard\plain\hyphpar} {
I can control how much work I put into my talk. I cannot control when my talk is
scheduled or the weather.\par\pard\plain\hyphpar} {
Yes, the other factors would also impact how many people
came.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Help Your Clients Reach Their Own
Conclusions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Sometimes you remember information that challenges your client\u8217?s negative
thought, but your client does not think of the information. Should you just tell
your client? Let\u8217?s go back to the basic principles of Socratic questioning.
You want to ask questions that draw your client\u8217?s attention to information
she is not thinking about. Once your client has the information, you want her to
draw her own conclusion.\par\pard\plain\hyphpar} {
For example, Raoul tells you that he has stopped contributing to meetings because
he believes that \u8220?no one is interested in my comments.\u8221? You remember
that a few weeks ago Raoul described making a comment in a project meeting, to
which one of his colleagues responded, \u8220?That is the best solution anyone has
suggested so far.\u8221? You could remind Raoul of his colleague\u8217?s comment
and then {\i
tell} Raoul that clearly people are interested in what he has to say. However, it
is more effective if Raoul can reach his own conclusions. It is better to ask Raoul
if he remembers what his colleague said, and then once Raoul has told you, ask him
what his colleague\u8217?s statement might mean about his thought, {\i
No one is interested in my comments}.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Help Cynthia Reach Her Own
Conclusions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Cynthia was in therapy because she was having trouble with low self-esteem that was
affecting many different areas of her life. She tells her therapist, \u8220?I was
so embarrassed. I was at a party and a guy I know from work kept hitting on me. He
kept telling me he wanted to go out with me and that I was beautiful. I just kept
ignoring him. Men are only interested in me for sex.\u8221?\par\pard\plain\hyphpar}
{
Cynthia\u8217?s hot thought is {\i
Men are only interested in me for sex}.\par\pard\plain\hyphpar} {
Cynthia\u8217?s therapist tells her, \u8220?You are a wonderful woman; you deserve
to find a great man. You have told me that lots of your male colleagues like and
respect you.\u8221?\par\pard\plain\hyphpar} {
Instead of telling Cynthia what to think, what questions could the therapist ask
that would help Cynthia reach her own conclusions?\par\pard\plain\hyphpar} {
From previous sessions her therapist knows that Cynthia is dating John, who
frequently tells her that he cares about her. John always checks that she also
wants sex before they have sexual relations. Cynthia has also talked about male
colleagues who made comments indicating they respect Cynthia, especially Mike and
Chris, whom she works closely with.\par\pard\plain\hyphpar} {
Your job is to think of questions that you could ask to help Cynthia reach her own
conclusion about whether men are only interested in her for sex. You can find my
suggestions in the appendix. \par\pard\plain\hyphpar} {
Exercise 8.2\par\pard\plain\hyphpar} {
Practice developing questions to help your clients reach their own
conclusions.\par\pard\plain\hyphpar} {
Exercise 8.3\par\pard\plain\hyphpar} {
Practice using a therapy dialogue to help clients reach their own
conclusions.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Consolidate the Evidence Against the Hot
Thought\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Most likely your client is used to thinking about the information that supports her
negative thoughts and tends to minimize the information against her negative
thoughts. If you want your client to emotionally connect to the information against
her negative thought, it is important to review the information. Reviewing focuses
your client\u8217?s attention on this information and starts to create new thought
habits.\par\pard\plain\hyphpar} {
Usually I simply say, \u8220?Let\u8217?s review the information we have
gathered.\u8221? If you have not written down the evidence, this is a good time to
do so. You can say, \u8220?You collected some very important evidence about your
thoughts. I think it would be helpful if we wrote it down, to be sure that we
don\u8217?t forget it.\u8221? I encourage my clients to do the writing, as I think
it helps with the review process. (If I am doing the writing, I repeat out loud
what I am writing.) This also provides the client with a piece of paper she can
take home and review as part of homework.\par\pard\plain\hyphpar} {
You can also use imagery to help evidence against a hot thought come alive
(Josefowitz, 2016) by asking your client to form an image in her mind of the
memories and situations that constitute the evidence against the hot thought. For
Suzanne, an important piece of evidence against her hot thought was eating lunch
almost every day with Rita and Faiza at her previous school. Her therapist asked
Suzanne to form an image in her mind of eating lunch with her friends. She asked
Suzanne to remember the lunchroom, the fun of being together, and how much they
liked each other. Her therapist then went over the rest of the evidence, asking
Suzanne to form an image for each example. When they had finished, the evidence
felt much more real and emotionally engaging.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #5{\i
: Develop Balanced Thoughts}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The final step in completing a thought record is evaluating the original hot
thought and creating a new more balanced thought that takes all of the evidence
into account. This is when you fill in the \u8220?Conclusion\u8221? section of the
Examine the Reality of Your Thoughts worksheet. The basic question is, \u8220?Given
all of the evidence, is your hot thought accurate, or does it need to be
modified?\u8221? Here are some questions I regularly use. You can find Questions
for a Balanced Thought at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
When you look at all of the evidence, what does this say about your original hot
thought?\par\pard\plain\hyphpar} {
When you look at all of the evidence, what would be a more accurate
thought?\par\pard\plain\hyphpar} {
What might be a thought that captures all of the evidence?\par\pard\plain\hyphpar}
{
Let\u8217?s take a moment and look at all of the evidence. What did you
learn?\par\pard\plain\hyphpar} {
You initially interpreted the situation in a specific way. When you look at the
evidence, is there another interpretation that either makes more sense or might be
equally true?\par\pard\plain\hyphpar} {
What would you tell someone who thought the way you did, and had all of this
evidence?\par\pard\plain\hyphpar} {
Let\u8217?s look at how Suzanne initially completed the Understand Your Reaction
worksheet and the Examine the Reality of Your Thoughts worksheet. Then, let\u8217?s
look at the evidence that Suzanne and her therapist
collected.\par\pard\plain\hyphpar} {\b
Situation} {\b
Feeling} {\b
Physical Reaction} {\b
Behavior} {\b
Thoughts} {
Principal invited me to barbecue with the three other new
teachers\par\pard\plain\hyphpar} {
Nervous (7)\par\pard\plain\hyphpar} {
Worried (8)\par\pard\plain\hyphpar} {
Embarrassed (6)\par\pard\plain\hyphpar} {
Clenched stomach (4)\par\pard\plain\hyphpar} {
Tense shoulders (5)\par\pard\plain\hyphpar} {
Did not respond\par\pard\plain\hyphpar} {
I don\u8217?t want to go; the other new teachers will be there; I won\u8217?t fit
in; I will just stand there looking awkward; no one will want to talk to me; I will
probably get all sweaty.\par\pard\plain\hyphpar} {
Image: Standing alone in backyard as other teachers talk\par\pard\plain\hyphpar} {
HOT THOUGHT: {\i
No one will want to be my friend}.\par\pard\plain\hyphpar} {\b
Thought I want to examine: No one will want to be my friend.} {\b
Evidence for My Thought} {\b
Evidence Against My Thought} {
No one has made an effort to talk to me.\par\pard\plain\hyphpar} {
I am alone at recess and lunch.\par\pard\plain\hyphpar} {
Other teachers do not say hi when I get to school in the
morning.\par\pard\plain\hyphpar} {
In high school, some girls started rumors and I lost almost all my
friends.\par\pard\plain\hyphpar} {
I had some friends in my previous school.\par\pard\plain\hyphpar} {
Rita and Faiza are good friends; ate lunch together, worked on the school play;
hung out on weekends; went out as couples; still call to see if I want to do
something; Faiza brought a cake\par\pard\plain\hyphpar} {
Friends from college whom I still see\par\pard\plain\hyphpar} {
Friends from the neighborhood\par\pard\plain\hyphpar} {
Try to think of a balanced thought that captures all of the evidence. Write it down
so you can compare it to the one Suzanne came up with.\par\pard\plain\hyphpar} {
{\i
Therapist:} It seems to me that when you think, {\i
No one will want to be my friend}, you are only considering the evidence that
supports your thought. What happens when you consider all of the
evidence?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I guess that it doesn\u8217?t seem to be so true.\par\pard\plain\hyphpar}
{
{\i
Therapist:} In what way is it not so true?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I do have friends who like me and want to be my friend. I think one
of the problems is that I have been avoiding my friends from my old
school.\par\pard\plain\hyphpar} {
{\i
Therapist:} I think you are right; we discovered that you have quite a few friends
who like you. What would be a thought that captures all of the
evidence?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I guess, even though I haven\u8217?t yet made friends at my new
school, I had friends in the past and there really is no reason I won\u8217?t have
friends in the future.\par\pard\plain\hyphpar} {
{\i
Is Suzanne\u8217?s balanced thought better than the one you came up with? My
clients often come up with far better balanced thoughts than I could ever have
\u8220?told\u8221? them. Your job as a therapist is now easy\u8212?you just need to
reinforce and consolidate the balanced thought.}\par\pard\plain\hyphpar} {
There are two tasks left before completing the thought record. First, ask your
client how much she believes the thought from 0 to 100 percent. Even if she gives a
fairly low score, it is still a start to believing a new balanced thought. Second,
ask your client if she believed the balanced thought, how would this affect her
feelings, and ask her to rerate her original feelings. Suzanne believed her
balanced thought 75 percent. She rerated her feelings Nervous: 5, Worried: 5, and
Embarrassed: 4.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Consolidate the Balanced Thought\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
You have just spent a great deal of time and effort creating a balanced thought. It
is worth spending a bit more time to consolidate this thought. First, be sure to
smile and express interest in your client\u8217?s balanced thought. Your enthusiasm
is reinforcing. Second, review the balanced thought in as many ways as you can.
Here are some suggestions.\par\pard\plain\hyphpar} {
Say the balanced thought out loud and add a compliment. For example, I might repeat
the balanced thought and say, \u8220?I like the way the balanced thought captures
all of the evidence.\u8221?\par\pard\plain\hyphpar} {
Ask your client if she would like to write down the balanced thought so that she
can remember it. My clients have written their balanced thoughts on coping cards,
kept the balanced thoughts on their phones, or made the balanced thought into their
screen saver.\par\pard\plain\hyphpar} {
Ask your client to repeat the balanced thought out loud. Depending on the balanced
thought, I might ask my client to try a more assertive tone, or a more
compassionate, gentle tone.\par\pard\plain\hyphpar} {
Ask your client to regularly review the balanced thought. I find it helpful to
specify a set time to review, such as first thing in the
morning.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Develop a metaphor or an image.} Often a balanced thought is fairly long and
complex and can be hard to remember. It can be helpful to create an image of the
evidence that is the most compelling for your client and attach it to the balanced
thought. An image that symbolizes the balanced thought, a metaphor, or even a
shortened version can increase the emotional strength of the balanced thought and
make it more memorable (Hackmann et al., 2011; Josefowitz, 2017). Here is
Suzanne\u8217?s shortened version of her balanced thought: {\i
Hang in there, you will make friends again}.\par\pard\plain\hyphpar} {
Exercise 8.4\par\pard\plain\hyphpar} {
Practice reviewing a balanced thought.\par\pard\plain\hyphpar} {
Video 8.4\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Use Balanced Thoughts to Create a New
Image\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
When Suzanne\u8217?s therapist initially asked her about her thoughts and images,
Suzanne reported that she had an image of herself alone in the principal\u8217?s
backyard while the other teachers talked to each other. Once you have examined the
evidence against the hot thought and created a balanced thought, you can go back
and directly modify your client\u8217?s original image. Given the close connection
between imagery and emotion, this can be a very powerful intervention. Let\u8217?s
see how Suzanne\u8217?s therapist helps her create a new
image.\par\pard\plain\hyphpar} {
{\i
Therapist:} You started out with a very clear image of yourself standing in the
principal\u8217?s backyard, awkward and alone, as the other teachers talked
together.\par\pard\plain\hyphpar} {
{\i
Suzanne:} That\u8217?s right, I wasn\u8217?t even aware that I had that image until
you asked.\par\pard\plain\hyphpar} {
{\i
Therapist:} Given the evidence that we just looked at, and your balanced thought,
how accurate do you think your original image is?\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
laughing softly}) Probably not accurate at all.\par\pard\plain\hyphpar} {
{\i
Therapist:} I think it would be really helpful if we could develop a more realistic
image of what you think will happen. Could we try?\par\pard\plain\hyphpar} {
{\i
Suzanne:} When I look at the evidence, and I really think about it, a more
realistic image would be of my standing in the principal\u8217?s backyard talking
to the other teachers, or at least being part of the group, even if I am not
talking.\par\pard\plain\hyphpar} {
{\i
Suzanne\u8217?s therapist thought this was a good start for a new image. However,
the initial negative image was very detailed and vivid. Suzanne\u8217?s therapist
wanted the new image to be as compelling.}\par\pard\plain\hyphpar} {
{\i
Therapist:} Can you tell me a little bit more about this new
image?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I see myself standing there with my drink, and I am part of a small
group. I am listening as one of the other teachers says
something.\par\pard\plain\hyphpar} {
{\i
Therapist:} Can you get a clear picture in your mind of this new
image?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Yes, I can see it clearly ({\i
smiling}).\par\pard\plain\hyphpar} {
{\i
Therapist:} And how do you feel when you get this image?\par\pard\plain\hyphpar} {
{\i
Suzanne:} A lot more relaxed about going, and a lot less depressed. Almost makes me
wonder if it could be a good experience.\par\pard\plain\hyphpar} {
After they had developed this new image, Suzanne\u8217?s therapist asked her to
consciously practice seeing the new image three times a day. They discussed
specific times that Suzanne could practice. Her therapist told Suzanne that the
practice could be very short, even a few minutes, but it was important to practice
regularly.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Use Balanced Thoughts to Manage
Stress\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Balanced thoughts generally move your client away from extreme thinking, such as
{\i
No one will like me}, to more balanced thinking that generally helps with anxiety
and depression as well as self-esteem. Balanced thoughts provide a more resilient
attitude toward life\u8217?s stressors. As we discussed earlier, most clients have
typical negative thoughts that tend to recur. This means that the balanced thoughts
you develop for one situation will most likely also be relevant to other
situations.\par\pard\plain\hyphpar} {
When Suzanne\u8217?s therapist asked if there were other situations where she had
the thought {\i
No one will want to be my friend}, Suzanne said she had this thought \u8220?all the
time.\u8221? Her therapist asked for examples, and Suzanne replied that she often
had these thoughts when she was alone at school during recess and lunch and at the
end of the day when she left without saying good-bye to anyone. If you look at all
of these situations, the thought {\i
No one will want to be my friend} leads to Suzanne feeling depressed and
withdrawing from the other teachers, making it almost impossible to make friends,
leading to a vicious cycle where it seemed true that no one wanted to be her
friend.\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist asked her, \u8220?Instead of thinking, {\i
No one will want to be my friend}, if you thought your new balanced thought, {\i
Hang in there, you will make friends again}, how do you think you would
feel?\u8221? Suzanne smiled as she responded that she would be less depressed.
Suzanne and her therapist problem solved how she could remember her new balanced
thought in the other situations when she starts thinking, {\i
No one will want to be my friend}. Suzanne\u8217?s therapist also encouraged her to
notice if she had any unrealistic images in these
situations.\par\pard\plain\hyphpar} {
Sometimes, completing a thought record influences how your client wants to behave.
After Suzanne developed a balanced thought, she turned toward her therapist and
said, \u8220?I have been really silly about the barbecue. I would like to go. It
would be good to meet the other teachers, and there is no reason to be so
anxious.\u8221? Let\u8217?s see how Suzanne\u8217?s therapist could help her use
her balanced thought.\par\pard\plain\hyphpar} {
{\i
Therapist:} When you think about it, you would like to go to the
barbecue.\par\pard\plain\hyphpar} {
{\i
Suzanne:} I think it would be a good thing to do. I want to make friends at my new
school, and it\u8217?s just silly to avoid social events because of my
anxiety.\par\pard\plain\hyphpar} {
{\i
Therapist:} After we did the thought record, you came up with a really good
balanced thought; do you remember what it was?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Yes, it was, {\i
Hang in there, you will make friends again}.\par\pard\plain\hyphpar} {
{\i
Therapist:} That\u8217?s right. I am wondering if you could remember your balanced
thought when you think of going to the barbecue, if that would help with your
anxiety.\par\pard\plain\hyphpar} {
{\i
Suzanne:} I think it would.\par\pard\plain\hyphpar} {
{\i
Therapist:} Sounds like a great plan.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Checklist of Common Problems with Thought
Records\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Thought records are generally an effective intervention; however, some are more
helpful than others. Below is a checklist you can use to check that a thought
record is well done. You can find a copy of Checklist of Common Problems with
Thought Records at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Is the situation a factual description of what occurred?\par\pard\plain\hyphpar} {
Did my client identify and rate his or her feelings?\par\pard\plain\hyphpar} {
Did my client identify his physical reactions?\par\pard\plain\hyphpar} {
Is the behavior a factual description of what my client
did?\par\pard\plain\hyphpar} {
Is the thought my client wants to focus on a hot thought?\par\pard\plain\hyphpar} {
Is the thought about self, others, or the future?\par\pard\plain\hyphpar} {
Is the thought related to his or her negative feelings?\par\pard\plain\hyphpar} {
Does the evidence against address the hot thought?\par\pard\plain\hyphpar} {
Does the balanced thought address the hot thought?\par\pard\plain\hyphpar} {
It is important that the evidence you gather challenge the hot thought you are
working on. For example, a colleague had passed Raoul in the hall and had not said
hi. Raoul thought, {\i
My colleague is avoiding me}. His evidence against his thought was, {\i
My bowling buddies are happy to see me}. This evidence will help Raoul feel better,
but it is not related to the thought, {\i
My colleague is avoiding me}. In this situation you need to keep exploring
Raoul\u8217?s thoughts using Questions to Identify Evidence Against Negative
Thoughts to find evidence related to the hot thought you are working
on.\par\pard\plain\hyphpar} {
It is equally important that the balanced thought directly address the hot thought.
For example, if the original thought was about self, the balanced thought needs to
be about self; if the original thought was about others, the balanced thought needs
to be about others. When Raoul was assigned to work with junior colleagues, his
original thought was {\i
My boss doesn\u8217?t respect me}. After examining the evidence for and against,
his initial balanced thought was {\i
I work very hard and do a good job}. This is a generally helpful thought that will
increase Raoul\u8217?s positive mood. If I were his therapist, I would be delighted
that he was able to have such a positive thought about himself. However, the hot
thought was about others (his boss), and the balanced thought needs to also be
about others. A better balanced thought would be, {\i
Even though I was asked to work with junior colleagues, this does not mean my boss
does not respect me. There is a lot of evidence that my boss still respects me and
my work}.\par\pard\plain\hyphpar} {
It is helpful to keep this list in mind when examining your clients\u8217? thought
records. Take a moment after your session is over and on your own review your
client\u8217?s thought record, using the checklist. After you have used it a few
times, it will become second nature.\par\pard\plain\hyphpar} {
Exercise 8.5\par\pard\plain\hyphpar} {
Practice using the checklist for identifying common problems in thought
records.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to a Clinical
Example\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 8.1:} Suzanne Is Upset with Her Husband\par\pard\plain\hyphpar} {
{\b
Exercise 8.2:} A Therapist Is Having a Bad Day\par\pard\plain\hyphpar} {
{\b
Exercise 8.3:} Suzanne Is Asked to Be a Maid of Honor\par\pard\plain\hyphpar} {
{\b
Exercise 8.4:} Suzanne Reviews Her Balanced Thought\par\pard\plain\hyphpar} {
{\b
Exercise 8.5:} Common Problems with Thought Records\par\pard\plain\hyphpar} {\s3
\afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I think you only become a committed CBT therapist when you experience how helpful
it can be to identify your own negative thoughts, step back and examine the
evidence, and then develop a balanced thought.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 What Is the
Evidence?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
This coming week, when you have a strong emotional reaction, try to identify the
situation, identify and rate your feelings, and then identify your thoughts. Choose
one thought to examine using Questions to Identify Evidence Against My Negative
Thoughts{\i
.} Record your answers on the following worksheet.\par\pard\plain\hyphpar} {\b
{\qc
Examine the Reality of Your Thoughts}} {\b
Thought I want to examine:} {\b
Evidence for My Thought} {\b
Evidence Against My Thought} {\b
Conclusion or thoughts that consider all the evidence:} {
{\qc
Homework Assignment #2 How Probable Is My
Prediction?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
This coming week when you are anxious, notice your negative predictions. Rate the
probability that each will occur, look at the evidence, and then rerate the
probability. Try to use the How Probable Are My Predictions
worksheet.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3 Is There Another
Interpretation?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
This coming week when you are upset by what someone did to you or by a situation,
ask yourself if there is a more benign interpretation. Ask yourself if you are
considering all of the facts of the situation. Are you blaming yourself for
something you have no control over? Try to use the Other Ways of Understanding the
Situation worksheet.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It is time to start asking your clients to examine the evidence for their thoughts.
Try to help a client identify her trigger situation and then identify and rate her
feelings and thoughts. Once you have identified a central thought, introduce the
idea of looking for evidence and use the Questions to Identify Evidence Against My
Negative Thoughts. Make sure that the evidence is concrete and addresses the hot
thought. Use the Examine the Reality of Your Thoughts worksheet to record your
client\u8217?s responses.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under each agenda item.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} What are thought records?\par\pard\plain\hyphpar} {
What are the essential steps in a thought record?\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Agenda Item #2:} Explain looking for evidence.\par\pard\plain\hyphpar} {
How could you introduce looking for evidence to your
clients?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Find evidence that supports negative
thoughts.\par\pard\plain\hyphpar} {
Why is it important to look for facts that support negative
thoughts?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Find evidence against negative thoughts.\par\pard\plain\hyphpar} {
What are three questions that will help gather information against a client\u8217?s
negative thoughts?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #5:} Develop balanced thoughts.\par\pard\plain\hyphpar} {
How could you consolidate a balanced thought?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 9\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Problem Solving\u8212?Finding a Better
Way\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
My hope is that you\u8217?re becoming more aware of your own thoughts. Did you try
looking for evidence for one of your hot thoughts? Did you try writing out the
evidence for and against a client\u8217?s hot thought? What did you learn from the
homework?\par\pard\plain\hyphpar} {
If you did not try any of the homework from the last chapter, take a moment to
think of a difficult situation from last week. Identify your hot thought, and now
look for the evidence.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this chapter I am going to cover problem solving. We\u8217?ll also see how a
problem-solving approach can help Raoul and Suzanne address the various issues they
bring up in therapy.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} What is problem solving?\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Develop a positive problem orientation.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Identify your client\u8217?s problems.\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} Brainstorm solutions.\par\pard\plain\hyphpar} {
{\b
Agenda Item #5:} Choose a solution.\par\pard\plain\hyphpar} {
{\b
Agenda Item #6:} Develop coping thoughts.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
One of the strengths of CBT is the universality of the approaches. All people
encounter problems, and everyone can benefit from a step-by-step approach to
solving them.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: What Is Problem Solving?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Problem-solving therapy was originally developed by D\u8217?Zurilla and Goldfried
(1971), and although it has been revised over the years (D\u8217?Zurilla & Nezu,
2006), the core process and principles have remained essentially the
same.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Overview of the Problem-Solving
Process\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Problem solving involves both an attitude that problems can be solved or at least
improved, and a process based on a specific set of skills. The process of problem
solving has four distinct steps. For many clients, you will want to go through the
whole problem-solving process step by step; however, for some clients, you may use
only parts of the process. Below are the four steps.\par\pard\plain\hyphpar} {
Identify the problem and set realistic goals.\par\pard\plain\hyphpar} {
Generate new solutions. This is often called {\i
brainstorming}.\par\pard\plain\hyphpar} {
Evaluate the different solutions and decide which one to
try.\par\pard\plain\hyphpar} {
Try one of the solutions: evaluate the consequences and decide whether the problem
is solved or whether you need to continue to problem solve.\par\pard\plain\hyphpar}
{
You can find the Problem-Solving Worksheet at http://www.newharbinger.com/38501.
The worksheet summarizes the steps and includes helpful questions for each section.
You can use the worksheet as a guide for therapy as well as a handout to give your
clients.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
The Theory Behind Problem Solving\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The theory underlying problem solving is that clients\u8217? emotional distress is
due to poor problemsolving skills which lead to dysfunctional ways of coping. Poor
problem solving leads to more problems, which in turn are poorly solved. Clients
quickly find themselves dealing with multiple problems and it becomes a vicious
negative cycle. Problem solving stops the vicious cycle and helps clients find
better ways to cope (D\u8217?Zurilla & Nezu, 2010).\par\pard\plain\hyphpar} {
{\b
{\ql
Problem-Solving
Theory\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Good Problem Solving = Better Coping = Improved Life and Better
Mood\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
When you help your client find solutions to his problems, you are also saying,
\u8220?You matter, I care about your welfare, and together we can figure out how to
address your problems.\u8221? These are very powerful messages. For many clients
the whole problem-solving process feels new and empowering.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Is Problem Solving Effective?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Let\u8217?s look at the research. Good problem-solving skills are consistently
associated with better overall emotional adjustment, and poor problem-solving
skills are associated with more distress and poorer adjustment (D\u8217?Zurilla &
Nezu, 2010). For example, poor problem-solving skills are related to drug and
alcohol addiction, criminal behavior, and psychological distress. The good news is
that individuals with good problem-solving skills are less likely to become
depressed after a stressful event (Nezu, Nezu, Saraydarian, Kalmar, & Ronan,
1986).\par\pard\plain\hyphpar} {
Over the past three decades, a large number of studies have demonstrated that
problem solving is an effective treatment for depression (Bell & D\u8217?Zurilla,
2009), anxiety, and a variety of other mental health problems (D\u8217?Zurilla &
Nezu, 2010; Malouff, Thorsteinsson, & Schutte, 2007). Problem solving has also
helped people learn to cope with serious physical illnesses such as diabetes
(Glasgow, Toobert, Barrera, & Stryker, 2004) and cancer (Nezu, Nezu, Felgoise,
McClure, & Houts, 2003). Interventions that focus on developing a positive problem-
solving attitude as well as teaching problem-solving skills seem to be the most
effective (Bell & D\u8217?Zurilla, 2009).\par\pard\plain\hyphpar} {
{\b
{\ql
Research
Summary\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Positive Problem-Solving Orientation + Problem-Solving Skills = Effective
Treatment\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #2{\i
: Develop a Positive Problem
Orientation}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
A positive problem orientation is a core element of good problem solving. The table
below compares the beliefs of individuals with positive and negative problem
orientations (Nezu, Nezu, & D\u8217?Zurilla, 2013).\par\pard\plain\hyphpar} {\b
{\qc
Characteristics of a Positive and Negative Problem Orientation}} {\b
Positive Problem Orientation} {\b
Negative Problem Orientation} {
Problems are a challenge. It is possible to improve most
situations.\par\pard\plain\hyphpar} {
One has the ability to successfully solve problems or make the situation
better.\par\pard\plain\hyphpar} {
Successful problem solving takes time, effort, and persistence. Initial failure is
part of finding a solution.\par\pard\plain\hyphpar} {
Problems are unsolvable and frightening. It is useless to try to improve most
situations.\par\pard\plain\hyphpar} {
One does not have the ability to successfully solve problems or make the situation
better.\par\pard\plain\hyphpar} {
Initial failure means the problem cannot be solved.\par\pard\plain\hyphpar} {
Individuals with a positive problem orientation see difficulties as normal life
challenges and try to find solutions to their problems. Individuals with a negative
problem orientation tend to either avoid their problems or approach them with an
impulsive or careless problem-solving style. Clearly, a positive orientation is
better, but how do you help your clients develop one?\par\pard\plain\hyphpar} {
Modeling optimism and having faith in your client\u8217?s ability to problem solve
is one of the most effective ways to help your client develop a positive problem
orientation. Here are some phrases I use to encourage a positive problem-solving
orientation:\par\pard\plain\hyphpar} {
Let\u8217?s see if we can find a way to solve your
problems.\par\pard\plain\hyphpar} {
I wonder if there is something you can do that will help this
situation.\par\pard\plain\hyphpar} {
I know it feels hopeless, but I wonder if we could find a way to make things even a
little better for you.\par\pard\plain\hyphpar} {
I\u8217?m not sure we\u8217?ve looked at all of the possible solutions. Would you
be willing to try to problem solve?\par\pard\plain\hyphpar} {
Such relatively simple interventions communicate that you believe in your
client\u8217?s ability to find a better solution, and that together you will be
able to improve his life. You will also find that as your client uses the problem-
solving process successfully, his problem orientation will start to automatically
become more positive.\par\pard\plain\hyphpar} {
Let\u8217?s see how Raoul\u8217?s therapist helps him develop a more positive
problem orientation. Raoul was telling his therapist about his poor relationship
with his boss, who gave him a poor work evaluation.\par\pard\plain\hyphpar} {
{\i
Raoul:} I feel so depressed when I think of going to work. I used to like going to
work, but I feel so awkward and anxious with my boss since I received the poor work
evaluation. I think we have a terrible relationship. It just seems hopeless to do
anything about it.\par\pard\plain\hyphpar} {
{\i
Therapist:} I hear you\u8217?re thinking that it is hopeless to try and change your
relationship with your boss, is that right?\par\pard\plain\hyphpar} {
{\i
His therapist has identified a negative problem orientation: It is hopeless to try
and change the relationship with his boss.}\par\pard\plain\hyphpar} {
{\i
Raoul:} Definitely, what can I do?\par\pard\plain\hyphpar} {
{\i
Therapist:} I am wondering if you would be willing to put aside the thought that it
is hopeless to do anything and see if we could find some better ways to cope with
the situation, to help you feel better.\par\pard\plain\hyphpar} {
{\i
Raoul:} What do you mean?\par\pard\plain\hyphpar} {
{\i
Therapist:} Well, when you tell yourself that it\u8217?s hopeless, how does that
affect your behavior?\par\pard\plain\hyphpar} {
{\i
Raoul:} I just avoid him, and keep doing the same old
thing.\par\pard\plain\hyphpar} {
{\i
Therapist:} And does avoiding help?\par\pard\plain\hyphpar} {
{\i
Raoul:} No, in fact, it is getting worse. I just feel more and more
awkward.\par\pard\plain\hyphpar} {
{\i
Therapist:} I am wondering if you would be willing to work with me to see if we
could problem solve some different ways of coping with your boss that might improve
the situation.\par\pard\plain\hyphpar} {
{\i
Raoul:} I would be willing, but I don\u8217?t think we will find
any.\par\pard\plain\hyphpar} {
{\i
Therapist:} You may be right, but I want to see if we put our heads together if we
could find a better way for you to cope.\par\pard\plain\hyphpar} {
{\i
Notice how the therapist acknowledges that Raoul might be right but asks him to try
problem solving. The therapist is modeling a calm, thoughtful approach to the
problem.}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Identify Your Client\u8217?s
Problems}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before your client can solve his problems, he needs to identify them. Defining the
problem and setting realistic goals are the first components of a problem-solving
skill set. Problems can be a one-time event, such as a divorce or a serious health
problem. They can be situations that happen fairly regularly, such as disciplining
a child who refuses to do chores, fighting over finances with a partner, or dealing
with constant daily difficulties such as a long commute to work, chronic pain, or
loneliness.\par\pard\plain\hyphpar} {
Sometimes it is very clear that a client needs help problem solving. A client may
start therapy saying, \u8220?I don\u8217?t know what to do about X,\u8221? or one
of your client\u8217?s thoughts may be, {\i
What else can I do?} or {\i
I don\u8217?t know how to handle this}. In other cases, it can be more difficult to
identify your client\u8217?s need to problem solve. Clients with a negative problem
orientation often avoid their problems but feel anxious. It is helpful to teach a
client who tends to avoid that if he is anxious, he should ask himself whether
there is a problem he is not looking at.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Problem Definition\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The more specific and concrete the problem, the easier it will be to think of
helpful solutions. For example, \u8220?I don\u8217?t communicate well with my
partner\u8221? is a very vague problem and hard to start solving, whereas, \u8220?
My partner and I don\u8217?t agree on how to discipline our children\u8221? is much
clearer and an easier problem to address.\par\pard\plain\hyphpar} {
Raoul had started his therapy session by saying in a low voice, \u8220?I feel so
depressed when I think of going to work. I used to like work, but I feel so awkward
and anxious with my boss since I received the poor work evaluation. I think we have
a terrible relationship. It just seems hopeless to do anything about
it.\u8221?\par\pard\plain\hyphpar} {
At this point, Raoul\u8217?s problem is not very specific. His therapist uses the
questions under \u8220?Questions to Help Define the Problem\u8221? in the Problem-
Solving Worksheet to help Raoul become more specific and concrete. Sometimes you
may want to use all of the questions, and sometimes only a few may be relevant. You
can find Raoul\u8217?s answers in the table below.\par\pard\plain\hyphpar} {\b
{\qc
Raoul Defines His Problem}} {\b
Questions to Help Define the Problem} {\b
Raoul\u8217?s Answers} {
What happened or did not happen that bothers your client?\par\pard\plain\hyphpar} {
Raoul\u8217?s boss handed him his poor work evaluation, but his boss has never
talked to him about it.\par\pard\plain\hyphpar} {
Tension between Raoul and his boss\par\pard\plain\hyphpar} {
Presently, almost no casual contact with his boss\par\pard\plain\hyphpar} {
Boss never asks for his opinion, never chat together, boss often ignores
him\par\pard\plain\hyphpar} {
Who is involved? Where does the problem happen? When does the problem
happen?\par\pard\plain\hyphpar} {
The problem involves Raoul and his boss; it happens at work during the
day.\par\pard\plain\hyphpar} {
Why is this problem difficult for your client?\par\pard\plain\hyphpar} {
Raoul feels ashamed about the poor work evaluation.\par\pard\plain\hyphpar} {
Raoul feels judged, hates work, has trouble concentrating, and thinks everyone
knows about his problems with his boss.\par\pard\plain\hyphpar} {
Raoul does not know what to do about the poor evaluation.\par\pard\plain\hyphpar} {
What does your client currently do to handle the problem? Is your client avoiding
or acting in an impulsive manner?\par\pard\plain\hyphpar} {
Raoul tries to avoid interacting with his boss. In the past, Raoul used to drop by
his boss\u8217?s office in the morning for a five-minute chat; he used to ask his
boss for his opinion on a project. Now Raoul goes straight to his
desk.\par\pard\plain\hyphpar} {
What does your client hope will happen as a consequence of his/her
behavior?\par\pard\plain\hyphpar} {
Raoul hopes \u8220?things will go back to normal.\u8221?\par\pard\plain\hyphpar} {
Exercise 9.1\par\pard\plain\hyphpar} {
Practice defining your clients\u8217? problems.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Setting Goals\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Both Raoul and his therapist now have a much better sense of his problems. The next
step is setting goals. Goals need to be specific and concrete, realistic, and
possible to accomplish. You also want to articulate both short-term and long-term
goals. For example, a short-term goal might be becoming more assertive with your
boss and asking for an extra two weeks of holiday time during the Christmas season,
but that might conflict with the long-term goal of being seen as a team player and
getting a promotion.\par\pard\plain\hyphpar} {
Often after your client answers the questions to help define the problem on the
Problem-Solving Worksheet, his goals are clear. If your client\u8217?s goals are
not clear, the following questions may be helpful.\par\pard\plain\hyphpar} {
How would your client like the situation to change or be
different?\par\pard\plain\hyphpar} {
How would your client like other people in the situation to change or be
different?\par\pard\plain\hyphpar} {
How would your client like to change or be different?\par\pard\plain\hyphpar} {
When Raoul\u8217?s therapist asked how he would like the situation to change, Raoul
responded that he wanted \u8220?everything to go back to normal.\u8221? This is not
a very specific goal. His therapist then asked how he would like his boss to change
and if there were ways that he would like to change. Raoul explained that generally
he wanted to have a good relationship with his boss again. He wanted his boss to
joke with him and talk to him easily. He also wanted to be comfortable asking his
boss for his opinion about projects. As Raoul articulated his goals, he realized
that he also wanted to understand his negative work evaluation better. When a
client slows down and examines his problems and goals, he often realizes aspects of
the problem that are important to him that he had not focused on
before.\par\pard\plain\hyphpar} {
You can also identify goals by paying attention to what your client hopes will
happen as a consequence of his current behavior. As ineffective as their behavior
may be, most people act in a way that they hope will make their situation better.
In Raoul\u8217?s case his therapist could have asked, \u8220?What are you hoping
will happen when you avoid your boss?\u8221?\par\pard\plain\hyphpar} {
Once you have identified your client\u8217?s goals and explored what he hopes will
happen as a consequence of his behavior, it is important to examine the{\i
actual} consequences of his behavior. Unless your client understands that his
behavior is ineffective, he will not be motivated to problem solve. In Raoul\u8217?
s case, he hoped that by avoiding his boss everything would \u8220?go back to
normal.\u8221? When his therapist asked Raoul what were the consequences of
avoiding, Raoul quietly acknowledged that it was not helping, and was in fact
making things worse.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Explain Problem Solving to Your
Client\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once you have established that what your client is currently doing is not working,
it is a good time to explain problem solving. You want to give your client an
overview of the process and instill hope that problem solving can help. Here is how
I explain problem solving (you can find a copy of this script at
http://www.newharbinger.com/38501):\par\pard\plain\hyphpar} {
We have been talking about your problem and how hopeless you feel. Sometimes people
get into negative cycles and don\u8217?t see alternative possibilities. I am
wondering if you would be willing to see if we could find some other ways of coping
with your problem. I want to explain a process called problem solving. We start
with identifying a specific problem and then we brainstorm to try to think of
different possible solutions. We are looking for as many solutions as we can find,
without judging them. Once we have thought of some alternative ways of handling
your problem, I want to spend some time evaluating the different solutions to see
if there is one that makes more sense. Would you be willing to
try?\par\pard\plain\hyphpar} {
{\qc
Your Turn! Practice in Your Imagination: Explain Problem
Solving\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I would like you to imagine explaining problem solving to a client. Before you
start, rate from 1 to 10 how comfortable you feel explaining problem solving. At
the end of the exercise, rate your level of comfort again to see if it changed.
Now, let\u8217?s try this exercise.\par\pard\plain\hyphpar} {
Choose a specific client who you think would benefit from a problem-solving
approach. Imagine that your client has identified a problem and you want to explain
problem solving. Try to get a picture of him or her in your mind. Imagine yourself
in your office with your client. See your office; notice the sounds and smells in
the room. Read over how I suggest explaining problem solving while imagining
yourself saying the words. You can also use your own phrases. Really hear and feel
yourself explaining problem solving. Imagine explaining problem solving two more
times with the same client. Each time, imagine that your client responds
positively.\par\pard\plain\hyphpar} {
Video 9.1\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4: Brainstorm
Solutions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The next phase involves helping your client find new solutions for his problem.
Finding new solutions to problems is difficult\u8212?if clients knew of better ways
to manage their lives, they would already be doing things differently. Problem
solving involves asking your client to step outside of his usual mind-set. You want
to engage in a process called brainstorming, which means coming up with as many
varied solutions as you can. When brainstorming, it is helpful to follow these
three principles:\par\pard\plain\hyphpar} {
{\b
Quantity:} Try to generate as many solutions as possible.\par\pard\plain\hyphpar} {
{\b
Variety:} The greater the variety of solutions, the more chances that you will have
a good idea.\par\pard\plain\hyphpar} {
{\b
Deferred Judgment:} Write down all solutions that come to mind, no matter how
silly, irrelevant, or outrageous.\par\pard\plain\hyphpar} {
Include a few far-fetched and seemingly impossible solutions; they can help your
client think outside the box. Sometimes combining a far-fetched solution with
another solution can lead to a good solution.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Finding New Solutions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It can be very hard not to jump in and solve your client\u8217?s problems. Ideally,
brainstorming new solutions is a collaboration between therapist and client. The
more your client can discover his own solutions, the more empowering the process
will be. I start with asking my client for his suggestions. Often, all I need to
say is, \u8220?I wonder if there are some other ways of handling this
situation.\u8221? If I think of a specific strategy that my client did not mention,
I usually say, \u8220?I have an idea that might help. Let\u8217?s see if you like
it.\u8221? If my client likes the suggestion, I encourage him to apply the strategy
to his specific problem.\par\pard\plain\hyphpar} {
For many of your clients, the process of stopping and consciously looking at their
problems will naturally lead to thinking of new, effective solutions. However, some
clients find it hard to think of alternative ways of handling their problems. Try
the \u8220?Questions to Help Find New Solutions\u8221? list on the Problem-Solving
Worksheet. Below are the questions.\par\pard\plain\hyphpar} {
What are some different ways you could handle your problem?\par\pard\plain\hyphpar}
{
What would you suggest to someone who had this problem?\par\pard\plain\hyphpar} {
What do you think a friend or someone who cared for you would suggest if he or she
knew that you had this problem?\par\pard\plain\hyphpar} {
How have you handled similar situations in the past?\par\pard\plain\hyphpar} {
How do you overcome obstacles in other areas of your life?\par\pard\plain\hyphpar}
{
Is there any positive information that you are ignoring that could be helpful in
solving this problem?\par\pard\plain\hyphpar} {
Is there an aspect of the problem that cannot be changed and that you have to
accept? (The challenge is to accept what cannot be changed and find coping
strategies for what can be changed.)\par\pard\plain\hyphpar} {
Let\u8217?s see how Raoul\u8217?s therapist helps him brainstorm. Initially Raoul
has some difficulty finding alternative solutions. However, his therapist maintains
an optimistic attitude and sticks to problem solving.\par\pard\plain\hyphpar} {
{\i
Therapist:} Right now you are avoiding your boss, and you were saying that it
doesn\u8217?t seem to be improving the situation. Let\u8217?s see if we can think
of some other things you could do. I want us to write down everything we think of.
In this early stage, we\u8217?re looking for quantity and variety of solutions.
Every idea is a good idea. Later we\u8217?ll figure out which one we want to
use.\par\pard\plain\hyphpar} {
{\i
Notice how his therapist explains the principles of quantity, variety, and deferred
judgment.}\par\pard\plain\hyphpar} {
{\i
Raoul:} Anything I can think of just seems impossible.\par\pard\plain\hyphpar} {
{\i
Therapist:} You may be right, but let\u8217?s see if we can think of what you could
do to improve your relationship with your boss.\par\pard\plain\hyphpar} {
{\i
Notice that Raoul\u8217?s therapist acknowledges that he might be right but
maintains an optimistic attitude.}\par\pard\plain\hyphpar} {
{\i
Raoul:} I think that the best solution may be to get out of the department and ask
for a transfer.\par\pard\plain\hyphpar} {
{\i
Therapist:} So one option is to ask for a transfer. Any other options you can think
of?\par\pard\plain\hyphpar} {
{\i
Raoul:} I could just keep doing what I am doing; it is not going so badly. I\u8217?
ve also thought of asking a friend who works in another department if he had any
ideas.\par\pard\plain\hyphpar} {
{\i
Therapist:} We have a couple of solutions; let\u8217?s write them down. First, ask
for a transfer; second, keep doing what you are doing; and third, ask a friend for
advice. I\u8217?m going to ask you some questions to see if they help you come up
with any other solutions. I\u8217?m wondering\u8230?if a colleague had this
problem, what would you suggest to him?\par\pard\plain\hyphpar} {
{\i
Notice how Raoul\u8217?s therapist starts with a summary statement to indicate she
heard Raoul, and then follows up with a question from the \u8220?Questions to Help
Find New Solutions\u8221? list.}\par\pard\plain\hyphpar} {
{\i
Raoul:} That\u8217?s easy, but I don\u8217?t think it would work for
me.\par\pard\plain\hyphpar} {
{\i
Therapist:} You might be right, but let\u8217?s look at what you would suggest in
any case.\par\pard\plain\hyphpar} {
{\i
Raoul:} Well, the first thing I would suggest is that my colleague stop avoiding
his boss and behave in a friendly manner.\par\pard\plain\hyphpar} {
{\qc
Your Turn! Help Raoul Find New
Solutions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Raoul\u8217?s suggestion that he stop avoiding his boss and behave in a friendly
manner is a good overall strategy, but it is not very
concrete.\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Raoul be
more specific and concrete.\par\pard\plain\hyphpar} {
{\ql
Great suggestion. I wonder if you started generally participating more in meetings
whether that would be helpful.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
When you think of being friendlier, what are your
thoughts?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
If your colleague wanted to stop avoiding his boss and be friendlier, what are some
things he could do? {\i
Response #3 is the most likely to help Raoul develop specific and concrete
solutions. In response #1, the therapist is solving the problem for Raoul. Response
#2 would be a good question if we had a specific, concrete solution, but it is too
soon in the problem-solving process.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} If your colleague wanted to generally stop avoiding his boss and be
friendlier, what are some things he could
do?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Raoul:} ({\i
laughing slightly}) Well, I guess I would suggest saying hello to his boss before
meetings, speaking up at meetings, and probably letting his boss know how some of
his projects are going.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Could we put these down as possible solutions for you? ({\i
Raoul nods and smiles.}) You\u8217?ve come up with quite a long
list.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Raoul
continue to find alternative solutions.\par\pard\plain\hyphpar} {
{\ql
I\u8217?m wondering whether we could find more solutions. What would someone who
knew you well suggest as a
solution?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What are the obstacles to starting to speak up at
meetings?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Let\u8217?s make a plan for when you could start speaking up more at meetings. {\i
Response #1 is the most likely to help Raoul continue to find solutions. Responses
#2 and #3 would be good responses if Raoul had already picked speaking up at
meetings as a solution; however, he has not yet finished listing all of his
possible solutions.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} I\u8217?m wondering whether we could find more solutions. What would
someone who knew you well suggest as a
solution?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Raoul:} Honestly? I think my wife would suggest that I wait until the next
evaluation, which is in six months, before I do anything. My daughter would suggest
that I make an appointment with my boss to talk about the poor work evaluation. But
that\u8217?s totally impossible for me to do. I would just be too
anxious.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Often when clients think of an assertive response, they immediately back away. It
just feels too hard. That\u8217?s what happened when Raoul thought of talking to
his boss about his poor work evaluation. It is worthwhile spending some time
exploring what exactly your client could say. Often when clients have a concrete
scenario, the assertive response feels more doable.\par\pard\plain\hyphpar} {
Here is Raoul\u8217?s list of possible solutions:\par\pard\plain\hyphpar} {
{\ql
\u8226? Keep doing what I am doing\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\ql
\u8226? Ask for a transfer to another
department\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Ask a friend for advice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Talk to my boss before meetings, participate in meetings, and tell my boss
how my projects are going\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Wait for next evaluation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
\u8226? Arrange a meeting with my boss to discuss my
evaluation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #5{\i
: Choose a Solution}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
For many clients, calmly evaluating different solutions is a new and empowering
experience. You want your client to evaluate the likelihood that the different
solutions will either resolve or improve the problem. I teach my clients to ask
themselves the following questions from the Problem-Solving Worksheet so that they
can make an informed choice.\par\pard\plain\hyphpar} {
What are the short-term and long-term benefits of each
solution?\par\pard\plain\hyphpar} {
What are the short-term and long-term drawbacks of each
solution?\par\pard\plain\hyphpar} {
If my client finds the concept of benefits and drawbacks too abstract, I ask,
\u8220?If you use this solution, what are some of the good things that might happen
and what are some of the bad things that might happen?\u8221? We make a chart and
write down the answers; clients can then take the chart home and spend more time
thinking about the decision. Below are some of the questions that I ask to
encourage clients to think about the short-term and long-term consequences of each
solution.\par\pard\plain\hyphpar} {
How will this solution affect me, other people, and the
situation?\par\pard\plain\hyphpar} {
How will I feel after implementing this solution?\par\pard\plain\hyphpar} {
Is this solution consistent with my values? Will implementing this solution be
important to me in terms of acting on my values?\par\pard\plain\hyphpar} {
Does the solution generally feel doable?\par\pard\plain\hyphpar} {
Does the solution feel doable in terms of time and effort
required?\par\pard\plain\hyphpar} {
Raoul has a large number of solutions; it\u8217?s hard to evaluate all of them. His
therapist asked him to pick three solutions to evaluate. Below is how Raoul
completed his evaluation. You can download the worksheet Benefits and Drawbacks of
My Solutions at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
Benefits and Drawbacks of My Solutions}} {\b
Solution} {\b
Short-Term Benefit} {\b
Short-Term Drawback} {\b
Long-Term Benefit} {\b
Long-Term Drawback} {
Ask for a transfer\par\pard\plain\hyphpar} {
Will get me out of the office\par\pard\plain\hyphpar} {
A change might be good\par\pard\plain\hyphpar} {
I have to tell my boss, and until I leave it will be worse\par\pard\plain\hyphpar}
{
Applying for a transfer is difficult, hard to get a good reference, can take a long
time\par\pard\plain\hyphpar} {
It might lead to a better situation\par\pard\plain\hyphpar} {
I lose some of my seniority if I change departments\par\pard\plain\hyphpar} {
Next job might be worse\par\pard\plain\hyphpar} {
Talk more with boss; discuss projects, etc.\par\pard\plain\hyphpar} {
Relationship might improve\par\pard\plain\hyphpar} {
Fairly easy to do\par\pard\plain\hyphpar} {
Does not address the poor work evaluation\par\pard\plain\hyphpar} {
Relationship might improve\par\pard\plain\hyphpar} {
Still do not understand poor work evaluation\par\pard\plain\hyphpar} {
Meet with boss to discuss poor work evaluation\par\pard\plain\hyphpar} {
Might resolve the issue\par\pard\plain\hyphpar} {
Might make it worse; could find out boss very critical of my
work\par\pard\plain\hyphpar} {
High anxiety\par\pard\plain\hyphpar} {
Ideally will help with relationship and work performance\par\pard\plain\hyphpar} {
Might make it impossible to stay in job\par\pard\plain\hyphpar} {
Once Raoul and his therapist had evaluated the three solutions, his therapist asked
him to summarize the benefits and drawbacks of each
solution.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Asking for a transfer:} It might make me feel good initially, but it will be a lot
of work and may not lead to a better solution. Plus, I lose my
seniority.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Talk more with the boss:} It might help with the relationship. There is no real
risk. Only problem is that it does not address the poor work
evaluation.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Meet with boss to discuss poor work evaluation:} The most high risk and the
hardest. Might be the best solution, but might make it hard to
stay.\par\pard\plain\hyphpar} {
When Raoul evaluated the different solutions, it was clear that asking for a
transfer was not a good idea. He decided he wanted to start with dropping by his
boss\u8217?s office to chat and also try talking to his boss about different
projects he was working on. He wanted to see what happened when he started talking
more to his boss before deciding whether he wanted to discuss his poor work
evaluation with him.\par\pard\plain\hyphpar} {
Video 9.2\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Make a Plan\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Next, your client needs to develop a plan for implementing the solution he chose.
Make sure that the plan is specific and concrete. It is helpful to write out what
your client will actually do. Next, specify a first step to the plan and a time and
date when your client will try the first step to the solution. You also want to
check if there are any obstacles to the plan, and try to address
them.\par\pard\plain\hyphpar} {
Raoul decided he wanted to try dropping by his boss\u8217?s office the next day. He
had meetings on Monday, Wednesday, and Friday, and he would make a point of getting
there early to chat with his boss before the meeting.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Prepare for the Worst\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Sometimes your client wants to try a solution where there is a realistic
possibility of a negative outcome. For example, my client Julia decided to disclose
to her partner that she had been sexually abused as a child, even though she knew
there was a realistic possibility her partner would blame her for the abuse. Other
clients have raised various difficult issues with their bosses, partners, and
friends, hoping to improve the relationship, but instead the discussion resulted in
increased tension. You want to be sure your client understands the realistic risk
of a negative reaction and is prepared for that should it
occur.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Use Imagery to Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Rehearsing using imagery is an opportunity to practice the new solution and to
check if there are any obstacles. I ask my client to imagine doing the new solution
in his mind. I encourage my client to close his eyes, and I describe him carrying
out the new solution. I ask him to see and feel himself in the situation, and if
the solution involves talking, to hear himself and the other people. After he has
imagined doing the solution once, I ask him to open his eyes and I ask if there
were any obstacles, or if he would like to change anything. We address the
obstacles. I then ask him to imagine doing the new solution two more times and
incorporate any changes he wanted. I ask my client to rate how doable the solution
is before and after practicing in his mind.\par\pard\plain\hyphpar} {
When Raoul imagined dropping by his boss\u8217?s office to chat, he realized it
would be easier if he had a specific question about a file that he wanted to ask.
His therapist incorporated that into the next two imaginal
rehearsals.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Your Client Tries His New Solution\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
Think of your client\u8217?s new solution as an experiment that will provide
additional data, rather than the one right way to proceed. Often clients
prematurely dismiss a solution because the outcome wasn\u8217?t perfect. Results
need to be evaluated on a continuum rather than a \u8220?perfect or else
failure\u8221? yardstick. It is helpful to decide ahead of time how your client
will evaluate whether his new solution is successful. If the solution did not work
out, or if aspects of the problem remain, you need to continue to problem solve. It
may also be helpful to reevaluate what aspects of the problem can and cannot be
changed. The reality is that many of life\u8217?s difficulties take time and effort
to address, and often there is no perfect solution.\par\pard\plain\hyphpar} {
It is also important to teach your client to give himself a pat on the back for
trying his new solution. Even if the new solution did not work out, trying
indicates a willingness to attempt to solve the problem rather than staying stuck.
I model a positive problem orientation. Depending on what happened, some of the
statements I use are, \u8220?That went well,\u8221? \u8220?Trying is an important
first step,\u8221? and \u8220?Even though it wasn\u8217?t perfect, it is a step in
the right direction.\u8221?\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Suzanne Problem Solves\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If you remember, in the last chapter we helped Suzanne manage her anxiety about
going to the barbecue by looking at her hot thought and developing a more balanced
thought. Her worry had decreased sufficiently that she decided to go to the
barbecue. However, she still worried that she would not know what to say and that
the other teachers would not talk to her.\par\pard\plain\hyphpar} {
Her therapist thought it would be helpful to problem solve what Suzanne could do to
make the barbecue easier for her. They came up with a number of strategies,
including offering to help with any food preparation and the cooking; thinking of
some questions she could ask that might start a conversation, such as how long the
other teachers had been at the school and whether they had children; approaching
the other teachers, introducing herself, and standing there as part of the group;
focusing her attention on what the other teachers were saying; and spending some
time playing with the principal\u8217?s young children.\par\pard\plain\hyphpar} {
When Suzanne evaluated the different solutions, she picked offering to help with
the cooking, thinking of some questions she could ask to start a conversation, and
then approaching one of the teachers at the party and starting to talk. She felt a
lot better once she had a plan.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #6{\i
: Develop Coping Thoughts}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once your client has decided how he wants to handle the problem, and has a plan, it
can be useful to develop coping thoughts that help him focus on the task and manage
any negative feelings. Highly critical thoughts about ourselves or others not only
make us feel bad, but also distract us from the present moment, making it harder to
handle a stressful situation. In a coping thought model, you and your client
actively develop thoughts that help your client execute his plan and manage his
negative emotions. Coping thoughts tend to be short and provide directions as to
what to do in a specific situation.\par\pard\plain\hyphpar} {
Here is the general process that I use to develop coping
thoughts:\par\pard\plain\hyphpar} {
Identify the behavior your client wants to accomplish and his
plan.\par\pard\plain\hyphpar} {
Check if your client\u8217?s current thoughts are interfering with or sabotaging
his plan.\par\pard\plain\hyphpar} {
Develop coping thoughts.\par\pard\plain\hyphpar} {
Use imagery to practice your client\u8217?s coping
thoughts.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Identify the Behavior Your Client Wants to
Accomplish\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In addition to being part of a problem-solving plan, coping thoughts can be used
for any specific behavior your client wants to accomplish. For example, I have used
coping thoughts to help my client Elyse stop procrastinating, sit down, and
complete her tax return; I have also used coping thoughts to help clients drink
only one glass of wine a night, start an exercise program, use relaxation for pain
control, and raise an awkward topic with a friend or family member. You can also
use coping thoughts to help clients manage their feelings of anxiety or of being
overwhelmed. You want to be sure the behavior is specific and doable. If Elyse does
not know how to complete her tax return, all the coping statements in the world
will not help her.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Identify Current Thoughts That Are Interfering with the
Plan\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Sometimes when clients think of a solution to their problem, they are optimistic;
however, often negative, sabotaging thoughts interfere with their ability to
implement their plan. I usually ask my client what might interfere with his plan,
and specifically whether there is anything he is likely to say to himself that
would sabotage the plan. I want to make sure my client understands the impact of
his thoughts on his ability to complete his plan. Let\u8217?s see if Suzanne has
any thoughts that will sabotage her plans for how to handle the
barbecue.\par\pard\plain\hyphpar} {
{\i
Therapist:} Suzanne, I am wondering, when you think of helping with the food at the
barbecue, or starting to talk to one of the other teachers, what thoughts go
through your mind?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Helping with the food at the barbecue is easy, a really great idea. When
I think of going up to the other teacher and starting a conversation, I get pretty
anxious.\par\pard\plain\hyphpar} {
{\i
Suzanne has identified a feeling, but we are looking for sabotaging thoughts. We
know from our four-factor model that thoughts lead to
feelings.}\par\pard\plain\hyphpar} {
{\i
Therapist:} What are some of your thoughts that go with your anxious
feeling?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I guess I think that no one will find my questions interesting, and that
it was probably a mistake to go to the party.\par\pard\plain\hyphpar} {
{\i
Suzanne\u8217?s therapist wants her to see how these thoughts might sabotage her
plan.}\par\pard\plain\hyphpar} {
{\i
Therapist:} When you have these thoughts, how does it affect your plan to start
talking to the other teachers?\par\pard\plain\hyphpar} {
{\i
Suzanne:} It makes it really hard and makes me not want to go or just stand there
quietly, instead of trying to talk.\par\pard\plain\hyphpar} {
I sometimes draw a diagram to help my client see how his thoughts are sabotaging
his plan. Many clients find it helpful to visualize the process. This can be
especially helpful if a client wants to accomplish his plan but then doesn\u8217?t
carry out the plan and doesn\u8217?t understand what got in the way. Figure 9.1
shows what Raoul\u8217?s therapist drew for Raoul to help him understand the impact
of his thoughts on his procrastinating around writing a
report.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

Figure 9.1. Raoul avoids a

project.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 9.2\par\pard\plain\hyphpar} {
Practice using a diagram to explain the consequences of your client\u8217?s
thoughts.\par\pard\plain\hyphpar} {
Once you have identified your client\u8217?s negative sabotaging thoughts, you use
a coping thought model to ask him to put aside these thoughts. Unfortunately, if
you tell your client to {\i
stop} a thought, it just bounces back stronger. However, your client can learn to
ignore his interfering thoughts, especially if he has developed coping thoughts.
You can\u8217?t think of coping thoughts and interfering thoughts at the same
time.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Help Your Client Develop Coping
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The next step is to develop thoughts that help your client cope with the situation
and manage his disruptive feelings. Below are questions to help your client develop
coping thoughts. You can download a Questions to Develop Coping Thoughts handout at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
What could you say to yourself that would help you cope with this
situation?\par\pard\plain\hyphpar} {
What advice could you give a friend in terms of helpful coping
thoughts?\par\pard\plain\hyphpar} {
What would someone who knows you well suggest as helpful coping
thoughts?\par\pard\plain\hyphpar} {
If you were in a more optimistic mood, what might you
think?\par\pard\plain\hyphpar} {
When you have coped successfully in the past, either with a similar or a different
type of situation, what have you told yourself?\par\pard\plain\hyphpar} {
Once you have a list of coping thoughts, write them down. Coping thoughts generally
fall into three categories: placing the situation in a realistic perspective,
focusing on the task at hand, and managing anxious or overwhelming feelings.
Different types of thoughts will be helpful in different situations. Let\u8217?s
look at some examples of thoughts in each category. You can download a copy of
Examples of Coping Thoughts at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {\b
{\qc
Examples of Coping Thoughts}} {\b
Place the Situation in a Realistic Perspective} {\b
Focus on the Task} {\b
Manage Anxiety} {
Try not to take this too seriously.\par\pard\plain\hyphpar} {
This is just one situation.\par\pard\plain\hyphpar} {
If this situation doesn\u8217?t work out, there will be
others.\par\pard\plain\hyphpar} {
Don\u8217?t blow this up out of proportion.\par\pard\plain\hyphpar} {
You have a plan.\par\pard\plain\hyphpar} {
Do the first step of your plan.\par\pard\plain\hyphpar} {
Focus on the task.\par\pard\plain\hyphpar} {
It does not have to be perfect.\par\pard\plain\hyphpar} {
One step at a time\par\pard\plain\hyphpar} {
Even if I\u8217?m upset, I can do my plan.\par\pard\plain\hyphpar} {
Anxiety is not dangerous.\par\pard\plain\hyphpar} {
It doesn\u8217?t matter if my heart is pounding.\par\pard\plain\hyphpar} {
I can take some deep breaths.\par\pard\plain\hyphpar} {
It will pass.\par\pard\plain\hyphpar} {
Anxiety is normal.\par\pard\plain\hyphpar} {
Remember your rational thoughts.\par\pard\plain\hyphpar} {
You don\u8217?t have to listen to worry thoughts.\par\pard\plain\hyphpar} {
Suzanne, together with her therapist, identified a number of thoughts she could use
as coping thoughts to help her start talking to one of the other teachers. They
included {\i
Stick to your plan}, {\i
Just ask a question}, {\i
There are only three other teachers}, and {\i
Don\u8217?t listen to anxiety}.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Use imagery to practice.} Once your client has developed coping thoughts, you take
him through his plan again in his imagination, this time adding coping thoughts.
After we have practiced once, I ask if there is anything he would like to change
and if any of the coping thoughts were particularly helpful or not that helpful. I
make any changes and then we practice two more times in his
imagination.\par\pard\plain\hyphpar} {
When Suzanne rehearsed her plan and coping thoughts in her imagination, she
particularly liked the thoughts {\i
Just ask a question} and {\i
Don\u8217?t listen to anxiety}.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Help Raoul Develop Coping
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Raoul decided that he wanted to call one of his colleagues whom he had been
avoiding and suggest that they have lunch together. He was fairly anxious about
calling, and rated his anxiety at a 6 out of 10. His thoughts were {\i
I haven\u8217?t had lunch with him in a long time; he will think it weird that I
phone him}. How could you help Raoul develop coping thoughts that would help him
call his colleague?\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Raoul
develop coping thoughts.\par\pard\plain\hyphpar} {
{\ql
How could you contact your colleague to ask him out for
lunch?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I think it is important that you tell yourself to stop thinking these thoughts;
they are clearly stopping you from calling your
colleague.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
I am wondering if you could try to put these thoughts aside and see if we could
come up with some thoughts that will help you call your colleague. {\i
Response #3 is the next step in developing coping thoughts. Response #1 will help
Raoul develop a specific plan of what he will do, but it will not help develop
coping thoughts. In response #2, the therapist is telling Raoul to try to stop his
thoughts. This will backfire\u8212?when we try to stop thinking a thought, we just
think about it more.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} I am wondering if you could try to put these thoughts aside and see if
we could come up with some thoughts that will help you call your
colleague.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Raoul:} What do you mean?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three possible responses below and pick the one that will help Raoul
develop coping thoughts.\par\pard\plain\hyphpar} {
{\ql
If a friend were anxious about inviting a colleague for lunch, what would you
suggest that he tell himself?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Your problem is that you are not positive
enough.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Just say to yourself\u8212?be positive! {\i
Response #1 is the best answer. It uses the question \u8220?What advice could you
give a friend in terms of helpful coping thoughts?\u8221? and applies it to
Raoul\u8217?s situation. In responses #2 and #3, the therapist is trying to use
positive thinking. The problem is that positive thinking doesn\u8217?t work because
it is too general and doesn\u8217?t address the specific behavior the client wants
to do.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Video 9.3\par\pard\plain\hyphpar} {
Video 9.4\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to a Clinical
Example\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 9.1:} Nasir Has a Busy Clinic\par\pard\plain\hyphpar} {
{\b
Exercise 9.2:} Suzanne Goes to the School Fair\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
For the following homework assignment, you can use the guided audio file to help
you go through each step; I think it is more effective than reading the
exercise.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Practice Using the Problem-Solving
Steps\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Accompanying audio file:} Solve Your Own Problems\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Think of a problem that is currently troubling you. Don\u8217?t choose something
huge, as it may be too challenging for an initial attempt at problem solving.
Choose a problem that is sufficiently large that you care about it, but
sufficiently small that there is a chance you could solve it. Go through the four
problem-solving steps in order using the Problem-Solving Worksheet as a
guide.\par\pard\plain\hyphpar} {
{\ql
Problem-Solving Steps:\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Identify the problem and set realistic goals. Remember to ask yourself what you
hope will be the consequences of your current
behavior.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Generate new solutions. Try to think of at least three. Don\u8217?t evaluate them
until you have completed your list.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\ql
Evaluate the different solutions and decide which one to try. Remember to look at
both the short-term and long-term benefits and
drawbacks.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Try one of the solutions: evaluate the consequences and decide whether the problem
is solved or if you need to continue to problem
solve.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
This coming week I would like you to try to apply the problem-solving process with
a client.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Help a Client Problem
Solve\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Start by asking your client to identify the problem that is causing his or her
distress. See if you can engage your client in a problem-solving process. Remember,
all you have to do is the following: identify the problem and how your client is
currently coping, identify his goal, brainstorm alternative solutions, choose a
solution to try, and make a specific and concrete plan. You may also want to try
asking your client to rehearse his new plan in his imagination. Fill in the form
below so you can monitor how you are doing.\par\pard\plain\hyphpar} {\b
Client} {\b
Identify the Problem and Set Goals} {\b
Brainstorm New Solutions} {\b
Evaluate and Choose a Solution} {\b
Make a Plan} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under the agenda items.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} What is problem solving?\par\pard\plain\hyphpar} {
How can you explain problem solving in one or two
sentences?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Develop a positive problem orientation.\par\pard\plain\hyphpar} {
What is the difference between a positive problem orientation and a negative
problem orien-tation?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Identify your client\u8217?s problems.\par\pard\plain\hyphpar} {
How can your clients use their anxiety to identify a
problem?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Brainstorm solutions.\par\pard\plain\hyphpar} {
What are the three principles of brainstorming solutions?\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Agenda Item #5:} Choose a solution.\par\pard\plain\hyphpar} {
What are two criteria for evaluating a solution?\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Agenda Item #6:} Develop coping thoughts.\par\pard\plain\hyphpar} {
What are two categories of coping thoughts?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Chose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Chapter 10\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Behavioral Activation\u8212?Action Plans for
Depression\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the last chapter we covered problem solving. Did you notice your clients\u8217?
problem orientation? Did you have a chance to try problem solving in your own life
or with any clients? What was it like to consciously evaluate different solutions?
Was it hard not to jump in and solve your clients\u8217?
problems?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this chapter you will learn how to help your clients who have depression by
increasing their activity level to improve their mood. The technical term for this
intervention is {\i
behavioral activation}.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} How does behavioral activation work?\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Help your clients understand their
depression.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Monitor your clients\u8217? daily
activities.\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} Plan activities that increase positive
moods.\par\pard\plain\hyphpar} {
{\b
Agenda Item #5:} Graded task assignments.\par\pard\plain\hyphpar} {
{\b
Agenda Item #6:} Increase well-being.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Behavioral activation is primarily a treatment for depression. It is based on the
premise that when your clients change their behaviors, and increase activities that
promote pleasure and a sense of competence, their mood will
improve.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #1{\i
: How Does Behavioral Activation
Work?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
You can think of depression as a cycle that is caused and maintained by avoidance
and a lack of positive reinforcement. Depression starts with changes in a
client\u8217?s life that lead to a decrease in events that she enjoys and an
increase in unpleasant events. As a result of these changes, your client\u8217?s
overall mood declines and activities she used to enjoy are less pleasurable.
Clients start avoiding activities such as seeing friends and family and pursuing
hobbies, exercise, or leisure activities. The more clients avoid activities that
might lift their mood, the less contact they have with positive reinforcements. The
less contact with positive reinforcements, the more down they feel and the less
they feel like doing anything (Martell, Dimidjian, & Herman-Dunn,
2010).\par\pard\plain\hyphpar} {
When clients become less active, their overall routine is disrupted, which may lead
to sleep problems, poor appetite, and generally feeling out of sync with their
environment, all of which exacerbate depression (Dimidjian, Barrera, Martell,
Mu\u241?oz, & Lewinsohn, 2011). The more your clients are caught in this cycle of
depression, the more they disengage from their normal life and the more likely they
are to develop secondary problems. For example, the student who is too depressed to
attend baseball practice may eventually be kicked off the team. Figure 10.1 shows
how the cycle of depression works.\par\pard\plain\hyphpar} {
{\i
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Figure 10.1. Cycle of

depression.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Breaking the Cycle of Inactivity and
Depression\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Behavioral activation interrupts the cycle of depression by directly targeting
avoidance and encouraging clients to engage in mood-boosting activities. Clients
identify activities that (1) are enjoyable, (2) increase their confidence or sense
of mastery, or (3) are functional in that they decrease the negative consequences
of avoidance. The therapist works with clients to schedule these activities into
their week in a step-by-step manner and uses the problem-solving process to address
any obstacles (Martell et al., 2010). As clients start to engage in pleasurable
activities, their mood improves. As clients feel better, they have more energy,
they stop wanting to avoid activities, and they engage in healthy routines. In
short, a mood-boosting cycle starts.\par\pard\plain\hyphpar} {
{\b
{\ql
Behavioral Activation
Theory\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Pleasurable Activities + Problem Solving = Behavioral
Antidepressant\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Overview of Behavioral Activation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The formal goal of behavioral activation is for your clients to return to their
pre-depression level of functioning. I prefer to tell my clients that our goal is
to help them have a life they enjoy. The focus is to actively encourage clients to
engage in activities even though they \u8220?feel\u8221? like avoiding or resting.
It seems to me that folk wisdom often captures the essence of behavioral
activation. My Aunt Tanya, who is eighty-eight, always told me, \u8220?No matter
what, get up every morning and put on your makeup, and before you go to bed at
night, have a sip of vodka.\u8221? In other words, according to Aunt Tanya, no
matter how you are feeling, get up and face the world, and before the day ends, do
something nice for yourself.\par\pard\plain\hyphpar} {
Generally, the behavioral activation process unfolds in the following
order.\par\pard\plain\hyphpar} {
Understand your client\u8217?s depression in relation to changes in his or her
daily activities.\par\pard\plain\hyphpar} {
Monitor your client\u8217?s daily activities.\par\pard\plain\hyphpar} {
Plan activities that increase positive mood.\par\pard\plain\hyphpar} {
Monitor your client\u8217?s mood before and after
activities.\par\pard\plain\hyphpar} {
Problem solve obstacles.\par\pard\plain\hyphpar} {
Establish healthy routines and prevent setbacks.\par\pard\plain\hyphpar} {\s4
\afs23
{\b
Is Behavioral Activation Effective?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
Even though I have practiced behavioral activation for many years, when a client
with severe depression comes into my office, I often find myself thinking that
behavioral activation will not be enough. How can adding pleasurable activities be
sufficient to help this very depressed client? But rather than believing my
automatic thoughts\u8230?I look at the evidence!\par\pard\plain\hyphpar} {
Over the past three decades, numerous studies, including a number of meta-analyses,
have consistently demonstrated that behavioral activation is an effective treatment
for mild, moderate, and severe depression (Dimidjian et al., 2011; Soucy-Chartier &
Provencher, 2013). This is true for children, teens, and adults of all ages.
Behavioral activation alone has been found to be as effective as treatments that
include both behavioral and cognitive interventions, such as identifying and
challenging negative thoughts (Dimidjian et al., 2006; Richards et al., 2016).
There is some indication that if clients are severely depressed, therapy provided
over a sixteen-week period that includes only behavioral activation is more
effective than therapy that includes behavioral and cognitive interventions.
Behavioral activation is also an effective intervention for relapse prevention
(Dobson et al., 2008). A recent study found that clients with complicated
bereavement also responded positively to behavioral activation (Hershenberg,
Paulson, Gros, & Acierno, 2014).\par\pard\plain\hyphpar} {
{\b
{\ql
Research
Summary\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Clients with mild and moderate depression: Behavioral activation should be a
component of treatment.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Clients with severe depression: Behavioral activation should be the first
intervention.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #2{\i
: Help Your Clients Understand Their
Depression}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
A client who is depressed often starts therapy saying, \u8220?What is wrong with
me? I used to be so strong\u8221? or, \u8220?I think I am going crazy, I just feel
like crying all day.\u8221? You want to help your client understand that her
depression is related to a lack of mood-enhancing activities and is not a personal
failure.\par\pard\plain\hyphpar} {
You can use the cycle of depression as a model for gathering information that will
help your clients understand the factors that caused and maintain their depression.
If your clients understand that their depression is related to a lack of
pleasurable activities in their lives, they will be more motivated to engage in
mood-boosting activities. This is important, as you are going to ask your clients
to engage in activities even if they don\u8217?t \u8220?feel like
it.\u8221?\par\pard\plain\hyphpar} {
Start with looking at the changes in your client\u8217?s life that preceded her
depression, in particular, decreases in reinforcing and/or pleasurable activities
and increases in unpleasant activities. You also want to look at how your client
coped with these changes, and the role of avoidance. The two main questions I ask
my client are:\par\pard\plain\hyphpar} {
What life changes occurred prior to your depression?\par\pard\plain\hyphpar} {
How did these changes affect your daily life activities in relation to an increase
or decrease in pleasurable activities?\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Suzanne\u8217?s Cycle of Depression\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
Suzanne started therapy saying she didn\u8217?t know what was wrong with her. She
had a great house, great kids, a good job, and a great husband, but she was just so
overwhelmed that she didn\u8217?t enjoy life anymore. She cried softly as she told
her therapist that she wasn\u8217?t coping.\par\pard\plain\hyphpar} {
In chapter 2 we listed the stressors and recent changes in Suzanne\u8217?s life
that happened prior to her depression.\par\pard\plain\hyphpar} {
Suzanne started teaching at a new school. The school is a thirty- to forty-minute
commute from home; she does not know the other teachers, who form a tight
group.\par\pard\plain\hyphpar} {
Her mother-in-law is no longer able to babysit.\par\pard\plain\hyphpar} {
Genia, her best friend, moved away.\par\pard\plain\hyphpar} {
Let\u8217?s see how her therapist uses the two questions we just identified to
understand Suzanne\u8217?s depression.\par\pard\plain\hyphpar} {
{\i
Therapist:} It sounds like there have been a lot of changes in your life. I am
wondering if we could spend a moment and think about how each change has affected
your life. Which one should we look at first?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I think the really big one is the new
school.\par\pard\plain\hyphpar} {
{\i
Therapist:} I think it would be helpful to look at how your life has changed since
starting at the new school. I want to look at activities you stopped doing, and
activities you started doing because of the new school.\par\pard\plain\hyphpar} {
{\i
The therapist instills hope by starting with, \u8220?I think it would be
helpful.\u8221? Notice her therapist did not ask Suzanne how she feels about the
new school. She asked her to look at how her life is
different.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} One of the biggest changes is the morning. I used to walk to school; it
was about fifteen minutes each way. I now spend forty-five minutes commuting. The
extra thirty minutes I used to have meant that I had time to get the kids ready in
the morning. Now everything has to be ready the night before. The kids have to be
completely ready to be dropped off at my neighbor\u8217?s home by 7:30. It\u8217?s
really hard getting them up, dressed, and fed. My neighbor takes them to school. My
husband leaves early for work and can\u8217?t help.\par\pard\plain\hyphpar} {
{\i
Therapist:} That sounds like a really big change to your morning
routine.\par\pard\plain\hyphpar} {
{\i
Suzanne:} Yes, I used to enjoy the mornings\u8212?it was a nice time with the kids,
and I liked the walk to school. Now it is just so
stressful.\par\pard\plain\hyphpar} {
{\i
The therapist makes a supportive comment, and Suzanne goes on to elaborate how her
life has changed.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I want to start making a list of the ways your life has changed. I
think it will help us understand your depression and how to help you. What would
you put down?\par\pard\plain\hyphpar} {
{\i
Notice how her therapist instills hope. The therapist asks Suzanne what she would
put on the list.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I guess, I no longer have the fifteen-minute walk to school, I no
longer have a nice time with my kids in the morning, and actually, I rarely eat
breakfast, I am so frazzled. I am often starving by the time I get to
school.\par\pard\plain\hyphpar} {
{\i
Therapist:} I think that\u8217?s a really good list of all the things that you are
no longer doing. What about anything that you now do because of the new school that
you were not doing before?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I guess I have to be really organized the night before, which I
find hard. I make my daughter\u8217?s lunch, put out the kids\u8217? clothes, and
make sure I am all organized for school. Also, I have to be really strict with the
kids, as I am on a tight schedule. Which means I yell more to get them going in the
morning. I also have the long drive to work, which I hate. I spend the whole time
in the car thinking about what a bad mom I\u8217?ve become, how I yelled at the
kids once again, and how I wish I were back at my old school. It\u8217?s just
awful.\par\pard\plain\hyphpar} {
{\i
Therapist:} Sounds like a lot of changes. When we look at how different your
morning is now to how it used to be, what are your
thoughts?\par\pard\plain\hyphpar} {
{\i
Note that the therapist first asked Suzanne what had changed, second asked her how
the change had affected her daily life, and third asked her what she thought when
she looked at the changes.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, no wonder I am depressed; it sounds like an awful way to start the
morning.\par\pard\plain\hyphpar} {
{\i
By examining how her morning has changed, Suzanne has shifted from \u8220?something
is wrong with me that I am depressed,\u8221? to realizing that the changes in her
morning routine may be contributing to her depression.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I think you said something important. Seems like the change in school
caused a lot of other changes in your life and had a negative effect on your
morning routine and mood. I think we are discovering some important information. I
want to see if there are other ways that starting at the new school has impacted
your life.\par\pard\plain\hyphpar} {
{\i
Notice how Suzanne\u8217?s therapist reinforces her awareness that her morning
routine is impacting her mood. Also notice how the therapist keeps Suzanne on track
with the task.}\par\pard\plain\hyphpar} {
Suzanne used to spend time with other teachers, who were her friends, and now she
sees few of her friends. She had enjoyed being involved in the school play and had
received a lot of positive feedback from many people in the school. She was well
known as a popular teacher. At her new school she participates in no
extracurricular activities and knows none of the other teachers socially. She gets
home late from work, tired and frazzled from the drive.\par\pard\plain\hyphpar} {
Suzanne had not realized that since her mother-in-law had become ill and could no
longer babysit, she and her husband had practically stopped going out in the
evening. It had been ages since they had seen many of their friends. Suzanne also
realized that since Genia had moved away, she had stopped her weekly walks and
talked to her friend much less. Suzanne was surprised when she looked at the impact
of all the changes in her life.\par\pard\plain\hyphpar} {
Exercise 10.1\par\pard\plain\hyphpar} {
Practice using the cycle of depression to understand your
clients.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Use a Written Summary\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After I have explored with my client how her life has changed, I find it helpful to
provide a written summary. Sometimes I draw the cycle of depression and together we
look at how it is related to my client\u8217?s specific situation. Other times I
use the Understand Your Depression worksheet, which you can download at
http://www.newharbinger.com/38501. The worksheet gives your client an overview of
how her activities have changed since she became depressed. When Suzanne looked at
her Understand Your Depression worksheet, it made sense that the changes in her
activities were affecting her depression.\par\pard\plain\hyphpar} {\b
{\qc
Understand Your Depression}} {
{\b
Changes or stressors in your life prior to your depression?} New school, mother-in-
law no longer babysitting, and Genia, her best friend, moving
away.\par\pard\plain\hyphpar} {
{\b
Since these changes or stressors, how have your activities changed?} Complete the
form below.\par\pard\plain\hyphpar} {\b
Increased Since Life Changes or Stressors} {\b
Decreased Since Life Changes or Stressors} {\b
Activities I enjoy or that provide pleasure or mastery} {
None\par\pard\plain\hyphpar} {
Walk to school; nice time with children in the morning; going out with husband and
seeing friends; Sunday walk with Genia; talking to Genia\par\pard\plain\hyphpar}
{\b
Activities I do not enjoy} {
Getting ready the night before; long drive to work; getting up early and getting
children ready\par\pard\plain\hyphpar} {
None\par\pard\plain\hyphpar} {\b
Exercise} {
No walk to school, no Sunday walk\par\pard\plain\hyphpar} {\b
Spending time with friends} {
Stopped seeing school friends, Genia moved away\par\pard\plain\hyphpar} {\b
Spending time with family} {
See mother-in-law more, as she has been ill\par\pard\plain\hyphpar} {
Less time with children in the morning; less time with husband
overall\par\pard\plain\hyphpar} {\b
Leisure or hobbies} {
None\par\pard\plain\hyphpar} {
No school play; no other extracurricular activities\par\pard\plain\hyphpar} {\b
Smoking, overeating, alcohol or drug use} {
None\par\pard\plain\hyphpar} {\b
Routines related to eating and sleeping} {
No breakfast routine, often fall asleep in front of TV\par\pard\plain\hyphpar} {\s4
\afs23
{\b
Use an Analogy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I sometimes use a flower analogy to help my client understand her depression. This
analogy was inspired by Melanie Fennell\u8217?s virtuous and vicious flowers
(Fennell, 2006). I explain that feeling happy is similar to a brightly colored
flower with lots of petals. I then draw a flower with a circle in the middle and
petals around the circle. I ask my client to fill in each petal with an activity
she did before she became depressed that she enjoyed or gave meaning to her life. I
look for healthy routines; social activities with colleagues, friends, and family;
activities that are pleasurable or meaningful; and activities that lead to a sense
of competence or mastery.\par\pard\plain\hyphpar} {
Once my client has completed filling in her flower, I ask her to draw an X through
all the petals that have changed since the depression. Usually, almost all of them
are gone. What was once a full bloom is often only a few
petals.\par\pard\plain\hyphpar} {
With some clients, instead of a flower I draw a picture of a wall. I use bricks to
build a strong wall; if you take out too many bricks, the wall will fall, or have
big holes.\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist used the flower analogy, and Suzanne was surprised to see
her flower. Her depression was making more and more sense to her. Her therapist
explained that together they would help Suzanne start to add petals back into her
life so that she could start to feel better. Suzanne said this was a good idea, but
added that she couldn\u8217?t imagine where to begin. Her therapist assured her
they would work together and go slowly.\par\pard\plain\hyphpar} {
{\qc
Your Turn! Understand Mayleen\u8217?s
Depression\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Below is a description of Mayleen, a fifty-eight-year-old woman who has come to
therapy because she is currently depressed. Try to complete the Understand Your
Depression worksheet with the information below. You can see my answers in the
appendix.\par\pard\plain\hyphpar} {
{\ql
Mayleen is a successful sculptor. She lives alone, has never married, and has no
children. Two years ago her mother became ill, and Mayleen has been very involved
in her care.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Mayleen\u8217?s mother lives alone in the town where Mayleen grew up, about three
hours away. Mayleen left when she was eighteen and no longer has any friends or
other family who live there. She spends four days a week visiting her mother and
attending to her needs, looking after the house, and taking her to doctor\u8217?s
appointments. Mayleen is happy that she is able to care for her sick mother but
feels lonely when she visits. She and her mother watch a lot of daytime TV, which
Mayleen finds boring.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Over the two years that her mother has been ill, Mayleen has become increasingly
depressed and feels guilty about not spending all her time caring for her mother.
She has stopped seeing many of her friends, has given up exercise, and has almost
completely stopped sculpting, as she believes there is no time for these
activities, and she is so tired most of the
time.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Video 10.1\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Monitor Your Clients\u8217? Daily
Activities}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Behavioral activation involves asking your clients to engage in pleasurable
activities. Sounds easy. The difficulty is that depressed clients don\u8217?t feel
like doing anything. They will tell you, \u8220?Nothing helps.\u8221? You are going
to ask your clients to act according to a plan rather than according to how they
feel. If your clients can see the connection between an increase in their activity
level and an increase in their mood, they will be more motivated to add pleasurable
activities to their lives, even if they don\u8217?t \u8220?feel\u8221? like doing
them.\par\pard\plain\hyphpar} {
The easiest way for clients to see the connection between their mood and specific
activities is to monitor their daily activities and rate their moods. I ask clients
to complete a Daily Activities Schedule (available at
http://www.newharbinger.com/38501), where they write what they do, hour by hour,
and rate their mood. I usually complete the first day of the Daily Activities
Schedule during the therapy hour. That way, I am sure my clients understand what to
do. (If the session is early in the morning, we complete it for the previous day.)
Then for homework I assign the Daily Activities Schedule for the rest of the
week.\par\pard\plain\hyphpar} {
Here is how I introduce the Daily Activities Schedule. I explain both the rationale
behind the intervention and what we will be doing.\par\pard\plain\hyphpar} {
I think it is important to understand how you spend your days, and if your mood
changes with the types of activities that you do. I have a Daily Activities
Schedule where you can write down what you do throughout the day, and rate your
mood. That way, we can see whether there are times during the day when you feel
better, and times when you feel worse. We are going to try and increase the times
you feel better and learn how to cope with the times when you feel worse. Does this
make sense to you?\par\pard\plain\hyphpar} {
Let\u8217?s take today and see if we can complete the schedule together. Is that
okay with you? What time did you wake up? If you had to rate your mood from 1 to
10, with 10 being the most depressed you have ever been, and 1 being not at all
depressed, where would you rate your mood when you woke up
today?\par\pard\plain\hyphpar} {
I then take my client through her day, rating her mood during each
activity.\par\pard\plain\hyphpar} {
{\qc
Your Turn! Practice in Your Imagination: Explain a Daily Activities
Schedule\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before you start, rate from 1 to 10 how comfortable you are explaining a Daily
Activities Schedule to a client who is depressed. At the end of the exercise, rate
your level of comfort again to see whether it changed. Now, let\u8217?s try this
exercise.\par\pard\plain\hyphpar} {
Choose a client who is depressed and who you think would benefit from using
behavioral activation. Try to get a picture of him or her in your mind. Imagine
yourself in your office with your client. See your office; notice the sounds and
smells in the room. Imagine that you want to introduce a Daily Activities Schedule.
Read over how I explain using a Daily Activities Schedule while imagining yourself
saying the words. You can also use your own phrases. Imagine getting out the Daily
Activities Schedule and explaining it to your client. Now, imagine explaining the
Daily Activities Schedule two more times with the same client. Each time, imagine
that your client responds positively.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What Did Your Client Learn?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The next step is to use the Daily Activities Schedule to help your client discover
an activity/mood relationship and to decide which times of day to target and which
activities to introduce or expand. I start with asking my client about the general
experience of completing the Daily Activities Schedule and then ask whether she
learned anything in the process. I then go over Questions to Explore a
Mood/Activity Relationship (Martell et al., 2010). When I first started doing
behavioral activation, I kept these questions next to me. You can download a copy
at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Do you see an activity/mood relationship? What activities help you feel better?
What activities or situations are connected to a low mood? \par\pard\plain\hyphpar}
{
What time periods are you most at risk for a low mood?\par\pard\plain\hyphpar} {
Do you have any routines that help you maintain a positive
mood?\par\pard\plain\hyphpar} {
Is there anything you are avoiding?\par\pard\plain\hyphpar} {
Below is the Daily Activities Schedule that Suzanne completed and brought to
therapy. She rated her depression from 1 to 10, 1 being not at all depressed and 10
being the most depressed she had ever been.\par\pard\plain\hyphpar} {\b
{\qc
Suzanne\u8217?s Daily Activities Schedule (1 = not at all depressed; 10 = very
depressed){
\par\pard\plain\hyphpar} }} {\b
Monday} {\b
Tuesday} {\b
Wednesday} {\b
Thursday} {\b
Friday} {\b
Saturday} {\b
Sunday} {\b
6:00} {
Wake kids (8)\par\pard\plain\hyphpar} {
Wake kids (8)\par\pard\plain\hyphpar} {
Wake kids (6)\par\pard\plain\hyphpar} {
Wake kids (7)\par\pard\plain\hyphpar} {\b
7:00} {
Drop off kids (8)\par\pard\plain\hyphpar} {
Drop off kids (9)\par\pard\plain\hyphpar} {
Drop off kids (9)\par\pard\plain\hyphpar} {
Drop off kids (7)\par\pard\plain\hyphpar} {\b
8:00} {
Drive to work (9)\par\pard\plain\hyphpar} {
Drive to work (9)\par\pard\plain\hyphpar} {
Drive to work (7)\par\pard\plain\hyphpar} {
Drive to work (7)\par\pard\plain\hyphpar} {
Lie in bed (9)\par\pard\plain\hyphpar} {
Lie in bed (9)\par\pard\plain\hyphpar} {\b
9:00} {
Teach (6)\par\pard\plain\hyphpar} {
Teach (5)\par\pard\plain\hyphpar} {
Sports day at school (4)\par\pard\plain\hyphpar} {
Teach (5)\par\pard\plain\hyphpar} {
Teach (5)\par\pard\plain\hyphpar} {
Clean house; errands (4)\par\pard\plain\hyphpar} {
Phone friend (3)\par\pard\plain\hyphpar} {
Play with kids (4)\par\pard\plain\hyphpar} {\b
10:00} {\b
11:00} {
Visit mother-in-law (4)\par\pard\plain\hyphpar} {\b
12:00} {
Recess and lunch (8)\par\pard\plain\hyphpar} {
Recess and lunch (8)\par\pard\plain\hyphpar} {
Help with food (4)\par\pard\plain\hyphpar} {
Recess and lunch (7)\par\pard\plain\hyphpar} {
Recess and lunch (7)\par\pard\plain\hyphpar} {
Lunch (5)\par\pard\plain\hyphpar} {
Lunch (5)\par\pard\plain\hyphpar} {\b
1:00} {
Teach (5)\par\pard\plain\hyphpar} {
Teach (5)\par\pard\plain\hyphpar} {
Sports day (4)\par\pard\plain\hyphpar} {
Teach (5)\par\pard\plain\hyphpar} {
Teach (5)\par\pard\plain\hyphpar} {\b
2:00} {
Take kids to park (4)\par\pard\plain\hyphpar} {\b
3:00} {
Meeting to discuss winter holiday assembly (4)\par\pard\plain\hyphpar} {
Drive home (9)\par\pard\plain\hyphpar} {
Clean up with other teachers (4)\par\pard\plain\hyphpar} {
Meeting to discuss winter holiday assembly (4)\par\pard\plain\hyphpar} {
Drive home (6)\par\pard\plain\hyphpar} {
Park with friend (4)\par\pard\plain\hyphpar} {\b
4:00} {
Drive home (7)\par\pard\plain\hyphpar} {
Pick up kids, watch TV (6)\par\pard\plain\hyphpar} {
Drive home (6)\par\pard\plain\hyphpar} {
Drive home (6)\par\pard\plain\hyphpar} {
Pick up kids, watch TV (6)\par\pard\plain\hyphpar} {\b
5:00} {
Pick up kids; make dinner (7)\par\pard\plain\hyphpar} {
Pick up kids; make dinner (6)\par\pard\plain\hyphpar} {
Pick up kids; make dinner (7)\par\pard\plain\hyphpar} {
Pick up kids; make dinner (6)\par\pard\plain\hyphpar} {
Pick up kids; make dinner (7)\par\pard\plain\hyphpar} {
Friends house for dinner with kids (4)\par\pard\plain\hyphpar} {
Parents came for pizza dinner (4)\par\pard\plain\hyphpar} {\b
6:00} {
Dinner with kids and husband (5)\par\pard\plain\hyphpar} {
Dinner alone with kids (7)\par\pard\plain\hyphpar} {
Dinner with kids and husband (4)\par\pard\plain\hyphpar} {
Dinner alone with kids (7)\par\pard\plain\hyphpar} {
Dinner at friend\u8217?s house (4)\par\pard\plain\hyphpar} {\b
7:00} {
Put kids to bed (7)\par\pard\plain\hyphpar} {
Husband puts kids to bed (4)\par\pard\plain\hyphpar} {
Put kids to bed with husband (5)\par\pard\plain\hyphpar} {
Put kids to bed (7)\par\pard\plain\hyphpar} {\b
8:00} {
Phone Genia (4)\par\pard\plain\hyphpar} {
TV with husband (4)\par\pard\plain\hyphpar} {
Play game with husband (4)\par\pard\plain\hyphpar} {
Chat with neighbor (4)\par\pard\plain\hyphpar} {
Put kids to bed with husband (4)\par\pard\plain\hyphpar} {
Put kids to bed with husband (4)\par\pard\plain\hyphpar} {
Put kids to bed (5)\par\pard\plain\hyphpar} {\b
9:00} {
Get ready for next day (8)\par\pard\plain\hyphpar} {
Get ready for next day (6)\par\pard\plain\hyphpar} {
Get ready for next day (5)\par\pard\plain\hyphpar} {
Get ready for next day (7)\par\pard\plain\hyphpar} {
Watch TV with husband\par\pard\plain\hyphpar} {
(3)\par\pard\plain\hyphpar} {
TV and games with husband (4)\par\pard\plain\hyphpar} {
Get ready for Monday (7)\par\pard\plain\hyphpar} {\b
10:00} {
Bed\par\pard\plain\hyphpar} {
Bed\par\pard\plain\hyphpar} {
Bed\par\pard\plain\hyphpar} {
Bed\par\pard\plain\hyphpar} {
Bed\par\pard\plain\hyphpar} {
Bed\par\pard\plain\hyphpar} {
Bed\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What Did Suzanne Learn?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before looking at Suzanne\u8217?s answers to Questions to Explore a Mood/Activity
Relationship, examine her week and see how you would answer the following
questions. After each question, I have included Treatment Implications, where I
encourage you to think about how you would use the answers to the questions in
guiding future therapy.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Do you see an activity/mood relationship? What activities help you feel better?
What activities or situations are connected to a low mood?} When Suzanne reviewed
her Daily Activities Schedule, it struck her that she was doing almost nothing fun.
She was surprised that when she was more active, her mood improved. In particular,
socializing with other people helped her feel better. Suzanne also noted that she
felt better when her husband was home and that she felt fairly good most of the
time at school. Suzanne had always thought that she felt better on the weekends
because she slept more and was away from school. After looking at her Daily
Activities Schedule, she wondered if she felt better because she was more active
and spending time with her husband, friends, and family.\par\pard\plain\hyphpar} {
Suzanne noted she was very depressed during her drives to and from school. She
explained that she spent most of the drive thinking about how horrible the morning
had been and how she wished she was back at her old school. Watching TV at night
with her kids and without her husband was also a low time. She also noted how much
she disliked getting ready for the next day and how hard she found the morning
routines.\par\pard\plain\hyphpar} {
{\i
Treatment implications:} How would you use Suzanne\u8217?s answers to the questions
above to reinforce the importance of adding pleasurable activities to her
life?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
What time periods are you most at risk for low mood?} Suzanne noted that mornings
were particularly bad. When she wakes up, she lies in bed and thinks about what a
bad mother she is and how her husband must be fed up with her. She has images of
him leaving her and of being alone and miserable. Suzanne had not realized how
depressed she was every morning and how hard it was for her to get the kids ready
on a tight time schedule. She also noted that the nights she was home alone with
the kids were particularly hard, and she was often
depressed.\par\pard\plain\hyphpar} {
{\i
Treatment implications:} What time period would you target first for adding
pleasurable activities?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Do you have any routines that help you maintain a positive mood?} Suzanne could not
see any routines that helped her feel better. She realized how different that was
from the previous year, when she had a good morning routine, walked to school, and
regularly saw friends. Her therapist noticed that she put her children to bed at a
regular and appropriate time. Suzanne and her husband also went to bed at a regular
time and early enough that they got eight hours of sleep. Her therapist thought
that these were real strengths and important routines.\par\pard\plain\hyphpar} {
{\i
Treatment implications:} How would you use this information in
therapy?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Is there anything you are avoiding?} Suzanne could not think of anything she was
avoiding. She mentioned that she did not go out with her friends much anymore, but
that was because she was so tired all of the time.\par\pard\plain\hyphpar} {
{\i
Treatment implications:} From a behavioral activation perspective, do you think she
is avoiding friends?\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: Plan Activities That Increase Positive
Moods}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After looking at her schedule, Suzanne agreed it would be a good idea to start a
mood-boosting plan. Her therapist explained that when you are depressed, doing
pleasurable activities is like taking medicine\u8212?you do it because you know it
will help, not because you want to. As a therapist, you need to encourage your
clients to follow their mood-boosting plan rather than their depressed
feelings.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Activities that Encourage Mastery and
Pleasure\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In behavioral activation you want to increase activities that provide your client
with a sense of mastery or competence and pleasure. However, such a general
statement does not provide much guidance for therapy. I suggest activities in the
following categories to help boost a client\u8217?s mood. It is important to
remember that this is a very individualized process, as activities that provide a
sense of mastery or competence and pleasure are different for every
individual.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Activities of daily living.} First and foremost, I want to be sure that my client
is accomplishing the basic business of living, including feeding herself, cleaning
her clothes, getting enough sleep, doing basic chores, and addressing
responsibilities to family, friends, or work such as taking care of children or
completing minimal work tasks. For example, Suzanne is often too frazzled to eat
breakfast and arrives at school starving. She often eats a chocolate bar or is
hungry all morning. It would be important for her therapist to help Suzanne make an
effort to eat breakfast.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Social contact.} People vary in how much and what kind of social contact they want,
but everyone needs some. When clients become depressed, they usually withdraw from
family and friends. It can be hard to re-engage. You want to start slowly with
small steps.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Exercise.} There is increasing evidence that regular exercise boosts your mood and
can counter depressed feelings (Trivedi et al., 2011). Exercising outdoors may lift
your mood even more than exercising indoors (Barton & Pretty, 2010). This makes
total sense to me; I am far happier walking outside on a beautiful spring day than
using the treadmill in the gym. In fact, I am even happier if I walk outside with a
good friend\u8230?and pick up a coffee (and maybe even a
cookie!).\par\pard\plain\hyphpar} {
Clients vary tremendously in how much exercise they want to do. Generally, any
increase in activity is good. With some clients I have started by encouraging them
to go outside for five minutes.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Pleasurable activities.} When clients are depressed it can be hard to find
activities that they find pleasurable. Here are some
suggestions.\par\pard\plain\hyphpar} {
Build on existing activities. Identify mood-boosting activities your client is
already doing and expand the activity. For example, if your client enjoyed talking
to a friend about the recent political situation, can she see this friend more
often? Can she contact another friend? Maybe the stimulation of discussing politics
increased her mood. Could she read the newspaper or listen to a
podcast?\par\pard\plain\hyphpar} {
Try activities your client used to enjoy before she was depressed. She may be
surprised at how much she still enjoys them. Just make sure your client
doesn\u8217?t expect to enjoy these activities as much as
before.\par\pard\plain\hyphpar} {
Use the Pleasurable Activities List, which you can download at
http://www.newharbinger.com/38501. The list can start clients thinking about
possible activities they don\u8217?t usually do but might like to
try.\par\pard\plain\hyphpar} {
Choose activities that lead to a sense of mastery or competence. People tend to
enjoy doing things they are good at. You also want to address any avoidant behavior
that is likely to create additional problems, such as avoiding completing a work
project or enrolling children in camp.\par\pard\plain\hyphpar} {
Encourage activities that are consistent with your client\u8217?s values and are
meaningful. For example, volunteering may be enjoyable because it is related to a
client\u8217?s values.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Practice being mindful.} I encourage my clients to gently put aside their critical
mind and allow themselves to concentrate on the activity in the moment. For
example, if a client is walking outside, I encourage her to notice the fresh air,
see the flowers, and feel the wind. Don\u8217?t tell your client to {\i
stop} thinking negative thoughts. When we tell ourselves to {\i
stop} thinking something, the thought bounces back stronger. Some of my clients
like the idea of taking a holiday from their negative
thoughts.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Guidelines for Effective Activity
Plans\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne wanted to start with an activity that would have an immediate effect on her
mornings, as she arrives at school already very depressed. She decided to try
listening to music and podcasts in the car on the way to work as a way to boost her
mood.\par\pard\plain\hyphpar} {
Suzanne also wanted to add telephoning Genia, her best friend; contacting Rita, her
friend from her previous school; and seeing her mother-in-law. She set a time when
she would call Rita and Genia. Rather than set a specific time to see her mother-
in-law, Suzanne wanted to see how her weekend developed. Sometimes it is helpful to
set specific times for activities, but sometimes clients want a more flexible
schedule. If we were flexible in terms of when an activity would get done, and my
client didn\u8217?t do the activity, the next week I try to set a specific time.
Suzanne was not optimistic that these would make much difference to her mood, but
she was willing to try.\par\pard\plain\hyphpar} {
Though these activities sound great, often clients don\u8217?t do the activities
they plan. Activities that follow the guidelines below have a better chance of
being done. You can find a Guidelines for an Effective Activity Plan handout at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Was the plan developed collaboratively with your client?\par\pard\plain\hyphpar} {
Is the plan specific and concrete?\par\pard\plain\hyphpar} {
Is the plan doable?\par\pard\plain\hyphpar} {
Is the plan naturally reinforcing?\par\pard\plain\hyphpar} {
Can the plan be part of a regular routine?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Developed collaboratively.} I start by asking, \u8220?What would be a good activity
to add to your week that would help you start to feel better?\u8221? Clients often
have very good suggestions; however, sometimes they need help thinking of good
activities. If you suggest the activity, try to involve your client in tailoring
your suggestions to her situation. The key is to develop the activity {\i
with} your client, not {\i
for} your client.\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist was careful that the activities were either
Suzanne\u8217?s idea or developed together.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Specific and concrete.} Use the same criteria we used to decide whether homework
was sufficiently specific and concrete: Is there a specific behavior your client is
going to do? How often will your client do the activity? Where and when will your
client do the activity?\par\pard\plain\hyphpar} {
Suzanne\u8217?s activities are specific and concrete. Suzanne wanted some
flexibility in planning to see her mother-in-law. That seemed fine to her
therapist. Not every activity has to be rigidly scheduled.\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Doable.} Start at your client\u8217?s current level of activity, not where she
would like to be, or where she used to be. Start small, so that your client can
experience success. I always ask if the activity \u8220?feels doable.\u8221? I also
check if my client has everything she needs to complete the activity. Ask if your
client foresees any obstacles and problem solve how to overcome
them.\par\pard\plain\hyphpar} {
When Suzanne\u8217?s therapist checked if the activities felt doable, Suzanne said
that listening to music while driving to and from school felt doable. However, the
idea of finding a podcast, downloading it, and then concentrating on someone
talking felt overwhelming. They decided she would focus on listening to
music.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Naturally reinforcing.} Choose activities that are intrinsically enjoyable or that
your client will receive positive reinforcement for doing. For example, fifteen
minutes of playing a board game with your child is more naturally reinforcing than
fifteen minutes of doing dishes. This is particularly important in the beginning,
when you want your client to experience positive results and stay
motivated.\par\pard\plain\hyphpar} {
The activities Suzanne and her therapist chose were naturally reinforcing. Suzanne
likes music and enjoys spending time with Rita, Genia, and her mother-in-
law.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Regular routine.} Many of my clients initially suggest planning a big, faraway
event, such as a vacation for next December. However, positive, routine activities
sustain a positive mood more than one-time, big events. Examples of routine
activities include a regular date with a friend or a weekly exercise class. A good
routine is like a good structure that maintains a good
mood.\par\pard\plain\hyphpar} {
The activities Suzanne and her therapist picked could become part of her
routine.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Develop Mood-Boosting Activities for
Anna\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Anna recently graduated from a community college program and has been living at
home with her parents for the past six months while she looks for work. She is
increasingly depressed. She completed a Daily Activities Schedule, which she
reviewed with her therapist, who wanted to add activities that would increase
pleasure or a sense of mastery or competence.\par\pard\plain\hyphpar} {
Anna noticed that her lowest mood is around 5:00 p.m. She is alone in the house,
and her parents do not get home for another two hours. She spends the time surfing
the web and ruminating. Her therapist tells her to stop ruminating and that surfing
the web is not helping her. Anna used to like running, but she has not run for over
a year. Her therapist suggests that Anna go back to running, starting with three
times a week for an hour. Anna likes the idea. Together they decide that Anna will
run Monday, Wednesday, and Friday for an hour at 5:00 p.m.\par\pard\plain\hyphpar}
{
Now try the following exercise:\par\pard\plain\hyphpar} {
{\ql
Evaluate her therapist\u8217?s interventions in relation to the Guidelines for an
Effective Activity Plan, and complete the following table. You can see my answers
in the appendix.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\b
Suggested Activity} {\b
Developed Collaboratively} {\b
Specific and Concrete} {\b
Doable} {\b
Naturally Reinforcing} {\b
Regular Routine} {
Run three times a week for an hour\par\pard\plain\hyphpar} {
{\ql
After you assess the current plan, design a more effective
one.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exercise 10.2\par\pard\plain\hyphpar} {
Practice assessing whether planned activities are likely to be
effective.\par\pard\plain\hyphpar} {
Video 10.2\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Monitor Your Client\u8217?s Mood Before and After
Activities\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If you ask your clients who are depressed if they will enjoy an activity, they will
probably say no. Clients who are depressed don\u8217?t enjoy activities as much as
they used to. However, clients tend to enjoy activities more than they think they
will. Often, starting the activity is the hardest part. Rating moods before and
after a pleasurable activity provides your client with important data on how adding
mood-boosting activities to her life affects her moods. I usually ask clients to
complete the Predict Your Mood worksheet, shown below. (You can download a blank
copy at http://www.newharbinger.com/38501.) After clients try an activity, if their
mood ratings improved, I ask what they learned. I want my clients to see that even
though they believe that they will not enjoy an activity, their predictions are not
necessarily accurate.\par\pard\plain\hyphpar} {
Let\u8217?s see how Suzanne completed the Predict Your Mood worksheet for two of
the activities she was going to try and how her therapist used the
worksheet.\par\pard\plain\hyphpar} {\b
{\qc
Predict Your Mood}} {\b
Date and Activity} {\b
How much will I enjoy this activity? {
(rate from 1\u8211?10; 1 = not at all; 10 = a lot)\par\pard\plain\hyphpar} } {\b
Mood Before Activity {
(rate from 1\u8211?10; 1 = very happy; 10 = very depressed)\par\pard\plain\hyphpar}
} {\b
How much did I enjoy this activity? {
(rate from 1\u8211?10; 1 = not at all; 10 = a lot)\par\pard\plain\hyphpar} } {\b
Mood After Activity {
(rate from 1\u8211?10; 1 = very happy; 10 = very depressed)\par\pard\plain\hyphpar}
} {
Monday: Listened to music in the car\par\pard\plain\hyphpar} {
3\par\pard\plain\hyphpar} {
7\par\pard\plain\hyphpar} {
5\par\pard\plain\hyphpar} {
5\par\pard\plain\hyphpar} {
Called friend, Rita\par\pard\plain\hyphpar} {
3\par\pard\plain\hyphpar} {
7\par\pard\plain\hyphpar} {
6\u8211?7\par\pard\plain\hyphpar} {
4\par\pard\plain\hyphpar} {
{\i
Therapist:} Looks like you did a great job of completing the Predict Your Mood
worksheet. When you look at your responses, what do you
notice?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, for one thing, in both cases my mood went
up.\par\pard\plain\hyphpar} {
{\i
Therapist:} Could you tell me more about that?\par\pard\plain\hyphpar} {
{\i
The therapist wants to expand and consolidate Suzanne\u8217?s awareness of the
activity/mood relationship. When her therapist asks for details, Suzanne remembers
the experience and it becomes more salient.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} Well, I actually enjoyed listening to music. I chose some really upbeat
old songs that I like. I think it distracted me from my bad
morning.\par\pard\plain\hyphpar} {
{\i
Therapist:} So listening to music was a good idea. What about talking to
Rita?\par\pard\plain\hyphpar} {
{\i
Suzanne:} That was also more enjoyable than I expected. We had a really good talk
and caught up. She told me she missed me, and all my friends have been asking about
me.\par\pard\plain\hyphpar} {
{\i
Her therapist uses a summary statement to consolidate the
experience.}\par\pard\plain\hyphpar} {
{\i
Therapist:} I hear Rita missed you, and your other friends also miss you. Hmm ({\i
therapist gently smiles}). Let\u8217?s look at the accuracy of your predictions.
What did you initially predict? ({\i
They look at the Predict Your Mood worksheet.}) {\i
Notice how Suzanne\u8217?s therapist is not giving Suzanne the answers but is
asking her for the information and letting her draw her own
conclusions.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} I predicted that I would not enjoy listening to music and calling Rita
very much. I gave both a 3.\par\pard\plain\hyphpar} {
{\i
Therapist:} And what actually happened?\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
laughing a bit}) Well, I actually enjoyed listening to music quite a bit; I gave it
a 5. And I enjoyed talking to Rita way more than I expected; I gave it a 6 to
7\u8212?it was great to catch up.\par\pard\plain\hyphpar} {
{\i
Therapist:} And what does that say about your predictions?\par\pard\plain\hyphpar}
{
{\i
Suzanne:} I guess I was wrong.\par\pard\plain\hyphpar} {
Video 10.3\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Overcoming Roadblocks: Your Client Did Not Try the Planned
Activity\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Despite your best efforts, your client will not always do the agreed-upon
activities. First, ask your client what got in the way. Sometimes it is a simple
answer. Next, ask what went though her mind when she thought of doing the activity.
Did she think it was too hard? Did she think it would not help, or did she have
other thoughts? I go back to the fundamental principle: Follow your mood-boosting
plan rather than your depressed feelings. Remember, for depression, activity is
like medicine. There is some evidence that clients who make a public commitment to
doing an activity are more likely to follow through (Locke & Latham, 2002). If my
client has supportive family members or friends, I encourage her to share her
plans.\par\pard\plain\hyphpar} {
I then problem solve how my client could do the activity the next week, or modify
the activity so that it is more doable. I make sure I remain encouraging and
optimistic and convey my belief that treatment will work.\par\pard\plain\hyphpar} {
The first week, Suzanne listened to music every day on the way to and from work.
However, at her next appointment, she told her therapist that she had stopped
listening to music, that this past week she was just \u8220?too down.\u8221? Her
therapist reviewed what Suzanne had learned from her Predict Your Mood worksheet.
She decided to try again. Suzanne laughed and said she would have to listen to
music \u8220?even with her depressed hat on.\u8221? Her therapist thought this was
a great image, and used it often in therapy.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
What If I Have Only a Few Sessions?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
The research on behavioral activation has generally evaluated a protocol that
involves sixteen weeks of treatment, and often two sessions a week for the first
eight weeks (see, for example, Dimidjian et al., 2006). However, many therapists
see clients for only a few sessions. If I have only a couple of sessions, I start
with exploring what my client is no longer doing that she used to enjoy. I then
explain the activity/mood relationship. Either in the first or second session, we
work together to identify specific pleasurable activities she could start doing. I
make sure the activities make sense given my client\u8217?s current level of
activity. I try to target a period of the day when her mood is particularly low. If
possible, I encourage social contact, as there is such strong evidence that it is a
mood booster.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Preventing Relapse\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
To maintain a positive mood, your client needs to have good routines. What is
involved in a good routine is different for every person, but it generally includes
a structure to the day, socializing, some exercise, activities that are meaningful
and connected to your client\u8217?s values, and some fun. I use the analogy of
creating a strong structure for a building. If the supporting beams are rotten and
weak, even if you have good drywall and a beautiful paint color, you will have an
unstable house.\par\pard\plain\hyphpar} {
I teach my clients that after therapy ends, if they start to get depressed again or
are going through a stressful time, they should examine their daily routine. I
encourage them to notice their worst times of the day and think about how they can
make those times better. I also encourage them to try adding even small mood-
boosting activities throughout the day.\par\pard\plain\hyphpar} {
I also use activity scheduling to prevent depression with clients who are going
through a particularly difficult time. If you have ever gone through a difficult
time, I am sure people have told you to \u8220?take care of yourself.\u8221? This
is good advice, but very general. I examine pleasurable activities my client has
stopped doing because of the stress and see if we can add them back into her life,
or add other activities that she enjoys. Together we make a specific plan that is
doable and can be part of my client\u8217?s routine.\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #5{\i
: Graded Task Assignments}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Graded task assignments are used primarily when your client is avoiding important
tasks that feel overwhelming. It is often a component of activity scheduling,
problem solving, and treating procrastination.\par\pard\plain\hyphpar} {
Graded task assignments involve looking at a whole activity and breaking it down
into smaller pieces, or chunks. These smaller chunks feel doable in a way that the
whole task does not. Your client starts with completing the first chunk and
progresses to additional chunks. It can be helpful to limit the amount of time a
client spends on each task to make it feel more manageable. By breaking tasks down
into specific chunks, your client can feel she is progressing as she completes each
task. It can also be helpful to set a specific time when the tasks will be
done.\par\pard\plain\hyphpar} {
For graded task assignments to be effective, the tasks have to be very specific and
concrete behaviors. For example, if a client is procrastinating over filing his
taxes, the first task might be spending twenty minutes reviewing the tax form, the
second task might be spending half an hour gathering income statements, and the
third task might be entering the income information he gathered on the tax form.
You don\u8217?t need to set out all the steps, but it is helpful to specify the
first few.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Use Graded Task
Assignments\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Below are examples of clients who are feeling overwhelmed. Their therapists want to
use graded task assignments as an intervention. Look at their first task and decide
if it is sufficiently specific and concrete, doable, and time-limited. I will do
the first one; you do the next two. You can find my answers in the
appendix.\par\pard\plain\hyphpar} {
{\ql
Cynthia\u8217?s boss asked her to be in charge of the site visit when members of
the head office come to inspect their unit. She is feeling very overwhelmed. She
and her therapist thought a good first task would be reorganizing the filing system
to make it more systematic.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Richard wanted to invite his whole family\u8212?about fifteen people\u8212?for
Thanksgiving dinner. He is feeling very overwhelmed. His therapist and he thought
that spending thirty minutes making a list of the food he wanted to cook would be a
good first task.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Alexandra wanted to find a part-time job. She is feeling very overwhelmed and tells
her therapist she does not know where to start. She and her therapist thought that
exploring her options for work would be a good first
step.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\b
Task} {\b
Specific and Concrete?} {\b
Doable?} {\b
Time-Limited and Specific Time for Task?} {\b
Cynthia: {
Reorganizing the filing system\par\pard\plain\hyphpar} } {
No. Not clear what the criteria are for a systematic filing system; first action is
not clear\par\pard\plain\hyphpar} {
Not sure who will do this and what exactly the person/people will do; hard to know
if it is doable\par\pard\plain\hyphpar} {
No time limit given; will Cynthia work for 10 minutes or the whole
day?\par\pard\plain\hyphpar} {
No specific time for starting the task\par\pard\plain\hyphpar} {\b
Richard: {
Make a list of food I want to cook\par\pard\plain\hyphpar} } {\b
Alexandra: {
Explore options for work\par\pard\plain\hyphpar} } {\s3 \afs28
{\b
Agenda Item #6{\i
: Increase Well-Being}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The goal of behavioral activation is to decrease depression; however, most clients
want to feel good, not just \u8220?less bad.\u8221? Positive psychology seeks to
identify factors that lead to a happy, engaged, and meaningful life. The focus is
on developing interventions that promote well-being rather than on alleviating
depression (Seligman, Steen, Park, & Peterson, 2005). Most CBT therapists I know
incorporate some of the following interventions into behavioral activation. Though
less robust than the research demonstrating the effectiveness of behavioral
activation, there is some evidence that these interventions may increase happiness
(Duckworth, Steen, & Seligman, 2005; Sin & Lyubomirsky,
2009).\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Activities That Increase Well-being\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Socialize with friends and family.} Social contact is the single factor most
consistently related to happiness (Leung, Kier, Fung, Fung, & Sproule, 2013; Parks,
Della Porta, Pierce, Zilca, & Lyubomirsky, 2012). Increasing positive social
interaction is also one of the most effective interventions to increase happiness
(Seligman et al., 2005).\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Keep a journal of positive experiences.} Write down one to three positive
experiences a day. I ask my clients to take a moment to remember the experience
fully and to see it occurring again in their mind\u8217?s
eye.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Savor the moment.} Make a conscious effort to enjoy a pleasant moment. It is
helpful to focus on one\u8217?s senses to stay present. For example, if a client
plans to take a walk, remind her to notice the flowers or the fresh
air.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Express gratitude.} Write one to three things to be grateful for every day. This is
also called \u8220?counting one\u8217?s blessings.\u8221? I ask my client to take a
moment to remember the blessing fully and to appreciate that it was in her life.
Another form of expressing gratitude involves consciously telling, or writing to,
others to say that you appreciate them or what they have
done.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Practice acts of kindness.} Consciously do a kind act you would not normally do.
This may involve consciously acting in a kind manner to someone you would not
normally be kind to, or doing an additional kind act to someone you would normally
be kind to. Ask your client to notice the other person\u8217?s reaction to her acts
of kindness. Often people smile, say thank you, or react in a positive manner,
which in turn will contribute to your client\u8217?s feeling happy. It\u8217?s nice
when someone smiles at you.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Think optimistically.} Identify a potentially stressful upcoming event and then
describe the best possible outcome. The more detailed the description, the more
emotionally engaged your client, and the more positive her mood. Encourage your
client to write the description and to form a detailed image in her mind of the
positive outcome.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to a Clinical
Example\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 10.1:} Raoul\u8217?s Cycle of Depression\par\pard\plain\hyphpar} {
{\b
Exercise 10.2:} Jamar Is Feeling Depressed\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Therapists often talk about the importance of self-care. The exercises below are an
opportunity for you to take some of the interventions from this chapter and,
instead of using them with your clients, apply them to your own life\u8212?and in
the process take care of yourself.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Add an Activity to Your Life That You
Enjoy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Identify a low time in your day. Think of a small, doable activity you could add
that you would enjoy or that provides a sense of competence. Use the Predict Your
Mood worksheet, available at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
When I did this exercise, I realized my husband and I used to have a favorite TV
series we watched Monday evenings. The series ended, and instead of watching TV
together, we each did our own chores. Watching a favorite show with my husband
versus doing chores\u8212?which do you think boosts my mood more? We picked a new
TV series to watch.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Increase Your
Happiness\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look over the list of interventions that increase
happiness:\par\pard\plain\hyphpar} {
{\ql
Socialize with friends and family.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\ql
Keep a journal of positive
experiences.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Savor the moment.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Express gratitude.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Practice acts of kindness.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Think optimistically.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Pick one intervention and try it for a week. Do the following: (1) rate your
overall mood before and after each time you practice the intervention; (2) rate
your overall mood at the beginning of the week and at the end of the
week.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
For this next assignment, pick a client whom you know well and who is
depressed.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3 Complete the Understand Your Depression Worksheet with a
Client Using the information you already know about your client, complete the
Understand Your Depression worksheet. How did this exercise help in understanding
your client? Remember, you can download the worksheet at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
{\qc
Homework Assignment #4 Try Behavioral
Activation\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Choose one of the following interventions, and try it with a client this coming
week. You can find the worksheets on the website.\par\pard\plain\hyphpar} {
{\ql
Introduce the Daily Activities Schedule and complete the first day in
session.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
With your client, pick an activity to add to his or her life that will promote
pleasure or mastery. Use the Predict Your Mood worksheet to evaluate whether the
activity had an effect on your client\u8217?s
mood.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under each agenda item.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} How does behavioral activation work?\par\pard\plain\hyphpar} {
What is the main idea in behavioral activation?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Help your clients understand their
depression.\par\pard\plain\hyphpar} {
How can you use the flower analogy to help your clients understand
depression?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Monitor your clients\u8217? daily
activities.\par\pard\plain\hyphpar} {
What is the purpose of the Daily Activities Schedule?\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Agenda Item #4:} Plan activities that increase positive
moods.\par\pard\plain\hyphpar} {
What are two types of activities you might want your clients to add to their lives
to help them feel better?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #5:} Graded task assignments.\par\pard\plain\hyphpar} {
What are graded task assignments?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #6:} Increase well-being.\par\pard\plain\hyphpar} {
What are two interventions that evidence indicates would increase well-
being?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\page } {\s1 \afs32
{\qc
Chapter 11\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Exposure Therapy\u8212?Clients Face Their
Fears\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the previous chapter we covered behavioral activation. Did you have a chance to
ask a client to monitor his or her daily activities? What about adding mood-
boosting activities to a client\u8217?s life, or your own? Did you try graded task
assignments to help a client break down an overwhelming
task?\par\pard\plain\hyphpar} {
If you did not have a chance to do the homework, think of a mood-boosting activity
you could add to your own life this week. Choose a small, doable activity. Schedule
it into your week. Then try it, and notice the effect on your
mood.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In this chapter we are going to learn how to use exposure therapy to help your
clients face situations they have been avoiding.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} What is exposure?\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Prepare to do exposure.\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Implement exposure.\par\pard\plain\hyphpar} {
{\b
Agenda Item #4:} Do postexposure debriefing.\par\pard\plain\hyphpar} {
{\b
Agenda Item #5:} Discuss relapse prevention.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
As with all interventions, to use exposure effectively, it\u8217?s critical to
begin with a clear understanding of how and why it works.\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #1{\i
: What Is Exposure?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exposure therapy is a treatment for anxiety based on gradual, planned, repeated
exposure to what we fear, starting with easy situations and progressing to more
difficult situations. It is based on the premise that the more we face our fears,
the less anxious we become and the more we learn we can
cope.\par\pard\plain\hyphpar} {
I want to start by telling you a story related to exposure from my own life. I am
at Disneyland. My kids want to ride the really big roller coaster. We wait in line.
I start to get anxious; the roller coaster looks pretty scary. I wonder, {\i
Are there lots of accidents?} It occurs to me that if planes can crash, roller
coasters can also crash. We get to the front of the line, I look at the roller
coaster, and I have one of the most intense anxiety reactions of my entire life. I
turn to my husband, with panic in my voice, and say, \u8220?I am absolutely not
going on that thing!\u8221?\par\pard\plain\hyphpar} {
If I do not get on the roller coaster, what will happen to my fear? Next time, will
I be more or less likely to go on a roller coaster? How will I feel about my
ability to cope with roller coasters? How will I feel about my ability to cope with
scary rides generally?\par\pard\plain\hyphpar} {
I am embarrassed to say, I turned around, made my way back through the long line,
and did not go on a roller coaster for many years. If I wanted to get over my fear
of roller coasters, what would you suggest? Here is my plan: Start with a really
small roller coaster, and ride it a few times until I am comfortable. Next, try a
slightly larger roller coaster. Once I am comfortable with this larger roller
coaster, try an even bigger one. Basically, my plan for overcoming my roller
coaster anxiety is exposure therapy.\par\pard\plain\hyphpar} {
Exposure therapy involves identifying the feared object or situation your client is
avoiding and making a plan to face the fear. Your client starts exposure with
objects or situations that elicit little fear and stays in the situation until
either habituation occurs or he learns that he can cope with the situation. Your
client then progressively faces situations that elicit more
fear.\par\pard\plain\hyphpar} {
{\b
{\ql
Exposure
Therapy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Overcome Anxiety = Face Your Fears\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
The Theory Behind Exposure\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
There are basically two theoretical models that explain exposure: habituation (Foa
& Kozak, 1986) and exposure as a behavioral experiment (Clark & Beck, 2010; Craske,
Treanor, Conway, Zbozinek, & Vervliet, 2014). My own sense is that both models are
accurate and reinforce each other.\par\pard\plain\hyphpar} {
Habituation is based on the observation that when an anxiety-provoking stimulus is
consistently paired with a neutral consequence, the fear response eventually
extinguishes. Let\u8217?s look at my roller coaster example. The roller coaster is
the anxiety-provoking stimulus. I think about riding a roller coaster and I get
anxious. If I frequently ride a roller coaster and consistently nothing bad
happens, riding the roller coaster becomes paired with a neutral consequence
(nothing bad happening). If I ride often enough, I will habituate to the roller
coaster and no longer be afraid. In our daily lives, exposure occurs naturally, all
the time. Can you remember a situation where you were initially anxious, but as you
got used to the situation, your anxiety diminished or disappeared? Maybe it was
your first night in a new house, driving on the highway, or jumping off a diving
board? By staying in the situation until you were no longer afraid, you were
naturally doing exposure therapy.\par\pard\plain\hyphpar} {
Exposure can also be understood as a behavioral experiment that tests your
client\u8217?s negative fear predictions (Clark & Beck, 2010; Craske et al., 2014).
If you remember, anxiety is about expecting bad things to happen. Anxiety is fueled
by your client\u8217?s overestimation of the danger of a situation and an
underestimation of his ability to cope with both the situation and his feelings of
anxiety. Clients often predict that something awful will happen or that their
anxiety will become intolerable. For example, I believe that if I go on a roller
coaster, there is a good chance that it will fall off the rails (this is an
exaggerated belief in the danger of roller coasters). I also believe that I will
become so anxious that I will be unable to stop screaming (this is an exaggerated
belief in my inability to cope).\par\pard\plain\hyphpar} {
The exposure task is an experiment that tests the accuracy of your client\u8217?s
negative predictions. By facing his fears, your client learns that the situation is
not dangerous and that he can cope with both the situation and his feelings of
anxiety. Your client will also learn that when feared situations are faced, over
time, anxiety diminishes. By the way, I did go on a roller coaster recently; it did
not crash, I did scream, and by the end of the ride I actually enjoyed
it!\par\pard\plain\hyphpar} {\s4 \afs23
{\b
How Avoiding Maintains Fears\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The key treatment component in exposure is to stop avoiding and to repeatedly
confront your fears until you are no longer afraid. When we avoid situations,
initially our anxiety decreases as we leave the feared situation. However, in the
long term our anxiety increases because when we avoid we never learn that the
situation is not dangerous and that we can cope. Over time, the number of
situations we fear expands. We are caught in a self-fulfilling cycle. Take a look
at Figure 11.1, the Cycle of Avoidance; you can see how avoiding leads to more
avoiding and more anxiety and becomes a vicious cycle.\par\pard\plain\hyphpar} {
{\i
{\ql

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Figure 11.1. Cycle of

avoidance.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Can exposure therapy help Suzanne?} At this point in therapy, Suzanne is doing
better. She has been listening to music on the way to work and arriving in a better
mood. She has also started socializing again with her old friends. As her mood has
lifted, her relationship with her husband has improved and her mornings with the
children have become less difficult. So generally things at home are going better.
However, she still dislikes her new school and hardly interacts with the other
teachers. Let\u8217?s see if exposure therapy can help her.\par\pard\plain\hyphpar}
{
First let\u8217?s check if the cycle of avoidance applies to Suzanne. Situations
that involve interacting with other teachers have become increasingly anxiety
provoking for Suzanne. She believes that the other teachers do not want to be her
friend and that even if she tried they would not like her (negative predictions).
She is coping by avoiding almost all social contact. Since she avoids social
contact, she never gets to check whether her negative predictions are accurate. In
addition, if Suzanne is avoiding the other teachers, how do you think they react to
her? Most likely they leave her alone, which reinforces her thought that they are
unfriendly. Suzanne is caught in a vicious cycle.\par\pard\plain\hyphpar} {
Exercise 11.1\par\pard\plain\hyphpar} {
Practice applying the cycle of avoidance.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Role of safety behaviors.} Anxiety is maintained not only by avoidance, but also by
what are called {\i
safety behaviors}; I think of them as \u8220?fake\u8221? safety behaviors. Fake
safety behaviors increase how safe you {\i
feel}; they do not actually decrease the danger of the situation. Real safety
behaviors, such as wearing a seat belt or looking both ways before crossing the
street, do in fact increase your safety. For example, if I was only willing to get
on a roller coaster with my daughter, having my daughter with me in the roller
coaster is a fake safety behavior\u8212?if the roller coaster crashes, will it help
if my daughter is with me? The problem with safety behaviors is as long as you use
them, you never learn that you can cope without them.\par\pard\plain\hyphpar} {
The best way I know to explain safety behaviors is to tell you one of my favorite
jokes. Harry is walking along the street, when he sees his old friend George.
George is shaking his head from side to side saying, \u8220?shush, shush.\u8221?
Harry goes up to George and says, \u8220?George, great to see you, but why are you
saying, \u8216?shush, shush\u8217??\u8221? George pauses. \u8220?I am keeping the
zebras away.\u8221? Harry is a bit stunned. \u8220?But George, there are {\i
no} zebras in America!\u8221? George smiles and says, \u8220?See, it works!\u8221?
So, why have I told you this silly joke? Saying \u8220?shush, shush\u8221? is
George\u8217?s safety behavior. Because he always says, \u8220?shush, shush,\u8221?
he never learns that if he stops, there still will be no zebras in
America.\par\pard\plain\hyphpar} {
It can take a while to learn to recognize safety behaviors. They generally fall
into four categories (Abramowitz, Deacon, & Whiteside,
2011):\par\pard\plain\hyphpar} {
{\b
Avoidance.} Never putting your hand up in class to avoid sounding stupid; avoiding
elevators because you fear they will fall.\par\pard\plain\hyphpar} {
{\b
Checking, reassurance seeking, and rehearsal.} Repeatedly checking if the door is
locked; spending hours searching the Internet for information on every small ache
and pain; mentally rehearsing what you say in casual conversations to be sure you
do not look silly.\par\pard\plain\hyphpar} {
{\b
Compulsive rituals.} Washing your hands for half an hour after you go to the
bathroom; needing to check twelve times that the windows are closed before you go
to bed.\par\pard\plain\hyphpar} {
{\b
Safety signals} (objects you carry or have near you to be sure you are safe, even
though the chances of needing them are slight or they could not really help).
Having another person or an animal with you; making sure your cell phone is in your
pocket with your finger on the emergency button in case you need to call for
assistance.\par\pard\plain\hyphpar} {
The problem with safety behaviors is that they interfere with everyday functioning,
and some safety behaviors actually make things worse. For example, a client is
worried about germs and washes his hands for half an hour every time he goes to the
washroom. This interferes with his ability to get his work and other tasks done,
and, if excessive, can cause irritation and skin problems. A client with social
anxiety is worried that she looks messy and awkward. While talking to a friend she
constantly checks her hair. The constant checking makes her hair look messy, annoys
and distracts her friend, and makes the client look
awkward.\par\pard\plain\hyphpar} {
During exposure therapy, clients give up their safety behaviors in a planned,
systematic manner so they can see that it is possible to cope without
them.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Identify your clients\u8217? safety behaviors.} Sometimes when clients describe
their anxiety, they include their safety behaviors. For example, when a client of
mine described her fear of flying, she mentioned that she always has two or three
glasses of wine before getting on the plane, to numb the anxiety. The wine is her
safety behavior; she believes she needs it to tolerate the anxiety of
flying.\par\pard\plain\hyphpar} {
You can also ask your clients directly about their safety behaviors. Next time one
of your clients is describing her anxiety, try using Questions to Assess Your
Client\u8217?s Safety Behaviors, available{\i
as a handout} at http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Are there things or situations you avoid because of your
anxiety?\par\pard\plain\hyphpar} {
Are there things you do to make yourself feel safe, or to be prepared in case of
danger, such as carrying things or being with certain
people?\par\pard\plain\hyphpar} {
Is there anything you do to make yourself feel comfortable in situations where you
feel anxious?\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Identify Suzanne\u8217?s Safety
Behaviors\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
See if you can help Suzanne identify her safety behaviors.\par\pard\plain\hyphpar}
{
{\ql
{\i
Therapist:} We\u8217?ve been talking about how anxious you feel around the other
teachers at work, and generally how hard it\u8217?s been for you to make friends. I
am wondering if there are things you do to make yourself feel more comfortable when
you are with them.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} Well, I guess I have just been trying to avoid everyone as much as
possible.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at three possible responses below and pick the one that will help Suzanne
identify her safety behaviors.\par\pard\plain\hyphpar} {
{\ql
What are some of your thoughts when you feel
anxious?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Is there anything you do to make yourself feel more comfortable in situations where
you have to interact with the other
teachers?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What are some of the worst situations for you, when you feel the most anxious? {\i
Response #2 is the best response to help Suzanne identify her safety behaviors.
Response #1 would be a good response if you wanted to explore her thoughts, but
that is not the task at the moment. Response #3 would be a good question if you
were starting to develop a hierarchy of situations, but not for identifying safety
behaviors.} \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Is there anything you do to make yourself feel more comfortable in
situations where you have to interact with the other
teachers?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} If I really have to interact with them I try very hard to say something
smart or funny. I will often rehearse a comment in my mind before saying
it.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} Anything else that you do to feel
comfortable?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} Well, I usually wait until someone asks me a question before speaking.
That way I don\u8217?t have to talk as
much.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne identified two safety behaviors. The first is to rehearse in her mind what
she will say before speaking. Do you think this will make her more or less fluent
as a speaker? More or less anxious? The second safety behavior is waiting to talk
until someone asks her a question. Is that likely to make her more or less engaged
in the conversation?\par\pard\plain\hyphpar} {
One of the difficulties with safety behaviors is that there can be a fine line
between coping and safety behaviors. For example, before cutting a piece of wood it
is good practice to double check your measurements; however, checking six times
becomes a safety behavior. Some safety behaviors are benign. For example, if my
daughter is happy to come with me on roller coasters, and I will only go on a
roller coaster if she is with me, this is a benign safety behavior. The assessment
issue is whether the behavior interferes with your client\u8217?s functioning or
causes her to avoid a situation that is not dangerous in
reality.\par\pard\plain\hyphpar} {
Exercise 11.2\par\pard\plain\hyphpar} {
Practice identifying safety behaviors.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Is Exposure Effective?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The answer is yes; in fact, exposure therapy is considered the most effective
treatment we have for fear and anxiety disorders (Clark & Beck, 2010). Exposure has
been used effectively for a variety of anxiety-related disorders, including panic
disorder, obsessive-compulsive disorder (OCD), social anxiety disorder, PTSD,
health anxiety, and specific phobias (Abramowitz et al., 2011; Clark & Beck, 2010).
Despite its effectiveness, exposure therapy does not work 100 percent of the time.
Some clients do not respond, and for some clients, after successful treatment,
fears return. Researchers are exploring factors that predict who will respond and
how to make exposure more effective.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Overview of Exposure Therapy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
There are three types of exposure: in vivo, virtual, and imaginal. In vivo exposure
involves exposure to what you actually fear. For example, if you fear needles,
exposure tasks would involve an actual needle. Virtual exposure involves using the
Internet, or another medium, to simulate the experience you fear. Often exposure to
fear of flying relies on virtual exposure. Imaginal exposure is when your client
uses his imagination to experience the situation. It is used primarily when in vivo
or virtual exposure is not feasible. Trauma work usually relies on imaginal
exposure to help clients face their trauma memories.\par\pard\plain\hyphpar} {
A word of caution: if your clients have poor impulse control, difficulty
controlling their substance use, or suicidal ideation or urges, or if they engage
in self-injurious behavior when under stress, it is generally not recommended to
use exposure until they are stabilized (Taylor, 2006).\par\pard\plain\hyphpar} {
Exposure therapy generally occurs in three phases: preparing to do exposure,
implementing exposure, and debriefing after exposure.\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #2{\i
: Prepare to Do Exposure}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before you actually implement exposure, you want to prepare your client by going
through the following steps:\par\pard\plain\hyphpar} {
Identify the fear your client wants to address.\par\pard\plain\hyphpar} {
Help your client understand how avoiding maintains his
fears.\par\pard\plain\hyphpar} {
Explain exposure.\par\pard\plain\hyphpar} {
Develop a hierarchy of feared objects or situations.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Identify the Fear Your Client Wants to
Address\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
You can use exposure in almost any situation where your client copes by avoiding.
Suzanne was socially anxious, and in particular she was anxious about interacting
with other teachers and colleagues at her new school. Below is a list of other
types of fears you could treat with exposure. Take a moment to think of your
clients and whether any of their fears fit into these
categories.\par\pard\plain\hyphpar} {
{\b
Fear of living creatures:} Clients may fear dogs, insects, or human beings who
remind them of an individual who hurt them.\par\pard\plain\hyphpar} {
{\b
Fear of inanimate objects:} Many clients fear germs, toilet seats, blood, or
needles.\par\pard\plain\hyphpar} {
{\b
Fear of specific situations:} Clients may fear going to the dentist, public
speaking, all kinds of social situations, and places that remind them of where they
were hurt.\par\pard\plain\hyphpar} {
{\b
Fear of specific thoughts, memories, or images:} Clients with PTSD fear remembering
the trauma; clients with OCD have specific thoughts that they try to
avoid.\par\pard\plain\hyphpar} {
{\b
Fear of specific physiological reactions:} Clients can fear the sensation of having
to cry, the physical symptoms related to going to the bathroom, or vomiting.
Individuals with panic disorder fear the physical symptoms of
anxiety.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Avoiding Is Not the Solution\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exposure is hard work. Unless clients understand the negative consequences of
avoiding, they will not be motivated to engage in exposure. Many clients are so
used to avoiding that they minimize the impact on their lives. I find the following
questions helpful:\par\pard\plain\hyphpar} {
How is avoiding a problem for you?\par\pard\plain\hyphpar} {
If you were not avoiding this situation, how would your life be different? What
would you be doing differently?\par\pard\plain\hyphpar} {
Why is it important to you to stop avoiding?\par\pard\plain\hyphpar} {
When Suzanne\u8217?s therapist explored the consequences of avoiding social contact
with the other teachers, Suzanne realized that she was lonely and felt
isolated.\par\pard\plain\hyphpar} {
You can also increase motivation to engage in exposure tasks by linking cessation
of avoiding to your client\u8217?s values. An important value for Suzanne is being
friendly and having good relationships with other people. When Suzanne saw the
connection between interacting with the other teachers and acting on her values,
her motivation to stop avoiding social contact at school increased. Especially if
clients are hesitant to engage in exposure, I examine how the exposure task is
related to values that are important to them.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Explain Exposure\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exposure involves asking clients to do what they fear most. They need to trust you.
I tell my clients that I will not ask them to do anything they do not want to do. I
fully explain exposure and communicate my optimism. I often say, \u8220?This will
initially be hard, but I think you will be glad you did
it.\u8221?\par\pard\plain\hyphpar} {
I model a matter-of-fact attitude toward anxiety: anxiety is unpleasant but not
dangerous. I let my clients know that anxiety will decrease as they avoid less and
face their fears. I cannot promise to eliminate anxiety, but I can help them learn
to cope with their anxiety. Below is how I generally explain exposure to my
clients, of course, tailoring the explanation to each client. You can find Explain
Exposure to Your Clients at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
We have been talking about how you avoid situations that make you anxious. We have
also talked about how avoiding these situations has not helped and has actually
caused you some difficulties. We have also talked about how being able to do the
activity you have been avoiding is related to some very important values for you.
(Only say this if you have been able to make the link to your client\u8217?s
values.)\par\pard\plain\hyphpar} {
I think exposure therapy would be a very helpful treatment for you. Exposure
therapy involves facing your fears. We will make a list of the situations that make
you anxious, starting with situations that are fairly easy and going up to
situations that are hard for you. We will start with the easiest and see if
together we can help you learn to cope with the situation.\par\pard\plain\hyphpar}
{
Once you have learned to cope with the easiest situation, we will progress to more
difficult ones. We will work together and go at whatever pace works for you. How
does that sound to you? (I pause to check if my client has any questions.) As you
face your fears, you will learn not to be afraid.\par\pard\plain\hyphpar} {
I want to talk a bit about anxiety. You will feel some anxiety as we do the
exposure tasks. But that\u8217?s okay; you need to feel some anxiety for exposure
to be effective. We\u8217?ll go slowly. Also, the more we face what makes us
anxious, the less anxious we feel. This means that the more you do the exposure
tasks, the less anxious you will feel and the more you will learn to manage your
anxiety.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Practice in Your Imagination: Explain Exposure
Therapy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I would like you to imagine explaining exposure therapy to a client. Before you
start, rate from 1 to 10 how comfortable you feel explaining exposure therapy. At
the end of the exercise rate your level of comfort again to see if it changed. Now,
let\u8217?s start this exercise.\par\pard\plain\hyphpar} {
Chose a client who you think would benefit from using exposure therapy. Try to get
a picture of him or her in your mind. Now, imagine yourself in your office with
your client. See your office; notice the sounds and smells in the room. Imagine
that you want to explain exposure therapy. Read over the words I suggested while
imagining yourself saying them. You can also use your own phrases. Really hear and
feel yourself explaining exposure therapy. Imagine explaining exposure therapy two
more times with the same client. Each time, imagine that your client responds
positively.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Develop a Fear Hierarchy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
A fear hierarchy is a list of situations that are increasingly anxiety provoking
for your client. Fear hierarchies usually include objects or situations that are
either increasingly similar in some way to the feared stimulus or involve
physically approaching the feared stimulus. For example, if a client is afraid of
spiders, a hierarchy of similar stimuli might include looking at a picture of a
spider, touching a plastic spider, looking at a real spider, and finally touching a
real spider. If a client was avoiding a street where she had been assaulted, a
hierarchy based on physically approaching the feared stimulus might start with
standing four blocks away, progressing to standing three blocks away, then two
blocks away, and eventually standing on the street where the assault
occurred.\par\pard\plain\hyphpar} {
I ask clients to give me examples of situations they find fairly easy, moderately
hard, and very difficult. Here is Suzanne\u8217?s list of anxiety-provoking
situations related to engaging in more social situations at school. Her therapist
asked her to list three situations for each level of
difficulty.\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Fairly easy:\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Saying hello to other teachers I pass in the hall when I arrive at
school\par\pard\plain\hyphpar} {
Saying hello to another teacher on the way to recess\par\pard\plain\hyphpar} {
Saying hello to the teacher next to me at assembly\par\pard\plain\hyphpar} {\s1
\afs32
{\qc
Moderately hard:\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Eating in the lunch room and sitting down at a table with the other
teachers\par\pard\plain\hyphpar} {
Starting a conversation with the teacher next to me at
assembly\par\pard\plain\hyphpar} {
Asking for help with a school-related task, for example how to use the copier or
where a resource is located\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
Very difficult:\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Asking another teacher to have lunch with me\par\pard\plain\hyphpar} {
Making a comment at a staff meeting\par\pard\plain\hyphpar} {
Volunteering to participate in the school play and letting the other teachers know
that I have experience\par\pard\plain\hyphpar} {
When creating fear hierarchies, clients rate the difficulty of the tasks and their
anxiety using subjective units of distress, or SUDS. A SUDS of 100 is the most
anxious your client has ever been, and a 0 is not at all anxious. Using SUDS
ratings helps clients keep track of their level of anxiety. You can download an
example of a fear hierarchy that I used with a client who was afraid to go into a
subway car after an accident. (See Sean\u8217?s Fear Hierarchy at
http://www.newharbinger.com/38501.)\par\pard\plain\hyphpar} {
Exercise 11.3\par\pard\plain\hyphpar} {
Practice developing a fear hierarchy.\par\pard\plain\hyphpar} {
Video 11.1\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #3{\i
: Implement Exposure}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
You are now ready to start doing exposure. This phase involves developing effective
exposure tasks, identifying your client\u8217?s negative predictions, and actually
doing exposure.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Develop Effective Exposure Tasks\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Exposure tasks should be sufficiently easy to ensure success, but sufficiently
difficult that your client learns that exposure works. I usually start with a task
that has a SUDS rating of around 30 to 40.\par\pard\plain\hyphpar} {
There are three criteria for good exposure tasks:\par\pard\plain\hyphpar} {
The task is sufficiently specific and concrete that it is clear to your client what
he will do as well as when and where he will do the task, and he will be able to
measure whether he was successful.\par\pard\plain\hyphpar} {
The task specifies an action your client will do, and not how he will
feel.\par\pard\plain\hyphpar} {
The task is under your client\u8217?s control.\par\pard\plain\hyphpar} {
Let\u8217?s look at a couple of tasks and see if they meet these
criteria.\par\pard\plain\hyphpar} {\b
Task} {\b
Specific and Concrete?} {\b
Action the Client Can Do?} {\b
In Client\u8217?s Control?} {\b
Conclusion: Is This an Effective Task?} {
Impress my boss with a good question\par\pard\plain\hyphpar} {
No, not clear what he will do, when or where\par\pard\plain\hyphpar} {
No, not clear what he will do\par\pard\plain\hyphpar} {
No, can\u8217?t control whether your boss will be impressed\par\pard\plain\hyphpar}
{
No\par\pard\plain\hyphpar} {
BETTER TASK: Ask one question at staff meeting.\par\pard\plain\hyphpar} {
Walk in the area where I was assaulted\par\pard\plain\hyphpar} {
Not sufficiently specific. Where will client walk? For how
long?\par\pard\plain\hyphpar} {
Yes, client can walk\par\pard\plain\hyphpar} {
Yes, in client\u8217?s control\par\pard\plain\hyphpar} {
No\par\pard\plain\hyphpar} {
BETTER TASK: Walk for fifteen minutes, three blocks from where the assault took
place.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Develop Effective Exposure
Tasks\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the two exposure tasks below and decide whether they are (1) sufficiently
specific, (2) an action that the client can do, and (3) under the client\u8217?s
control. If you do not think they are good tasks, develop a better task. You can
find my answers in the appendix.\par\pard\plain\hyphpar} {\b
Task} {\b
Specific and Concrete?} {\b
Action the Client Can Do?} {\b
In Client\u8217?s Control?} {\b
Conclusion: Is This an Effective Task?} {
Stand in front of the elevator in my building for 5 minutes every
day\par\pard\plain\hyphpar} {
Look at photos on the Internet of cars similar to the one that hit
me\par\pard\plain\hyphpar} {\s4 \afs23
{\b
First Exposure Task\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If possible, either conduct the first exposure task with your client in your office
or go with your client to the situation he fears; that way, you can be sure that
your client understands the process and you are there for support. In my many years
of doing exposure, I have played with plastic spiders and plastic knives; stood in
front of elevators, subways, and streetcars; and looked at photos of cars, knives,
and vomit. The Internet is fabulous for exposure therapy\u8212?you can find photos
and videos of almost anything!\par\pard\plain\hyphpar} {
For her first exposure task, Suzanne suggested starting with saying hello to
teachers she passed in the hall on the way to class in the morning. Her SUDS rating
was a 40. The task is specific and involves an action that Suzanne will do.
However, her therapist thought the task was not sufficiently specific, and it would
be hard to measure whether she was successful. They decided she would say hello to
at least three teachers, five days a week in the morning on the way to
class.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Move Up the Hierarchy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once a client has accomplished the first task on the hierarchy, we develop the next
step collaboratively. I ask my client what would be a good next task. Generally I
aim for tasks with SUDS of 40 or 50, though sometimes clients want to try a task
with a higher SUDS rating that they feel is doable. Traditionally, you would not
move up the hierarchy until your client\u8217?s anxiety in response to the present
task had decreased by 50 percent. However, recent research (Craske et al., 2014)
suggests that this may not be necessary. I usually move up the hierarchy when my
client indicates he is ready and can manage the next task.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Make Exposure Effective\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
There are some specific factors that can help make exposure tasks more
effective.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Tasks should be frequent and prolonged.} Do you think it would be more effective
for me to ride a roller coaster three times a day for five days in a row or once a
week for fifteen weeks? Probably three times a day for five days. What about a two-
minute ride or a fifteen-minute ride? It is important to repeat the exposure task a
number of times to consolidate the learning experience.\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Tasks should be varied and done in multiple contexts.} Do you think I should ride
one roller coaster at one amusement park over and over, or a variety of roller
coasters in a variety of amusement parks? Various roller coasters in various
amusement parks will be more effective.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Exposure should be mindful.} Clients often distract themselves during exposure to
avoid really facing their fears. When a client is mindful, he is present in the
moment (Teasdale, Williams, & Segal, 2014). Many of my clients say mantras, space
out, close their eyes, or pretend they are not there. I use various grounding
techniques to help clients stay present (Dobson & Josefowitz, 2015). For example, I
watch my client\u8217?s eyes to make sure he is looking at the anxiety-provoking
stimuli, and during exposure I ask him to label what he sees, to feel the ground
beneath his feet, and to notice any sounds. I also ask my client to notice and
label his feelings or thoughts without needing to change the thoughts or the
physical sensations.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Safety behaviors should be eliminated gradually over the course of exposure
therapy.} Eliminating safety behaviors is part of the fear hierarchy (Rachman,
Shafran, Radomsky, & Zysk, 2011). For example, a client kept a clonazepam in his
pants pocket as a safety signal whenever he had to fly. As he became more
comfortable with flying, he moved the clonazepam to a bag at his feet, then to a
bag in the overhead compartment, and finally, he flew without the clonazepam. For
my roller coaster exposure, I would start with riding roller coasters with my
daughter (being with my daughter is my safety behavior) and then go on them by
myself.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Between-session exposure tasks should be assigned.} It may not be possible to
conduct the exposure tasks with your client, as the anxiety-provoking stimuli may
not be easily accessible. This occurred in Suzanne\u8217?s case, where the exposure
task involved behavior that would take place at school. A lot of exposure work is
done between sessions, as homework. If we completed an exposure task during
therapy, my client\u8217?s homework is usually to do the same task on his own. This
enables the client to consolidate the work we did together.\par\pard\plain\hyphpar}
{
Video 11.2\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Identify Your Client\u8217?s Negative
Predictions\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Remember that you can think of exposure as a behavioral experiment. This means you
ask your client to predict what will happen during the exposure task. The exposure
task is a test to see if the prediction was accurate (Craske et al., 2014).
Remember, in chapter 6 we defined anxiety as expecting bad things to happen and we
used the following equation to understand anxiety.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

Figure 11.2. Understand

anxiety.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I want clients to predict what will occur and how they will react so that we can
examine the accuracy of their predictions and change the anxiety
equation.\par\pard\plain\hyphpar} {
Clients often have \u8220?realistic\u8221? predictions and \u8220?worst-case\u8221?
predictions. I ask for worst-case predictions because I want to test whether the
belief that is driving the anxiety is accurate. I look for two types of
predictions: first, what is my client\u8217?s worst fear, or what is he most
worried will occur? I then ask my client to rate the likelihood of his prediction
occurring. Second, I ask my client to predict his worst fear about how he will
react\u8212?about how he will feel, about the symptoms of these feelings, and about
what he will do. I then ask him to rate the likelihood of this occurring. It is
important that the predictions are sufficiently concrete that your client can judge
the accuracy of his predictions. Often a client\u8217?s prediction involves how he
or other people will feel. Try to specify the behaviors your client predicts will
happen as a consequence of the feelings; predictions that are behaviors are easier
to assess than predictions that involve feelings. For example, if a client predicts
he will be anxious, ask what he is afraid he will do because of his anxiety, or
what symptoms he is afraid he will have. For example, is he afraid he will talk too
quickly, or blush, or have a crushing feeling in his chest? If a client predicts
that a friend will be bored, ask how he will know that the friend is
bored.\par\pard\plain\hyphpar} {
Below are some examples of predictions.\par\pard\plain\hyphpar} {\b
Exposure Task} {\b
What are you most worried will occur? (Likelihood 0\u8211?100%)} {\b
How am I most worried I will react? (Likelihood 0\u8211?100%)} {
Stand in the subway station and watch a train\par\pard\plain\hyphpar} {
Someone will throw himself on the track and get killed. (80%
likely)\par\pard\plain\hyphpar} {
I will be so anxious that I will lose control and throw myself on the track. (50%
likely)\par\pard\plain\hyphpar} {
Look at a drawing of a cockroach for 15 minutes\par\pard\plain\hyphpar} {
I will find it too difficult to do. (50% likely)\par\pard\plain\hyphpar} {
I will be so anxious that I will run out of the room screaming or faint. (40%
likely)\par\pard\plain\hyphpar} {
Ask a question in class\par\pard\plain\hyphpar} {
The teacher will say it is a stupid question. (60% likely)\par\pard\plain\hyphpar}
{
I will freeze and stumble on my words. (95% likely)\par\pard\plain\hyphpar} {
Ask a friend to go to the movies\par\pard\plain\hyphpar} {
My friend will not want to go. (90% likely)\par\pard\plain\hyphpar} {
If my friend says no, I will be quiet on the phone and stay home feeling depressed
the rest of the day. (90% likely)\par\pard\plain\hyphpar} {
If we do go out, I will have nothing to say and will be quiet the whole evening.
(80% likely)\par\pard\plain\hyphpar} {
Below are some questions to help your clients identify their predictions. You can
download Questions to Identify Your Client\u8217?s Predictions During Exposure at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
I start with saying, \u8220?When you think of doing the exposure
task,\u8221?\par\pard\plain\hyphpar} {
What is your worst-case scenario?\par\pard\plain\hyphpar} {
What is your worst fear about what will happen, including how other people will
react?\par\pard\plain\hyphpar} {
What is your worst fear about how you will feel, including your worst fear of the
symptoms you will have?\par\pard\plain\hyphpar} {
What is your worst fear about what you will do or how you will
behave?\par\pard\plain\hyphpar} {
What do you imagine will happen? Do you see it happening? (Clients often have
images of what will occur during the exposure task.)\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist asked her what was the worst that could happen if she
said hello to the teachers in the hall. Suzanne responded that she would be anxious
and rated her anxiety a 5 out of 10. Her worst-case scenario was that she would say
hello in a hesitant and awkward manner and her face would turn bright red. She
rated the likelihood of being hesitant at 75 percent and turning bright red at 45
percent. Suzanne\u8217?s therapist then asked for her worst-case scenario of how
she expected the other teachers to react. Suzanne responded that the other teachers
will \u8220?ignore me and walk past me without saying anything.\u8221? She had a
clear image of two teachers in particular smirking at her. Suzanne now has a
concrete prediction that she can assess. Suzanne\u8217?s therapist wrote down her
worst-case predictions and her likelihood ratings so that they had a record to
refer back to.\par\pard\plain\hyphpar} {
In exposure therapy you do not verbally challenge your client\u8217?s predictions,
no matter how farfetched they may seem. You write them down and use the exposure
task as an experiment to test whether the prediction is
accurate.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #4{\i
: Do Postexposure Debriefing}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once your client has completed the exposure task, you want to discuss what he
learned.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Monitor Outcome of Exposure Tasks\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
It is helpful if your client can monitor, on a written worksheet, the outcome of
his exposure task and his anxiety level. This provides data that can be used to
challenge his predictions. I ask clients to monitor their anxiety every five
minutes if the task involves staying in a situation for a prolonged period of time,
or until their anxiety decreases. In Suzanne\u8217?s case, she recorded her anxiety
at the beginning and the end of the task. Below is Suzanne\u8217?s monitoring
worksheet.\par\pard\plain\hyphpar} {\b
Task: Say hello to three teachers a day on the way to class in the morning.} {\b
Number of Teachers Said Hello To} {\b
Anxiety (SUDS)} {\b
Start of Task} {\b
End of Task} {
Monday\par\pard\plain\hyphpar} {
3\par\pard\plain\hyphpar} {
40\par\pard\plain\hyphpar} {
40\par\pard\plain\hyphpar} {
Tuesday\par\pard\plain\hyphpar} {
3\par\pard\plain\hyphpar} {
40\par\pard\plain\hyphpar} {
35\par\pard\plain\hyphpar} {
Wednesday\par\pard\plain\hyphpar} {
4\par\pard\plain\hyphpar} {
30\par\pard\plain\hyphpar} {
25\par\pard\plain\hyphpar} {
Thursday\par\pard\plain\hyphpar} {
5\par\pard\plain\hyphpar} {
20\par\pard\plain\hyphpar} {
10\par\pard\plain\hyphpar} {
Friday\par\pard\plain\hyphpar} {
5\par\pard\plain\hyphpar} {
10\par\pard\plain\hyphpar} {
10\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Complete the Postexposure
Debriefing\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The next step is to debrief or explore what your clients learned from the exposure
task. I use the anxiety equation we looked at earlier as the conceptual model that
guides my debriefing. You want to review:\par\pard\plain\hyphpar} {
The accuracy of your client\u8217?s initial predictions\par\pard\plain\hyphpar} {
The danger or difficulty of the situation\par\pard\plain\hyphpar} {
Your client\u8217?s ability to cope with the task and with his
anxiety\par\pard\plain\hyphpar} {
What happens to anxiety with exposure\par\pard\plain\hyphpar} {
In debriefing, you are gathering evidence and looking for facts that will enable
your client to evaluate the accuracy of his prediction. I usually use the Are My
Predictions Accurate? worksheet, which you can download at
http://www.newharbinger.com/38501. Let\u8217?s look at how Suzanne and her
therapist completed the worksheet.\par\pard\plain\hyphpar} {\b
{\qc
Are My Predictions Accurate?}} {\b
Exposure Task} {\b
Your Predictions (Likelihood of Happening: 0\u8211?100)} {\b
Gather Data} {\b
What Did You Learn?} {
{\b
Specific?}\par\pard\plain\hyphpar} {
{\b
Action you will do?}\par\pard\plain\hyphpar} {
{\b
Under your control?}\par\pard\plain\hyphpar} {
{\b
Worst that could happen?}\par\pard\plain\hyphpar} {
{\b
Worst I could feel?}\par\pard\plain\hyphpar} {
{\b
Worst behavior I could do?}\par\pard\plain\hyphpar} {
{\b
Images of what will happen?}\par\pard\plain\hyphpar} {
{\b
What occurred?}\par\pard\plain\hyphpar} {
{\b
How did I feel?}\par\pard\plain\hyphpar} {
{\b
How did I behave?}\par\pard\plain\hyphpar} {
{\b
Was my image accurate?}\par\pard\plain\hyphpar} {
{\b
Was my prediction accurate? (Yes or No)}\par\pard\plain\hyphpar} {
{\b
How dangerous or difficult was the task?}\par\pard\plain\hyphpar} {
{\b
Could I cope with the task and my anxiety?}\par\pard\plain\hyphpar} {
{\b
What happened to my anxiety with exposure?}\par\pard\plain\hyphpar} {
Say hello to three teachers in hallway on the way to class, five days a
week.\par\pard\plain\hyphpar} {
Other teachers will ignore me, walk past me, and two teachers will smirk (90%
likely).\par\pard\plain\hyphpar} {
I will be anxious (8/10).\par\pard\plain\hyphpar} {
I will say hello in a hesitant and awkward manner (75% likely) and my face will get
bright red (45%).\par\pard\plain\hyphpar} {
Clear image of teacher smirking\par\pard\plain\hyphpar} {
Other teachers said hello and smiled. At least one teacher a day stopped and
chatted. No one smirked.\par\pard\plain\hyphpar} {
I felt anxious in the beginning, but by the end I was fine.\par\pard\plain\hyphpar}
{
I was not hesitant or awkward and my face was not red.\par\pard\plain\hyphpar} {
My image was not accurate.\par\pard\plain\hyphpar} {
No\par\pard\plain\hyphpar} {
The task was not very difficult, and became easier.\par\pard\plain\hyphpar} {
I could cope with my anxiety and still do the task.\par\pard\plain\hyphpar} {
The more I did the task, the easier it became.\par\pard\plain\hyphpar} {
You will use the data you collected to debrief and assess whether your
client\u8217?s predictions were accurate. I explore both my clients\u8217? ability
to stay in the anxiety-provoking situation and their ability to tolerate anxiety.
Anxious clients often use their anxiety as a sign that they need to avoid the
situation. I want my clients to learn that they don\u8217?t need to listen to their
anxiety but rather can make decisions about how they want to behave. You also want
to reinforce that anxiety will decrease with exposure.\par\pard\plain\hyphpar} {
Let\u8217?s look at how we might debrief with Suzanne. Notice how her therapist
helps Suzanne reach her own conclusions and then reinforces the
conclusions.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Was Suzanne\u8217?s prediction accurate in relation to the danger or difficulty of
the situation?}\par\pard\plain\hyphpar} {
{\i
Therapist:} Do you remember what you predicted would occur if you went up to
teachers and said hello?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Yes, I predicted that they would ignore me, and two teachers would
smirk.\par\pard\plain\hyphpar} {
{\i
Therapist:} And what occurred?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Almost all of them smiled and said hello back.\par\pard\plain\hyphpar} {
{\i
Therapist:} Hmmm, what do you make of that?\par\pard\plain\hyphpar} {
{\i
The therapist is asking Suzanne to reach her own
conclusions.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} I guess my prediction was wrong; people were
friendly.\par\pard\plain\hyphpar} {
{\i
Therapist:} ({\i
smiling}) Can you say that again?\par\pard\plain\hyphpar} {
{\i
The therapist is reinforcing Suzanne\u8217?s conclusions by asking Suzanne to
repeat her conclusion.}\par\pard\plain\hyphpar} {
{\i
Suzanne:} ({\i
laughing slightly}) People were friendly.\par\pard\plain\hyphpar} {
{\i
Therapist:} I think that is a very important observation.\par\pard\plain\hyphpar}
{\s5 \afs23
{\b
Was Suzanne able to cope with the task and her anxiety?}\par\pard\plain\hyphpar} {
{\i
Therapist:} When you started the task, on the first day, where was your
anxiety?\par\pard\plain\hyphpar} {
{\i
Suzanne:} It was at a 40.\par\pard\plain\hyphpar} {
{\i
Therapist:} And were you still able to say hello to the other teachers and
accomplish the task?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Yes, I was.\par\pard\plain\hyphpar} {
{\i
Therapist:} The fact that you were able to say hello to teachers even though you
were anxious, what does that tell you about needing to avoid if you are
anxious?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I guess I can still do things, even if I am anxious. It seems that just
because I am anxious, I don\u8217?t have to avoid.\par\pard\plain\hyphpar} {
{\qc
YOUR TURN! Continue Debriefing with
Suzanne\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Try using what you\u8217?ve learned to help Suzanne understand the effects of
exposure on her anxiety.\par\pard\plain\hyphpar} {
{\ql
{\i
Therapist:} I\u8217?m curious what happened to your anxiety over the course of the
week as you said hello to the other
teachers.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
{\i
Suzanne:} Well, it got easier and easier, and my anxiety went
down.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Look at the three responses below. How could you help Suzanne reach her own
conclusions about the effect of exposure on anxiety?\par\pard\plain\hyphpar} {
{\ql
I think that\u8217?s great. This is exactly what we would expect from exposure
therapy. The more you do a task, the easier it will be and the less anxious you
will be.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Given that your anxiety went down, what did you learn about what happens to anxiety
when you do exposure?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What helped you confront the task? {\i
Response #2 is the best response to help Suzanne reach her own conclusions.
Response #1 would be a good response after Suzanne had reached her own conclusions
in order to reinforce them. Response #3 would be a good question if you wanted to
understand how Suzanne had motivated herself.}
\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Consolidate What Your Client
Learned\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After you have debriefed the exposure task, you want to help your client
consolidate what he learned. I use three approaches: developing a more accurate
prediction, imaginal rehearsal, and review.\par\pard\plain\hyphpar} {
To develop a more accurate prediction, I refer to my client\u8217?s original
prediction and then ask what would be a more accurate prediction, given what
occurred during the exposure task. I encourage my client to write down his new
prediction. Next I use imaginal rehearsal to review the outcome of the exposure
task and the new prediction. In Suzanne\u8217?s case her new prediction was that
the teachers would be friendly when she said hello. Her therapist asked her to
create an image and see the various teachers smiling at her and saying hello. Her
therapist then asked Suzanne to review this memory three times a day as part of her
homework.\par\pard\plain\hyphpar} {
Video 11.3\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Agenda Item #5{\i
: Discuss Relapse Prevention}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
One of the difficulties with exposure treatment is that fears can return after
treatment (Craske & Mystkowski, 2006). I explain to clients that exposure is
similar to exercise. Even if you exercise every day and get into really good shape,
you have to keep exercising or you will not stay in shape. Exposure is similar; you
have to keep practicing for the benefits to last. At the end of therapy, I explain
the principles of relapse prevention:\par\pard\plain\hyphpar} {
Continue to face situations you previously avoided. Remember: anxiety is not a
reason to avoid.\par\pard\plain\hyphpar} {
The more you face your fears, the easier it becomes. Remember: anxiety is normal
and exposure works.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before continuing with the next chapter, take some time to try the
homework.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to a Clinical
Example\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Complete the following exercises.\par\pard\plain\hyphpar} {
{\qc
\u9660?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\b
Exercise 11.1:} Suzanne Avoids the Other Teachers\par\pard\plain\hyphpar} {
{\b
Exercise 11.2:} Maia Was Attacked\par\pard\plain\hyphpar} {
{\b
Exercise 11.3:} Aiden Uses a Knife Again\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After you have completed the homework assignments below, pause and take a moment to
think about what you learned about yourself. Then, think about the implications of
your experience with these exercises for your therapy with
clients.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #1 Identify Your Own Safety
Behaviors\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Think of a situation in the past month where you were anxious. What did you do to
make yourself more comfortable? For example, did you carry an object or be with a
certain person? Did any of your strategies involve avoidance, checking, reassurance
and rehearsal, compulsive rituals, or safety signals? What was the consequence of
your safety behavior?\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #2 Develop a Fear
Hierarchy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Try to think of any situations that you have been avoiding. It could be a social
situation or a specific fear.\par\pard\plain\hyphpar} {
{\ql
Develop a fear hierarchy for your problem. Think of situations that are fairly
easy, moderately hard, and very
difficult.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Choose a first task; make sure it is concrete, an action that you can perform, and
in your control.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Make a prediction of what will occur if you do the first
task.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Now, it is up to you to try the
task.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
For this next assignment, think of a client whom you are currently working with and
who suffers from anxiety.\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #3 Identify Your Client\u8217?s Safety
Behaviors\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Once you have chosen a client, complete the following
steps.\par\pard\plain\hyphpar} {
{\ql
Ask one or two questions from the handout Questions to Assess Your Client\u8217?s
Safety Behaviors. \u8226? Are there things or situations you avoid because of your
anxiety? \u8226? Are there things you do to make yourself feel safe or to be
prepared in case of danger, such as carry things or be with certain people? \u8226?
Is there anything you do to make yourself feel comfortable in situations where you
feel anxious? \par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
If your client is avoiding, ask how avoiding is a problem in his
life.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Once you have identified your client\u8217?s safety behavior, explain safety
behaviors and explore the consequences of the client\u8217?s safety
behavior.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\qc
Homework Assignment #4 Develop a Fear
Hierarchy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Think of a client who is avoiding and who you think would benefit from facing his
or her fears.\par\pard\plain\hyphpar} {
{\ql
Develop a fear hierarchy with this client. Identify situations that are fairly
easy, moderately hard, and very
difficult.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Identify a first exposure task. Make sure it is concrete, an action your client
will take, and under his or her
control.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Ask your client to predict what he or she thinks will
occur.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Steps 1 through 3 may be enough for your first experience with developing a
hierarchy. However, if you feel you are ready, and it would be helpful to your
client, ask your client to try this first
task.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
Check whether your client\u8217?s predictions were
accurate.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Let\u8217?s
Review\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Answer the questions under each agenda item.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #1:} What is exposure?\par\pard\plain\hyphpar} {
What is the central theory of exposure?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #2:} Prepare to do exposure.\par\pard\plain\hyphpar} {
What two things do you want to do before you start
exposure?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #3:} Implement exposure.\par\pard\plain\hyphpar} {
What are three factors that make for an effective exposure
task?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda Item #4:} Do postexposure debriefing.\par\pard\plain\hyphpar} {
Why is it important to have a postexposure debriefing?\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Agenda Item #5:} Discuss relapse prevention.\par\pard\plain\hyphpar} {
What are two important things to tell your clients about relapse
prevention?\par\pard\plain\hyphpar} {
{\b
{\qc
What Was Important to
You?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or concept(s) would you like to
remember?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What idea(s) or skill(s) would you like to apply to your own
life?\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
{\ql
What would you like to try this coming week with a client? (Choose a specific
client.)\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page
} {\s1 \afs32
{\qc
Part 4\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s1 \afs32
{\qc
CBT in Action\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\par\pard\hyphpar }
{\page } {\s1 \afs32
{\qc
Chapter 12\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Suzanne\u8217?s and Raoul\u8217?s
Therapy\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the last chapter we covered exposure therapy. Did you notice your own or one of
your client\u8217?s safety behaviors? Did you identify any clients who you thought
might benefit from exposure? What about explaining exposure or developing a fear
hierarchy?\par\pard\plain\hyphpar} {
If you did not have a chance to do the homework, think of a situation you are
currently avoiding, and try to develop a plan to face your
fear.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Set the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Although Suzanne and Raoul are composites of a number of clients, they are based on
my clinical experience. I want to give you a sense of how their therapy unfolded
and how I used the various interventions we covered in the book. The preceding
chapters were too short to cover everything we did in Suzanne\u8217?s and
Raoul\u8217?s therapy, so I\u8217?ve included some of the additional interventions
in this final chapter. However, I want to start with discussing core
beliefs.\par\pard\plain\hyphpar} {
{\b
Agenda Item #1:} Identify Suzanne\u8217?s and Raoul\u8217?s core
beliefs.\par\pard\plain\hyphpar} {
{\b
Agenda Item #2:} Suzanne\u8217?s therapy\par\pard\plain\hyphpar} {
{\b
Agenda Item #3:} Raoul\u8217?s therapy\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Work the
Agenda\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Up to now we have focused on automatic thoughts and behavior. I want to look at how
we can use core beliefs to understand Suzanne and Raoul.\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #1{\i
: Identify Suzanne\u8217?s and Raoul\u8217?s Core
Beliefs}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Automatic thoughts are situation specific and are just below consciousness. This
means that it is fairly easy to teach people to notice their automatic thoughts and
then to evaluate and modify them. Core beliefs are stable, deeply held beliefs that
affect how you feel and behave in many different situations. It is much harder to
identify and modify core beliefs than automatic thoughts. Most CBT focuses on
modifying automatic thoughts and behaviors.\par\pard\plain\hyphpar} {
In chapter 1 we talked about how we all have core beliefs about the self, others,
and the world. Core beliefs can be negative or positive. Examples of core beliefs
about one\u8217?s self might be {\i
I am lovable} or {\i
I am incapable}; examples of core beliefs about others might be {\i
People do not care about me} or {\i
People will try to help me}; and examples of core beliefs about the world might be
{\i
The future will be good} or {\i
The world is unpredictable}.\par\pard\plain\hyphpar} {
I want to go over three approaches for identifying core beliefs: (1) noticing
patterns in problematic situations and automatic thoughts, (2) identifying themes
in a client\u8217?s psychosocial history, and (3) the downward arrow
technique.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Noticing Patterns in Automatic
Thoughts\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Core beliefs are basically an information-processing filter; they influence what
you notice, the meaning you give to events, and what you remember. You can think of
core beliefs as large magnets that go around attracting and picking up information
that confirms the core belief. People either don\u8217?t notice information that
contradicts their core beliefs or minimize the information. For example, before
Suzanne started therapy, how would you expect her to react if a teacher came up to
her at recess and said hello? Would she think (A) {\i
I am starting to make friends; this teacher likes me} or (B) {\i
This is a fluke; I am sure that she won\u8217?t talk to me tomorrow}? I would guess
B. What about when she gets home at night and her husband asks her about her day?
Will she remember the teacher who came up to her, or will she remember that a lot
of the time she was alone at recess? I would guess she will remember that she was
alone. We can look for patterns in the types of situations that are stressful for
our clients and patterns in the types of automatic thoughts that cause our
clients\u8217? distress. Once we identify these patterns, we can start to
hypothesize about our clients\u8217? core beliefs.\par\pard\plain\hyphpar} {
I find it helpful to think of core beliefs about the self as falling into three
areas: (1) judgments about how competent or incompetent one is; this includes
beliefs related to being helpless, unintelligent, or incapable; (2) judgments about
how lovable or unlovable one is; this includes beliefs related to being
unattractive, unlikable, vulnerable, or different; and (3) judgments about how
basically worthy or worthless one is; this involves a very deep sense of being
basically an okay person or a deep sense of something being horribly wrong with
you. Core beliefs related to worthlessness often are the result of severe childhood
abuse. Noticing which category is the most triggering for your client can help you
focus on situations and thoughts that are central to your client\u8217?s distress.
When I look for patterns in my client\u8217?s automatic thoughts, I ask myself
which of the three categories seems the most relevant to my
client.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Suzanne\u8217?s core beliefs.} Let\u8217?s think about Suzanne. The major stressors
in her life have been a new school, which has disrupted her friendships and family
relationships; her best friend moving away; and her mother-in-law\u8217?s illness.
From what you know, would you expect her core beliefs to center on competence,
lovability, or worthlessness? It seems to me that the types of situations that
caused her stress were social.\par\pard\plain\hyphpar} {
Suzanne\u8217?s negative thoughts frequently center on not being liked or feeling
accepted. At both the barbecue and recess, her thoughts are related to the other
teachers not liking her or not wanting to be her friend. When her husband
didn\u8217?t give their son a bath, one of her thoughts was {\i
He doesn\u8217?t care about me}. During the exposure tasks, she didn\u8217?t expect
people to react positively to her friendly overtures.\par\pard\plain\hyphpar} {
What would you hypothesize were Suzanne\u8217?s core beliefs? When we examine the
type of situations that she found stressful and the pattern to her automatic
thoughts, I would hypothesize that these were her core
beliefs:\par\pard\plain\hyphpar} {
Core belief about self: I am not lovable.\par\pard\plain\hyphpar} {
Core belief about others: People will not like me and will not be
friendly.\par\pard\plain\hyphpar} {
Core belief about the world: The world is not safe.\par\pard\plain\hyphpar} {\s5
\afs23
{\b
Raoul\u8217?s core beliefs.} From what you know of Raoul, what would you guess were
his core beliefs? Being passed over for a promotion triggered his difficulties. I
would hypothesize that being successful is very important to Raoul. This leads me
to hypothesize that his core beliefs would center more on being competent than on
being lovable. I wondered if one of his core beliefs about self was {\i
I am only valuable if I achieve}, or maybe, {\i
If I fail, this is proof that I am stupid}. I also wondered if there was an
underlying core belief: {\i
I am incompetent}.\par\pard\plain\hyphpar} {
What about his core beliefs about others? I noticed that he doesn\u8217?t trust his
boss or colleagues to be supportive and helpful. However, he has a good
relationship with his wife and children. I wondered if one of his core beliefs
about others was {\i
You can\u8217?t trust people outside the family}. What about his core belief about
the world? Raoul was very upset about being passed over and felt that it was
unfair. I would wonder if he sees the world as unfair, and not just this one
experience. These would all be initial hypotheses; I would want to know more
information. Given my hypothesis of Raoul\u8217?s core beliefs, what kinds of
information do you think he might ignore about himself and
others?\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Clinical implications.} Once I have a hypothesis of my client\u8217?s core beliefs,
I am particularly attuned to how she dismisses or minimizes information that would
challenge her core belief. Let\u8217?s take an example. Suzanne tells her therapist
that one of the teachers asked her if she would volunteer to be on the committee
that was responsible for the winter holiday assembly. Will Suzanne think: (A) {\i
This is a good start to being more part of the school; I will get to know some of
the teachers better} or (B) {\i
I am sure I will not fit in}? I would guess B. As her therapist, I am especially
attuned to how she interprets social situations that might challenge her core
belief. I pay particular attention to gathering facts about the situation because I
know that Suzanne will minimize indications that others are friendly or like her. I
also know that Suzanne will have a hard time remembering examples that contradict
her core belief and that reviewing them will be very
important.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Identify Themes in a Client\u8217?s Psychosocial
History\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Core beliefs generally develop during childhood and are a consequence of
experiences in one\u8217?s family and the larger social world, though experiences
in later life can also influence core beliefs. I know of many shy, socially anxious
children and teens who developed into outgoing young adults after positive
experiences at camp, school, work, or college. These young people had a series of
positive social experiences that changed their core belief from {\i
Others will not like me} to {\i
Others will respond positively to me}. Traumatic experiences can also change core
beliefs. Subsequent to trauma, many people start to believe that the world is
dangerous, and if the trauma involved another person, their belief about others
becomes {\i
Other people can hurt you}. Often individuals who experience trauma also develop
core beliefs about the self, such as {\i
I am vulnerable or weak} or {\i
I am somehow damaged after the trauma}.\par\pard\plain\hyphpar} {
Remember in chapter 2 we talked about listening for the meaning of events when you
take a psychosocial history? When I take a history, I am listening for the core
messages my client learned about herself, others, and the world. Let\u8217?s look
at Suzanne\u8217?s and Raoul\u8217?s psychosocial history and see if we can
hypothesize what their core beliefs might be.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Suzanne\u8217?s history.} Suzanne was the eldest of four siblings. Her parents were
hard-working people who had enough money for the family\u8217?s needs, but there
was no extra. Suzanne described her parents as cold and strict. They had very high
standards for Suzanne, expecting her to do well at school and help take care of the
household and her three younger brothers. They made it clear that they preferred
boys, and she worried about pleasing them and being good enough. Suzanne did well
in school, the one area where her mother did not criticize her; otherwise, her
mother was very critical of her, which Suzanne thought was \u8220?for her own
good.\u8221? Her mother was also a very anxious woman who had few friends and
worried about whether she would fit in and whether people would like
her.\par\pard\plain\hyphpar} {
Suzanne described herself as a \u8220?good kid\u8221? with no problems. She had
very few friends at school, which she attributed to often being needed at home and
having no time to be with her peers. She did make some friends in high school, but
after she refused to let her house be used for a drinking party, most of the class
turned against her. She graduated from high school and attended a teacher\u8217?s
college. She was the first person in her family to go to college and was very proud
of her accomplishment. She is married to her first boyfriend, who was her high
school sweetheart.\par\pard\plain\hyphpar} {
If you remember, from examining the types of situations that she found stressful
and the pattern to her automatic thoughts, I had hypothesized that her core beliefs
were {\i
I am unlovable}, {\i
People will not like me and will not be friendly}, and {\i
The world is not safe}. Her psychosocial history is consistent with the development
of these core beliefs.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Raoul\u8217?s history.} Raoul\u8217?s family had immigrated to the United States
when he was two years old. He lived close to his aunt and uncle and grew up in a
large extended family. Raoul described having a happy childhood until age eight
when his father died, after which his life became more difficult. His mother had
two jobs, and he was often home alone. He continued to see his extended family, but
he missed his father. In school he felt that the teachers did not respect him or
his family, who had less money than many of the other families. He also had a
slight learning disability, which was not diagnosed until high school. Though he
tried hard at school, his teachers often complained to his mother that he was not
working up to his potential. He remembers being humiliated at school when he could
not answer questions or did poorly on a test. The one area where he did well was
math. He was also on the football team, which he loved. After high school, his
uncle paid for his college education and he obtained a degree in accounting. He met
his wife after college, and they have had a good marriage.\par\pard\plain\hyphpar}
{
Raoul\u8217?s psychosocial history supports the development of the core beliefs we
wondered about earlier. We hypothesized that one of his core beliefs about self was
{\i
I am only valuable if I achieve}, or maybe, {\i
If I fail, this is proof that I am stupid.} We wondered if there was an underlying
core belief: {\i
I am incompetent}. His history of not doing well in school and having a learning
disability would support the hypothesis that one of his core beliefs about self was
{\i
I am incompetent}. His psychosocial history also supports his core beliefs about
others and the world that we identified earlier: {\i
You can\u8217?t trust people outside the family} and {\i
The world is unfair}. Given my hypotheses of Raoul\u8217?s core beliefs, what kinds
of information do you think he might ignore about himself and
others?\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Downward Arrow Technique\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
The downward arrow technique involves starting with an automatic thought and
tracing it back to the core belief. Because you are accessing very deep beliefs
about the self, others, and the world, you don\u8217?t want to use this approach
until you have worked with your client for a while, have established a solid
relationship, and know that she is strong enough to find this kind of work helpful.
As in all therapy, it is important to use a gentle tone and caring
curiosity.\par\pard\plain\hyphpar} {
The therapist starts with the automatic thought, usually a thought that is (1) a
negative prediction, such as {\i
My new date will not call back}; (2) a fact, such as {\i
I did not get the promotion}; (3) a \u8220?what if\u8221? statement, such as {\i
What if my mother gets angry at me?;} (4) a prediction of the future, such as {\i
No one will talk to me at the party}; or (5) a thought about self, such as {\i
I did not study hard enough to get good grades}. The therapist then asks, \u8220?If
the thought was true, what would that mean?\u8221? Additionally, I sometimes
ask, \u8220?What would that mean about you?\u8221? or, \u8220?If that was true, how
would that be a problem for you?\u8221?\par\pard\plain\hyphpar} {
Let\u8217?s look at a brief example. One of Suzanne\u8217?s thoughts at the
barbecue was {\i
I will stand there looking awkward}. Let\u8217?s see what happens when we use the
downward arrow technique. Look at figure 12.1. Suzanne\u8217?s therapist starts
with the thought {\i
I will stand there looking awkward}, which is a prediction about the future. The
therapist then asks what it would mean if that was true. After all, you could think
that if I stand there looking awkward, if the principal is a good host, she will
come up and talk to me. Suzanne\u8217?s therapist uses the downward arrow technique
to discover Suzanne\u8217?s core belief: {\i
I am not a likable person}. You can see from the example how this technique can
lead to important but painful cognitions and how vital it is to have a good
therapeutic relationship before using this technique.\par\pard\plain\hyphpar} {
{\i
Suzanne:} I will stand there looking awkward.\par\pard\plain\hyphpar} {
{\i
Therapist:} If that was true, how would that be a problem for
you?\par\pard\plain\hyphpar} {
{\i
Suzanne:} No one would talk to me.\par\pard\plain\hyphpar} {
{\i
Therapist:} And if that was true, what would that mean?\par\pard\plain\hyphpar} {
{\i
Suzanne:} I guess it would mean that none of the teachers likes
me.\par\pard\plain\hyphpar} {
{\i
Therapist:} (gently) And if it was true that none of the teachers liked you, what
would that mean about you?\par\pard\plain\hyphpar} {
{\i
Suzanne:} (softly) That I am not a very likable person ({\i
looking sad}).\par\pard\plain\hyphpar} {
{\i
Therapist:} And do you think that sometimes?\par\pard\plain\hyphpar} {
{\i
Suzanne:} Yes, often.\par\pard\plain\hyphpar} {
{\i
{\ql
Figure 12.1. Suzanne\u8217?s therapist uses the downward arrow
technique.\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Agenda Item #2{\i
: Suzanne\u8217?s Therapy}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
This book has roughly followed the order of Suzanne\u8217?s therapy. After
completing the assessment and setting goals, we started with thought records, moved
on to problem solving and coping thoughts, then worked on behavioral activation,
and lastly I introduced exposure therapy.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Sessions 1 and 2\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
In the first two sessions, I focused on understanding Suzanne\u8217?s problems,
taking a history, and identifying her goals. Suzanne was easy to connect with, and
from the first session we started to form a good
relationship.\par\pard\plain\hyphpar} {
From the very beginning, I noticed Suzanne\u8217?s strengths and started thinking
about which interventions might make sense. I also started to hypothesize about her
core beliefs.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Session 3\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
If one of my clients is suffering from depression, I usually start with behavioral
activation. However, at the start of session 3, Suzanne\u8217?s main agenda item
was the barbecue she had just been invited to. I had to decide whether to focus on
the barbecue or introduce behavioral activation. Although Suzanne was depressed,
she was in the moderate range. I was concerned that if we did not start with the
barbecue, she might think that therapy would not address the problems that she
identified and that our relationship would be negatively affected. If she had been
significantly depressed, I might have started with behavioral activation, as the
evidence is clear that for severely depressed clients, behavioral activation is an
essential component of treatment.\par\pard\plain\hyphpar} {
We started by exploring Suzanne\u8217?s reaction to the barbecue using the four-
factor model, and we completed the Understand Your Reaction worksheet. Suzanne
found it helpful to see the links between her thoughts and feelings, and it started
making sense to her that she found the decision about the barbecue so difficult.
Her homework was to use the Understand Your Reaction worksheet to try and identify
her thoughts, feelings, physical reactions, and behavior in two other situations in
the coming week. (Some of the work we did was described in chapters 6 and
7.)\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Sessions 4 and 5\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne came to session 4 having completed the Understand Your Reaction worksheet
for two other situations: one, being alone at recess, and two, a staff meeting
where she had made a comment and no one had responded. She was surprised at how
often she thought, {\i
No one will want to be my friend} and, {\i
The other teachers will not like me}. Suzanne also wanted to focus on a situation
at home with her husband, where she had gotten angry that he had not bathed their
son.\par\pard\plain\hyphpar} {
Suzanne wanted to spend most of the time talking about the invitation to the
barbecue, though we spent some time exploring the situation at home. I explained
the idea of looking for evidence and creating balanced thoughts. We continued
working on the invitation to the barbecue and looked for evidence for her hot
thought {\i
No one will want to be my friend}. We also created a balanced thought. (See chapter
8 for how I looked for evidence and helped Suzanne create a balanced thought.) We
then explored whether the evidence we had collected was relevant to the other two
situations she had identified in her homework, where her hot thoughts were the same
or almost the same. At the end of the session Suzanne had decided she wanted to
attend the barbecue.\par\pard\plain\hyphpar} {
I asked Suzanne what she thought would be helpful as homework. She suggested
reviewing the thought record we had completed every morning before she went to
school. I thought this was an excellent idea, as I wanted her balanced thought to
be fresh in her mind when she started school. I also suggested that she complete an
entire thought record for two other situations.\par\pard\plain\hyphpar} {
In session 5, we started by going over the two thought records Suzanne had
completed as homework. She had found them helpful and spontaneously mentioned that
she wondered if she was being unfair to the other teachers at her new school. Her
agenda items for session 5 were her anxiety about attending the barbecue the next
week and her continuing depression.\par\pard\plain\hyphpar} {
We problem solved how to handle the barbecue and developed coping thoughts. (See
chapter 9 for excerpts of this session.) Since Suzanne had mentioned her
depression, I thought this was a good opening to introduce behavioral activation.
We explored her depression using the Understand Your Depression worksheet, and it
made sense to her. I then explained that it would be helpful for us to understand
how she spends her week and whether her mood fluctuates with the different
activities. I introduced the Daily Activities Schedule, and we filled in half of
the previous day before our time was up. I asked her to complete the Daily
Activities Schedule as homework for the following week.\par\pard\plain\hyphpar}
{\s4 \afs23
{\b
Sessions 6\u8211?9\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Suzanne had completed the Daily Activities Schedule for homework. We reviewed it
using Questions to Explore a Mood/Activity Relationship{\i
.} (You can find the work we did in chapter 10.) The next few sessions were focused
on a combination of behavioral activation, problem-solving obstacles, and
developing coping thoughts. We focused on her early morning schedule as well as the
time at home after school, as these were the lowest times of her day. We carefully
planned activities that she could do to boost her mood and used problem solving and
coping thoughts to address any obstacles. Over the course of these few sessions,
her mood improved as she started seeing friends again, playing with her children
more, and spending quality time with her husband.\par\pard\plain\hyphpar} {
Many of the activities we considered to improve her mood in the morning and after
school involved asking her husband to be more active with the children and
housework. I did not have a chance to address this issue earlier in the book, so
let me spend some time explaining how I dealt with it.\par\pard\plain\hyphpar} {
Suzanne was anxious about talking to her husband about his lack of participation in
household chores and childcare. Her negative thoughts included {\i
He will react negatively and be resentful}; {\i
He will be angry, as it is my job to take care of the children}; {\i
Even if asked, he will not help more}; and {\i
I am an inadequate mother for having difficulties}.\par\pard\plain\hyphpar} {
Over sessions 6 through 9 we spent about half of each session on increasing
pleasurable activities and the other half on examining these thoughts. I asked
Suzanne to list her specific worries about what would happen if she raised the
issue with her husband, and we looked at the evidence for how likely these outcomes
were. (In chapters 7 and 8 I helped Suzanne list her worries about going to the
barbecue, and then we looked at the probability of each worry. We did a similar
type of intervention for her worries around raising issues of childcare and
housework with her husband.)\par\pard\plain\hyphpar} {
When Suzanne started looking at the evidence, she realized that it was unlikely
that her husband would resent being asked to be more involved with the children,
and it was unlikely that he would think that it was only her job to take care of
the children. Suzanne thought that there were probably realistic limits to what he
could do, given his work schedule, but she thought it was worthwhile to raise the
topic. We problem solved and role-played how best to raise the subject, and Suzanne
also practiced in her imagination.\par\pard\plain\hyphpar} {
Suzanne found getting the children ready in the morning very difficult. I suggested
we do a thought record. She initially identified the situation as \u8220?I am a bad
mother for being angry at the kids in the morning when they don\u8217?t get
up.\u8221? In chapter 5 we talked about the importance of separating the facts of a
situation from the meaning of the situation. I helped Suzanne specify the facts of
the situation: her children refusing to get up in the morning. We then identified
her thought: {\i
I am a bad mother}, and her feelings: anger. Once Suzanne was able to separate her
thoughts from the situation, we could then evaluate her thought that she was a bad
mother.\par\pard\plain\hyphpar} {
Next we made a list of criteria for being a good mother. Suzanne\u8217?s criteria
included expressing love and affection, spending time with your children, providing
for them financially, organizing their lives, and reading to them. We then
evaluated her behavior in relation to the criteria she had developed. Initially, I
had to draw Suzanne\u8217?s attention to evidence that she was a good mother,
though I was careful not to {\i
tell} Suzanne about the evidence. For example, I asked her what she did with the
children on the weekend. What had she done for their birthdays? And even though the
mornings were difficult, did she give them breakfast and get them ready for school?
When she described what she did with the children, I asked her if that was part of
being a good mother. Eventually she was able to recognize that she was a good
mother.\par\pard\plain\hyphpar} {
We also examined her belief that if she is having difficulty getting her four- and
six-year-old children ready in the morning, this meant she is an inadequate mother.
I tried to help Suzanne take another perspective. (In chapter 8 we covered taking
another perspective.) Let me ask you, besides being an inadequate mother, are there
any other explanations that could account for Suzanne having difficulty getting her
four- and six-year-old children ready in the morning? I know when my children were
little, they wanted to dawdle, stay in bed, and play rather than get ready for
school on a tight schedule. When we looked at all the facts, it seemed to Suzanne
that most mothers would find it a challenge to get young children dressed, fed, and
ready on time every morning. Taking a different perspective on her morning
difficulties with her children helped Suzanne be less stressed and consider
different ways of handling the children. She started leaving for work in a better
mood and was less critical of herself.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Sessions 10\u8211?16\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
By session 10 Suzanne\u8217?s mood had significantly improved. She was regularly
using thought records at school and often at home when she was upset with her
husband and children. However, she remained very withdrawn at school. I thought she
was caught in a negative cycle where the more she withdrew, the harder it was for
her to get to know the other teachers, and the more she then withdrew. Suzanne
agreed with me that she was caught in a vicious cycle and thought it would be a
good idea to engage socially with the other teachers. However, she felt very
anxious whenever she thought of starting to make friends with them and did not know
where to begin. In sessions 10 through 16 we used exposure therapy to help Suzanne
overcome her social anxiety and start to make friends at school. (In chapter 11 you
can see excerpts from Suzanne\u8217?s exposure therapy.)\par\pard\plain\hyphpar} {
Often during the exposure tasks her thought {\i
No one will want to be my friend} was triggered. Suzanne used the positive
experiences from the exposure tasks as additional evidence to challenge this
thought. For example, when Suzanne talked to her colleague sitting next to her in
assembly, they discovered they had gone to the same school as children. The talk in
assembly led naturally to having lunch together, and they started talking to each
other at recess. This became evidence against her thought {\i
No one will want to be my friend}. We started a written log of situations that
challenged this belief.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Sessions 17 and 18\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
At session 17 Suzanne wondered if it was time to end therapy. She was no longer
depressed, her husband was helping more at home, their relationship had improved,
and she was feeling better about herself. When her children were difficult, she was
able to see their behavior as normal and cope rather than blame herself. She was
developing some friends at her new school, and she no longer minded the commute as
much; she had even started listening to books on tape during the drive. Suzanne and
I reviewed her goals, and she had met all of them or was well on her
way.\par\pard\plain\hyphpar} {
When we started talking about ending, Suzanne realized she was worried about being
able to cope without therapy. We decided that we would meet in two weeks and see
how Suzanne had managed.\par\pard\plain\hyphpar} {
Suzanne had to cancel our next meeting, so it was three weeks before we met. We
went over all the ways her life had changed and what she had learned. Suzanne found
the thought records and behavioral activation the most helpful. We talked about
continuing to face her fears in social situations. Suzanne thought that therapy had
been very helpful. While she would miss me, she was ready to end. I told her that
she was welcome to come back for a booster session any
time.\par\pard\plain\hyphpar} {
I usually end therapy with telling my clients how much I have enjoyed working with
them. If a client gives me a compliment, I accept the compliment but add that we
worked well together and had a good relationship. That way we share the compliment,
and the importance of our relationship is central.\par\pard\plain\hyphpar} {\s3
\afs28
{\b
Agenda Item #3{\i
: Raoul\u8217?s Therapy}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Although we have followed Raoul throughout the book, the order of the interventions
I used was different than the order of the book. I started with problem solving and
graded task assignments. We then did behavioral activation and used cognitive
interventions only in the latter part of therapy.\par\pard\plain\hyphpar} {\s4
\afs23
{\b
Sessions 1 and 2\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Raoul was harder to engage in therapy than Suzanne was, and he was much more
skeptical about whether therapy would work. Initially, Raoul had a hard time
identifying his feelings and thoughts, and I believed that he would have an easier
time with behavioral interventions. From the beginning I hypothesized that his core
beliefs were related to being successful. I consistently listened for thoughts
related to being respected or valued. I also made an effort to notice any times he
minimized evidence that he was respected.\par\pard\plain\hyphpar} {
Let\u8217?s look at Raoul\u8217?s goals:\par\pard\plain\hyphpar} {
Cope better at work, particularly concentrate on my work and get my projects done
on time.\par\pard\plain\hyphpar} {
Socialize with people at work the way I used to. This includes talking to people,
having lunch in the lunchroom, going out for lunch, and chatting in the
hallways.\par\pard\plain\hyphpar} {
Not get anxious every time the boss talks to me.\par\pard\plain\hyphpar} {
Start to like work again.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Sessions 3 and 4\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
After the first two sessions I was somewhat unsure where to start. I was concerned
about Raoul\u8217?s depression and considered starting with behavioral activation.
On the other hand, his first goal was to cope better at work and get his projects
done on time. I wanted to address an issue that was immediately relevant to him. I
was also concerned that if Raoul continued to procrastinate, he would receive
another poor evaluation. This would potentially cause real difficulties at work,
and also add to his depression. I decided to first address his procrastination and
other work-related difficulties.\par\pard\plain\hyphpar} {
We started with identifying projects that were going well and projects where he was
procrastinating. We also assessed where his procrastination might have the most
negative consequences. We discovered that Raoul was accomplishing the majority of
his work on time and at a level he was satisfied with. I used this information to
question his global negative judgment that he was not coping at work. Since I had
hypothesized that one of his core beliefs centered on not being respected, I also
made sure to ask if other people respected this aspect of his
work.\par\pard\plain\hyphpar} {
We spent most of sessions 3 and 4 looking at the projects where he was
procrastinating. We used a combination of problem solving (see chapter 9) and
graded task assignments (see the end of chapter 10). Raoul found it very helpful to
break the projects down into chunks, as it made the tasks more manageable. We also
looked at his schedule and specified the time during the day when he could complete
each chunk.\par\pard\plain\hyphpar} {
Raoul liked the idea of developing coping thoughts. We examined how he approached
the projects that were going well and applied these strategies to the projects he
was struggling with. We developed a number of coping thoughts, including {\i
One step at a time}; {\i
This is just a task, get it done}; and {\i
Play ball}. Raoul had been a successful football player in high school. We explored
how he had coped as an athlete when he was feeling down or having trouble
concentrating. He replied that he just focused on the task; it was not an option to
stop playing. I wondered how he could apply this strategy to his current work. The
phrase \u8220?play ball\u8221? reminded him to treat his current work as if it were
a football game\u8212?no option but to play!\par\pard\plain\hyphpar} {
When Raoul began procrastinating less, he started to feel somewhat better, but he
was still depressed. At the end of session 4, I introduced the idea of behavioral
activation. In session, we completed the Daily Activities Schedule for the day
before. Raoul agreed to try and complete a Daily Activities Schedule for the
following week as homework.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Sessions 5\u8211?8\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Raoul completed the Daily Activities Schedule and we used Questions to Explore a
Mood/Activity Relationship to understand his day and how his activities were
affecting his mood{\i
.} Raoul had not realized how much he had withdrawn from family and friends. Given
the strong evidence for the importance of social relations in boosting and
maintaining a positive mood, I focused on having him increase his social activities
with his wife, children, and friends. The next few sessions involved a combination
of behavioral activation, problem solving, and coping thoughts. Within a couple of
weeks, his mood had started to improve.\par\pard\plain\hyphpar} {
It also became clear when we looked at his Daily Activities Schedule that Raoul did
not have a good sleep routine. This was very different from when he was not
depressed. Clients who have experienced sleep difficulties for many years may need
to see a therapist who specializes in CBT for insomnia (Edinger & Carney, 2014).
However, for many clients, adhering to basic sleep hygiene guidelines can be
sufficient to significantly improve sleep. Below is the Good Sleep Guidelines list
that I use; you can download it in handout form at
http://www.newharbinger.com/38501.\par\pard\plain\hyphpar} {
Have regular bedtimes, both for going to sleep and for waking
up.\par\pard\plain\hyphpar} {
Restrict napping to twenty minutes a day and only in the early
afternoon.\par\pard\plain\hyphpar} {
Do not do strenuous exercise within two hours of bedtime.\par\pard\plain\hyphpar} {
Avoid exposure to bright lights and make sure the bedroom is dark; some people find
computer use before bed disruptive to sleep.\par\pard\plain\hyphpar} {
Avoid heavy meals or drinking before bedtime.\par\pard\plain\hyphpar} {
Avoid caffeine or alcohol before bedtime.\par\pard\plain\hyphpar} {
When Raoul looked at his Daily Activities Schedule, he noted that he came home from
work, watched TV, and immediately fell asleep for at least an hour. He then went to
bed between 1:00 and 2:00 a.m., and he was exhausted in the morning. On the weekend
he woke up tired and lay in bed until 9:00 or 10:00 a.m., hoping to \u8220?make
up\u8221? for his lack of sleep.\par\pard\plain\hyphpar} {
We went over the Good Sleep Guidelines. Raoul decided he would try to establish a
regular sleep schedule. Raoul wanted to try to go for a walk when he got home from
work instead of watching TV and napping, and to try to go to bed at 11:00
p.m.\par\pard\plain\hyphpar} {
The next session, Raoul reported that he had found it very hard to give up napping
in front of the TV. He had liked the idea of taking a walk when he got home, but in
reality he never did it. We problem solved other activities he could do, and he
suggested that he help his wife with the cooking, call his children, and go through
his emails. The next session Raoul reported that this plan worked better. When
Raoul stopped napping, it became easier for him to get to bed at an earlier time,
and his sleep started to improve with a more regular sleep
schedule.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Sessions 9\u8211?16\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
We continued to work on a combination of behavioral activation, problem solving,
graded task assignments, and coping thoughts. Raoul started coming to therapy with
increasingly more agenda items he wanted to address. Once Raoul was no longer
procrastinating, he started bringing up issues related to social relations at work.
We made a list of social activities he had stopped doing since his depression and
slowly introduced the ones that felt the easiest. I always made sure that Raoul had
a concrete plan that was doable. Raoul started having lunch with colleagues in the
lunchroom, speaking up at meetings, talking to his boss about some of the projects
he was involved with, and generally acting more like his \u8220?old self.\u8221?
(You can see some of this work in chapter 9.)\par\pard\plain\hyphpar} {
Usually Raoul expected that he would not enjoy these social activities and that
they would not go well. However, he learned that the activities usually did go well
and that once he did them, he felt better. We stressed the importance of acting
according to his plan and not his depressed feelings.\par\pard\plain\hyphpar} {
In the course of trying to connect with his colleagues and boss, Raoul often
thought, {\i
They do not respect me,} or {\i
They do not value my opinion}. (See chapter 7 for how I identified Raoul\u8217?s
thoughts.) Situations he raised included a time when he thought his boss had
criticized him at a meeting (see chapter 5) and another time when he asked a
colleague to go to lunch and his colleague was busy. In both those situations Raoul
was able to look at possible alternative, more benign interpretations. I suggested
to Raoul that he tended to catastrophize (see chapter 6 for a list of cognitive
distortions), and he agreed. We often used catastrophizing as a shorthand way of
checking if there was another more benign interpretation.\par\pard\plain\hyphpar} {
By session 9, Raoul had started spontaneously applying some of the interventions we
were using for work to his personal life. For example, a friend had told Raoul that
he could not go bowling. Normally Raoul would have thought this meant his friend
did not respect him, especially if his friend canceled on short notice. However, he
was able to consider that there could be other
interpretations.\par\pard\plain\hyphpar} {
In session 14, Raoul told me that he had had his six-month review and everything
seemed to be back on track. We talked about how much progress he had made since he
started therapy. Raoul wondered whether he could skip the next session as there was
an office social event and he wanted to go. He usually looked forward to our
sessions, but he seemed quite casual about planning our next meeting. I asked how
he was feeling about coming to therapy. Raoul explained that I was a very nice
lady, but he didn\u8217?t think he needed therapy anymore. Raoul\u8217?s experience
is very common. As clients get better, therapy becomes less important to them, and
the rest of their life becomes more important. I suggested that we have a session
in two weeks to check that everything was going well, and if it was that we plan
one more meeting after that to end therapy.\par\pard\plain\hyphpar} {\s4 \afs23
{\b
Session 17\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
At our final meeting, we reviewed what Raoul had accomplished in therapy and looked
at his original goals. Raoul was surprised to see how much he had improved, as he
had forgotten how he was feeling when he first came. His sleep was more regular and
he was no longer depressed. He and his wife were back to socializing and seeing
friends and family. I stressed the importance of continuing to engage in enjoyable
activities with his wife, family, and friends. We spent some time exploring what
had been the most helpful for him. He thought that breaking large projects down
into chunks had really helped, and he said he used it all the time and had even
taught it to other colleagues. He also thought not catastrophizing was helpful. As
I had said to Suzanne, I told Raoul that if he needed a booster session I was
available and that I had enjoyed working with him.\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Homework: Practice
CBT\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I hope you\u8217?ve found the homework throughout this book valuable. I know that
for myself, in the course of writing this book, I have found many of the CBT
interventions extremely helpful. I rediscovered positive psychology, and I have
been trying to pause and savor the moment. Throughout the course of writing, I was
particularly appreciative of the following CBT friends, without whom this book
would never have been written.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Agenda setting:} You kept me organized. Reviewing at the end of a day of writing
helped me remember that I actually had accomplished
something!\par\pard\plain\hyphpar} {\s5 \afs23
{\b
The four-factor model:} Whenever I got stuck, you helped me pause and figure out my
thoughts. I noticed my negative automatic thoughts, looked for the evidence, and
usually was able to get back to the task.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Coping thoughts:} You kept me focused.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Behavioral activation:} I think my whole family wants to thank you. For a while I
did nothing but write this book; you made me schedule daily walks and fun
times.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Problem solving:} When I found myself staring at the computer and ruminating, I
problem solved. My favorite solution was emailing the paragraph I was struggling
over to one of my colleagues or a student and then asking my husband when he got
home; all of them always had good advice.\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Graded task assignments:} Without you this book would not have been completed. No
matter how overwhelmed I got, you were there to help me break the task down into
manageable chunks. I think you are the hero of the book. \par\pard\plain\hyphpar}
{\s3 \afs28
{\b
Apply What You Learned to Your Own
Life\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Take a moment to think over everything that we have covered. How have you applied
it to your own life? What changes have you made? What do you want to keep doing? I
hope that you have had a chance to see firsthand how helpful CBT can be. Remember,
the data is clear that if you apply CBT to your own life, you will become a better
CBT therapist.\par\pard\plain\hyphpar} {\s3 \afs28
{\b
Apply What You Learned to Your Therapy
Practice\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Before we say good-bye, let\u8217?s end with a self-assessment. How have you
changed your therapy practice over the course of reading this book? What new skills
and interventions have you tried with your clients? Are you setting agendas?
Identifying your clients\u8217? thoughts? What about looking for the evidence and
creating balanced thoughts? Did you have a chance to try problem solving,
behavioral activation, or exposure therapy? What do you need to do to keep learning
and improving your CBT skills? Can you set one or two professional goals and
develop a learning plan?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Time to End\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
Dear reader, we have come to the end of the book. At this point it is up to you
whether you use what you learned. I surely hope you will. If you have made some
changes in your therapy practice, or in your own life, take a moment to acknowledge
the work you have done and give yourself a well-deserved pat on the back. Change is
hard for both our clients and ourselves.\par\pard\plain\hyphpar} {
By reading this book, it\u8217?s as if you have taken a course on CBT, complete
with check-ins and reviews, agenda setting, action plans, homework, and practice,
practice, practice. My hope is that you will have an easier time applying this
structure to your therapy practice, and that both you and your clients will benefit
from the work you have put in. It has been a pleasure to be your
guide.\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
Acknowledgments\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
We have been married for over thirty years, have raised our children together, and
have had countless discussions about our patients and CBT. This book comes out of
our partnership.\par\pard\plain\hyphpar} {
The book would not have been possible without our many client and patients who were
willing to share their stories and problems, and in the process help us learn to
apply CBT principles and become better therapists.\par\pard\plain\hyphpar} {
We would like to thank the editors at New Harbinger for their enthusiasm and
support for this project and for all of their helpful guidance. We would
particularly like to thank Elizabeth Hollis Hansen and Vicraj Gill, who always had
time for our numerous questions. Rona Bernstein provided detailed and constructive
advice that greatly improved the final drafts.\par\pard\plain\hyphpar} {
Nina would like to thank her many students at the University of Toronto, as well as
all of the participants in the various workshops she has given over the years. This
book would not exist without the many gifted students whose questions pushed her to
think about how to explain CBT.\par\pard\plain\hyphpar} {
We would also like to thank our many colleagues and friends who read parts or all
of the manuscript. In particular, Dr. Joyce Isbitsky was never too busy to read and
reread numerous versions of the same chapter, our research assistant Julie Hong was
invaluable, and our friend Bernice Eisenstein was particularly
helpful.\par\pard\plain\hyphpar} {
David would like to thank Zindel Segal, Martin M. Antony, and Cynthia Crawford, who
over many years of friendship were always willing to discuss challenging cases.
David would also like to thank Dr. David Conn, Dr. Victoria Lee, and his many
wonderful colleagues at Baycrest for their ongoing support and friendship. He would
also like to thank the Geriatric Psychiatry Outreach Team, and in particular Joy
Lipkin, Nira Rittenberg, and Peggy Solomon.\par\pard\plain\hyphpar}
{\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
Appendix\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s3 \afs28
{\qc
Answers to YOUR TURN!Exercises\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Chapter 1\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Identify Situations, Thoughts, Feelings, Physical Reactions, and
Behavior\par\pard\plain\hyphpar} {\b
{\qc
Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior}} {\b
} {\b
Situation, Thought, Feeling, Physical Reaction, or Behavior?} {
Staying up late and studying\par\pard\plain\hyphpar} {
Situation\par\pard\plain\hyphpar} {
No matter what I do, no one likes me.\par\pard\plain\hyphpar} {
Thought\par\pard\plain\hyphpar} {
I feel tense all over.\par\pard\plain\hyphpar} {
Physical reaction\par\pard\plain\hyphpar} {
Even if I study hard, I will still fail.\par\pard\plain\hyphpar} {
Thought\par\pard\plain\hyphpar} {
I am so happy.\par\pard\plain\hyphpar} {
Feeling\par\pard\plain\hyphpar} {
My boss hates my work.\par\pard\plain\hyphpar} {
Thought\par\pard\plain\hyphpar} {
I am late for work.\par\pard\plain\hyphpar} {
Situation\par\pard\plain\hyphpar} {
How Thoughts Influence Feelings and Behavior\par\pard\plain\hyphpar} {
Below is how I completed figure 1.4.\par\pard\plain\hyphpar} {
{\i
{\ql

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\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Identify Clients\u8217? Thoughts, Feelings, Physical Reactions, and
Behavior\par\pard\plain\hyphpar} {
{\i
Situation:} Boyfriend arrived thirty minutes late, did not let her know he would be
late\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Thoughts:} I hate it, he doesn\u8217?t care about me; I am worthless;
what else can I do?; he takes me for granted.\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Feelings:} Depressed, irritated\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Physical Reactions:} Tense\par\pard\plain\hyphpar} {
{\i
Sara\u8217?s Behavior:} Gives dirty looks, acts cold\par\pard\plain\hyphpar} {
Maria\u8217?s Symptom Maintenance Cycle\par\pard\plain\hyphpar} {
Below is how I completed Maria\u8217?s symptom maintenance
cycle.\par\pard\plain\hyphpar} {
{\i
{\ql

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}}

\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Chapter 2\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Raoul\u8217?s Stressors and Strengths\par\pard\plain\hyphpar} {\b
{\qc
Raoul\u8217?s Stressors and Strengths}} {\b
Difficulties or Stressors} {\b
Strengths or Areas of Resilience} {
{\b
Family}\par\pard\plain\hyphpar} {
No information\par\pard\plain\hyphpar} {
Children live out of town\par\pard\plain\hyphpar} {
Long-term marriage\par\pard\plain\hyphpar} {
Wife encouraged him to bowl, suggests caring relationship Close enough relationship
with daughter that she noticed his distress and was able to convince him to go for
therapy\par\pard\plain\hyphpar} {
{\b
Friends and Social Contacts}\par\pard\plain\hyphpar} {
No information\par\pard\plain\hyphpar} {
No information\par\pard\plain\hyphpar} {
{\b
Recreation & Organizations}\par\pard\plain\hyphpar} {
No information\par\pard\plain\hyphpar} {
Past five years, part of a bowling league\par\pard\plain\hyphpar} {
{\b
Work or School}\par\pard\plain\hyphpar} {
Recently passed over for a promotion\par\pard\plain\hyphpar} {
Recent poor work evaluation\par\pard\plain\hyphpar} {
Has maintained steady employment for twenty years Works in a demanding area that
requires understanding of taxes Previously enjoyed work\par\pard\plain\hyphpar} {
Risked applying for a promotion\par\pard\plain\hyphpar} {
History of good work evaluations\par\pard\plain\hyphpar} {
{\b
Health}\par\pard\plain\hyphpar} {
Sleep difficulties\par\pard\plain\hyphpar} {
Anxiety\par\pard\plain\hyphpar} {
Moderate drinking\par\pard\plain\hyphpar} {
Health \u8220?good\u8221?\par\pard\plain\hyphpar} {
{\b
Finances}\par\pard\plain\hyphpar} {
Postponed retirement\par\pard\plain\hyphpar} {
Some indication that financially responsible Planning for
retirement\par\pard\plain\hyphpar} {
{\b
Changes}\par\pard\plain\hyphpar} {
Financial worries\par\pard\plain\hyphpar} {
No information\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Chapter 3\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Identify Specific, Measurable Goals\par\pard\plain\hyphpar} {\b
{\qc
Assess Whether the Goal Is General or Specific and Measurable}} {\b
Goals} {\b
Is This Goal General or Specific and Measurable?} {
Talk to my boss about getting paid for working overtime\par\pard\plain\hyphpar} {
Specific and measurable\par\pard\plain\hyphpar} {
Be less demanding of my friends\par\pard\plain\hyphpar} {
General\par\pard\plain\hyphpar} {
Stop smoking by the end of the month\par\pard\plain\hyphpar} {
Specific and measurable\par\pard\plain\hyphpar} {
Take better care of my health\par\pard\plain\hyphpar} {
General\par\pard\plain\hyphpar} {
Get along better with my parents\par\pard\plain\hyphpar} {
General\par\pard\plain\hyphpar} {
Do a pleasant activity with my partner on a weekly basis\par\pard\plain\hyphpar} {
Specific and measurable\par\pard\plain\hyphpar} {
Learn better parent management skills for when my eight-year-old has a temper
tantrum\par\pard\plain\hyphpar} {
Specific\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Chapter 4\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Evaluate Suzanne\u8217?s Homework\par\pard\plain\hyphpar} {
Suzanne\u8217?s therapist says, \u8220?I would like to give you some homework. I
think it would be really helpful if you could try to do some fun things with your
children this coming week.\u8221?\par\pard\plain\hyphpar} {\b
Helpful Homework Guidelines} {\b
Does Suzanne\u8217?s Homework Meet This Guideline?} {
The homework is developed collaboratively.\par\pard\plain\hyphpar} {
No, the therapist suggested the homework at the last minute. There is no
opportunity for Suzanne to have input.\par\pard\plain\hyphpar} {
The homework is specific and concrete.\par\pard\plain\hyphpar} {
No, no clear idea what Suzanne will do.\par\pard\plain\hyphpar} {
The homework is related to the session.\par\pard\plain\hyphpar} {
Yes, Suzanne had been talking about her feelings related to not doing fun things
with her children and indicated she would like to start
again.\par\pard\plain\hyphpar} {
The homework is doable.\par\pard\plain\hyphpar} {
We don\u8217?t know, as there is no specific task.\par\pard\plain\hyphpar} {\s2
\afs28
{\b
{\qc
Chapter 5\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Separate the Facts about the Situation from the Thoughts about the
Situation\par\pard\plain\hyphpar} {\b
Examples of Situations} {\b
Facts about the Situation} {\b
Client\u8217?s Thoughts about the Situation} {
Instead of doing homework, I was lazy and went out with
friends.\par\pard\plain\hyphpar} {
Instead of doing homework, client went out with friends.\par\pard\plain\hyphpar} {
I was lazy.\par\pard\plain\hyphpar} {
My boss told me I did a good job, but he didn\u8217?t really mean
it.\par\pard\plain\hyphpar} {
Boss said client did a good job.\par\pard\plain\hyphpar} {
He didn\u8217?t really mean it.\par\pard\plain\hyphpar} {
My child is not normal; he is not crawling at age five
months.\par\pard\plain\hyphpar} {
Client\u8217?s child is not crawling.\par\pard\plain\hyphpar} {
My child is not normal.\par\pard\plain\hyphpar} {
The huge mess my husband left in the kitchen.\par\pard\plain\hyphpar} {
Not clear what the husband did; therefore, you don\u8217?t have any facts. You
would need to gather facts.\par\pard\plain\hyphpar} {
My husband left a huge mess in the kitchen.\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Chapter 6\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Identify Suzanne\u8217?s Thoughts about Self, Others, and the
Future\par\pard\plain\hyphpar} {
He didn\u8217?t give Andrew his bath.\par\pard\plain\hyphpar} {
{\ql
{\i
This is a fact. It is true that her husband did not give Andrew his bath. This
thought is not an evaluation but a statement of
fact.}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
No matter what I do, it won\u8217?t make a difference.\par\pard\plain\hyphpar} {
{\ql
{\i
This thought is about the future. She thinks the future will be the same as the
present.}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
He doesn\u8217?t care about me or the kids.\par\pard\plain\hyphpar} {
{\ql
{\i
This thought is a judgment about her husband. Therefore, it is about
others.}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
You can\u8217?t count on men.\par\pard\plain\hyphpar} {
{\ql
{\i
This is a general rule about men. Therefore, it is about
others.}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
I\u8217?m a completely inadequate mother.\par\pard\plain\hyphpar} {
{\ql
{\i
This thought is a negative judgment about herself. Therefore, it is about
self.}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Why do I have to do everything in the house?\par\pard\plain\hyphpar} {
{\ql
{\i
I ended with a trick question. This is a question. We are going to look at
questions in more detail. However, for this exercise, there are a number of implied
thoughts that you would want to help your client make explicit. It is a thought
about self, as Suzanne is really saying, \u8220?I have to do everything in the
house,\u8221? but it is also a thought about others, as the implication is \u8220?
My husband does nothing.\u8221?}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
What Thoughts Go with These Feelings?\par\pard\plain\hyphpar} {
The correct answer is in bold.\par\pard\plain\hyphpar} {
Cameron is feeling {\i
furious}. What might he be thinking? Our team will never have another chance to
play in the semi-finals. {\b
That guy is an animal; he should be punished; it\u8217?s unfair.} This thought is
most likely to lead to feeling furious. It is about rules being broken, and being
treated unfairly. If we lose, it is all my fault. \par\pard\plain\hyphpar} {
Annette is feeling {\i
disappointed}. What might she be thinking? I will never get a decent job; my life
is over. They should have hired me; what idiots! {\b
I had hoped to get the job, but at least I was second choice.} This thought is most
likely to lead to disappointment. Disappointment is related to sadness, but it is
not a strong feeling. The other thoughts are too extreme for disappointment.
\par\pard\plain\hyphpar} {
Orly is feeling {\i
guilty}. What might he be thinking? {\b
I am a bad friend; I should have gone; I bet I hurt Roy\u8217?s feelings.} This
thought is most likely to lead to guilt as it is about breaking a moral rule. My
friend is probably furious at me. I bet Roy will not want to be my friend
anymore. \par\pard\plain\hyphpar} {
Identify the Cognitive Distortion\par\pard\plain\hyphpar} {
If I don\u8217?t get this job, my life will be over. Cognitive distortion:
catastrophizing \par\pard\plain\hyphpar} {
To be a good therapist, you have to give it your all and be there 100 percent of
the time for your clients. Cognitive distortion: shoulds \par\pard\plain\hyphpar} {
I\u8217?m sure that no one will ever want to hire me after this last fiasco of a
job interview. Cognitive distortion: overgeneralizing \par\pard\plain\hyphpar} {
If I don\u8217?t help all of my clients, I am an inadequate therapist. Cognitive
distortion: polarized thinking \par\pard\plain\hyphpar} {
I know that my last client canceled because she thinks I\u8217?m a bad therapist.
Cognitive distortion: personalizing and mind reading \par\pard\plain\hyphpar} {
A colleague told me he wondered if the group check-in should be a bit shorter next
time. That was a terrible mistake I made in the first group. Cognitive distortion:
magnifying; could also be catastrophizing \par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Chapter 8\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
Help Cynthia Reach Her Own Conclusions\par\pard\plain\hyphpar} {
Below are some questions you could ask.\par\pard\plain\hyphpar} {
Can you tell me about your relationship with John?\par\pard\plain\hyphpar} {
Are there ways that John shows he cares about and respects you? ({\i
If Cynthia did not mention their sexual relationship}) In your sexual relationship,
are there ways John shows he cares about and respects you?\par\pard\plain\hyphpar}
{
How do Mike and Chris treat you? Can you give me some
examples?\par\pard\plain\hyphpar} {
Have Mike and Chris ever made any comments indicating that they respect you? Could
you give me examples?\par\pard\plain\hyphpar} {
When you think of the evidence from John, Mike, and Chris, what does it tell you
about your belief that men are only interested in you for
sex?\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Chapter 10\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
Understand Mayleen\u8217?s Depression\par\pard\plain\hyphpar} {\b
{\qc
Mayleen\u8217?s Understand Your Depression worksheet}} {\b
Increased Since Life Changes or Stressors} {\b
Decreased Since Life Changes or Stressors} {\b
Activities I enjoy or that provide pleasure or mastery} {
Taking care of mother Going to mother\u8217?s doctor\u8217?s appointments (mixed:
enjoy as sense of purpose and consistent with values, but do not enjoy
activity)\par\pard\plain\hyphpar} {
Stopped sculpting\par\pard\plain\hyphpar} {\b
Activities I do not enjoy} {
Driving to see mother Looking after the house TV\par\pard\plain\hyphpar} {\b
Exercise} {
Stopped exercise\par\pard\plain\hyphpar} {\b
Spending time with friends} {
Stopped seeing many friends No friends when with mother\par\pard\plain\hyphpar} {\b
Spending time with family} {
More time with mother\par\pard\plain\hyphpar} {\b
Leisure or hobbies} {\b
Smoking, overeating, alcohol or drug use} {\b
Routines related to eating and sleeping} {
Develop Mood-Boosting Activities for Anna\par\pard\plain\hyphpar} {\b
Suggested Activity} {\b
Developed Collaboratively} {\b
Specific and Concrete} {\b
Doable} {\b
Naturally Reinforcing} {\b
Regular Routine} {
Run three times a week for an hour\par\pard\plain\hyphpar} {
No\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {
No\par\pard\plain\hyphpar} {
Yes, if she could do it\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {\s5 \afs23
{\b
Run three times a week for an hour.} This is a concrete plan, and it is naturally
reinforcing because Anna likes to run. It could also be part of a routine. The
problem is that it is probably not doable. Very few people could go from no
exercise to running for an hour three times a week. Plus, if she has not exercised
in a while, an hour of running may be physically too much. In conclusion, it is not
a good plan.\par\pard\plain\hyphpar} {
{\i
A more effective plan}{\b
:} To develop a more effective plan, you would start with asking Anna what she
would like to add to her life and how she would like to change the period of time
around 5:00 p.m. If running was of interest to Anna, it would be important for her
to start slowly. Depending on how long it has been since Anna has exercised, it
might make sense to start with walking, or a combination of walking and
running.\par\pard\plain\hyphpar} {
Use Graded Task Assignments\par\pard\plain\hyphpar} {\b
Task} {\b
Specific and Concrete?} {\b
Doable?} {\b
Time-Limited and Specific Time for Task?} {\b
Cynthia: {
Reorganizing the filing system\par\pard\plain\hyphpar} } {
{\i
No. Not clear what the criteria are for a systematic filing system; first action is
not clear}\par\pard\plain\hyphpar} {
{\i
Not sure who will do this and what exactly the person/people will do; hard to know
if it is doable}\par\pard\plain\hyphpar} {
{\i
No time limit given; will Cynthia work for 10 minutes or the whole
day?}\par\pard\plain\hyphpar} {
{\i
No specific time for task}\par\pard\plain\hyphpar} {\b
Richard: {
Make a list of food I want to cook\par\pard\plain\hyphpar} } {
Yes, this is a specific task.\par\pard\plain\hyphpar} {
Yes, though you would have to check\par\pard\plain\hyphpar} {
Yes, a time limit was set, but no specific time was specified when the task would
be done\par\pard\plain\hyphpar} {\b
Alexandra: {
Explore options for work\par\pard\plain\hyphpar} } {
No, it is not clear how Alexandra would explore her options for
work.\par\pard\plain\hyphpar} {
Because as task is unclear, hard to know if it is doable\par\pard\plain\hyphpar} {
No time limit and no specific time set for task\par\pard\plain\hyphpar} {\s2 \afs28
{\b
{\qc
Chapter 11\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}\par\pard\plain\hyphpar}
{
Develop Effective Exposure Tasks\par\pard\plain\hyphpar} {\b
Task} {\b
Specific and Concrete?} {\b
Action the Client Can Do?} {\b
In Client\u8217?s Control?} {\b
Conclusion: Is This an Effective Task?} {
Stand in front of the elevator in my building for 5 minutes every
day\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {
Look at photos on the Internet of cars similar to the one that hit
me\par\pard\plain\hyphpar} {
No. We do not know which photos he will look at. There is a great range of cars
that are \u8220?similar\u8221? to the one that hit the
client.\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {
Yes\par\pard\plain\hyphpar} {
No, because it is not sufficiently concrete and specific\par\pard\plain\hyphpar}
{\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
References\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
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{\ql
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{
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{
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{\b
Nina} {\b
Josefowitz, PhD}, is a psychologist in private practice and has taught a graduate-
level course on cognitive behavioral therapy (CBT) for over fifteen years in the
Counselling and Clinical Psychology Program at the Ontario Institute for Studies in
Education (OISE) at the University of Toronto. Josefowitz has offered workshops in
CBT throughout Ontario and internationally. She has appeared in court numerous
times as an expert witness in cases involving interpersonal violence. Josefowitz
was on the Council of the College of Psychologists of Ontario for nine years, and
president of the college from 2001\u8211?2003. She has published in the areas of
trauma, women\u8217?s issues, ethics, the therapeutic relationship, and a variety
of issues related to CBT. Her most recent interests include incorporating imagery
into CBT.\par\pard\plain\hyphpar} {
{\b
David} {\b
Myran, MD}, (1949\u8211?2016) was a geriatric psychiatrist and assistant professor
in the department of psychiatry at the University of Toronto. For many years, he
was director of the Geriatric Psychiatry Outreach Team at Baycrest Health
Sciences\u8212?a University of Toronto-affiliated hospital, where he served as a
staff psychiatrist. Myran was also a CBT supervisor for psychiatry residents at the
University of Toronto. Myran published and presented at professional conferences on
a wide number of topics, including psychological treatment for irritable bowel
syndrome, a range of topics within geriatric psychiatry, the therapeutic
relationship, and depression. His interests also included using telehealth to
provide psychiatric services to older adults who are
housebound.\par\pard\plain\hyphpar} {
Foreword writer {\b
Zindel} {\b
V. Segal, PhD}, is professor of psychology at the University of Toronto
Scarborough. He is coauthor of {\i
Mindfulness-Based Cognitive Therapy for Depression} and {\i
The} {\i
Mindful} {\i
Way} {\i
through} {\i
Depression}.\par\pard\plain\hyphpar} {\par\pard\hyphpar }{\page } {\s1 \afs32
{\qc
Index\par\pard\plain\hyphpar}\par\pard\plain\hyphpar} {
A\par\pard\plain\hyphpar} {
Aabir Explores His Images exercise, 131\par\pard\plain\hyphpar} {
about this book, 2\u8211?4\par\pard\plain\hyphpar} {
active learning, 3\par\pard\plain\hyphpar} {
activities: monitoring daily, 204\u8211?208; planning mood-boosting, 209\u8211?
215\par\pard\plain\hyphpar} {
affect regulation, 90\par\pard\plain\hyphpar} {
agendas: collaboratively setting, 67\u8211?69; working in a session,
69\par\pard\plain\hyphpar} {
Aiden Uses a Knife Again exercise, 232\par\pard\plain\hyphpar} {
all-or-nothing thinking, 110\par\pard\plain\hyphpar} {
analogy use, 203\par\pard\plain\hyphpar} {
anger, understanding, 108\par\pard\plain\hyphpar} {
anxiety: exposure therapy for, 223\u8211?245; how to understand, 106\u8211?107;
safety behaviors and, 226\u8211?228, 243, 244. {\i
See also} fears\par\pard\plain\hyphpar} {
Are My Predictions Accurate? worksheet, 239\u8211?240\par\pard\plain\hyphpar} {
assumptions, 18, 111\par\pard\plain\hyphpar} {
audio files, 4; on explaining a Daily Activities Schedule, 204\u8211?205; on
explaining exposure therapy, 231; on explaining goal setting to clients, 47\u8211?
48; on explaining looking for evidence, 148; on explaining problem solving, 180; on
identifying cognitive distortions, 118; on introducing the Understand Your Reaction
worksheet, 89\u8211?90; on using questions to explore client problems, 27. {\i
See also} Practice in Your Imagination exercises\par\pard\plain\hyphpar} {
automatic thoughts, 9, 248; core beliefs and, 18, 19, 249\u8211?250, 252;
identifying, 122\u8211?124\par\pard\plain\hyphpar} {
avoidance: cycle of, 224\u8211?225; questions for considering, 230; safety
behaviors as, 226\par\pard\plain\hyphpar} {
B\par\pard\plain\hyphpar} {
balanced thoughts, 163\u8211?167; consolidating, 165; creating a new image using,
166\u8211?167; managing stress using, 167; questions for developing,
163\par\pard\plain\hyphpar} {
Beck, Judy, 155\par\pard\plain\hyphpar} {
behavioral activation, 196\u8211?221; cycle of depression and, 197\u8211?198; daily
activity monitoring in, 204\u8211?208; graded task assignments in, 215\u8211?217;
and helping clients understand their depression, 199\u8211?204; homework
assignments on, 219\u8211?220; increasing well-being through, 218; planning mood-
boosting activities in, 209\u8211?215; research on effectiveness of, 198\u8211?199;
steps in process of, 198\par\pard\plain\hyphpar} {
behavioral experiments, 224\par\pard\plain\hyphpar} {
behaviors: cognitive distortions and, 115\u8211?116; coping thoughts related to,
188; describing specific and concrete, 98; examples of vague vs. specific, 95;
four-factor model for understanding, 10; helping clients identify, 94\u8211?96;
influence of thoughts on, 12; linking thoughts to, 135\u8211?137; problems
maintained by, 16\u8211?17\par\pard\plain\hyphpar} {
beliefs. {\i
See} core beliefs\par\pard\plain\hyphpar} {
Benefits and Drawbacks of My Solutions worksheet, 185\par\pard\plain\hyphpar} {
black-and-white thinking, 110\par\pard\plain\hyphpar} {
brainstorming solutions, 180\u8211?183\par\pard\plain\hyphpar} {
C\par\pard\plain\hyphpar} {
Carol Wants to Apply for a Job exercise, 132\par\pard\plain\hyphpar} {
catastrophizing, 111\par\pard\plain\hyphpar} {
CBT. {\i
See} cognitive behavioral therapy\par\pard\plain\hyphpar} {
check-in process, 62\u8211?66; components of, 63\u8211?64; dialogue example, 65;
staying focused in, 64, 66\par\pard\plain\hyphpar} {
Checklist of Common Problems with Thought Records handout,
168\par\pard\plain\hyphpar} {
clarifying questions, 122\par\pard\plain\hyphpar} {
cognitive behavioral therapy (CBT): building blocks of, 7\u8211?11; definition of,
1; explaining to clients, 39; fundamental principles of, 1; homework on practicing,
259\u8211?260; self-application of, 3; study on effectiveness of,
2\par\pard\plain\hyphpar} {
cognitive distortions, 109\u8211?116; common types of, 110\u8211?112; dysfunctional
behaviors and, 115\u8211?116; exercises for identifying, 112\u8211?113, 116;
helping clients identify, 113\u8211?114; homework assignments on, 117\u8211?118,
120; worksheet for identifying, 114, 117\par\pard\plain\hyphpar} {
collaboration: in agenda setting, 67\u8211?69; in homework development,
70\par\pard\plain\hyphpar} {
Common Problems with Thought Records exercise, 168\par\pard\plain\hyphpar} {
compulsive rituals, 226\par\pard\plain\hyphpar} {
consequences of behaviors, 95\par\pard\plain\hyphpar} {
content specificity, 106\par\pard\plain\hyphpar} {
coping thoughts, 187\u8211?191\par\pard\plain\hyphpar} {
core beliefs: automatic thoughts and, 18, 19, 249\u8211?250, 252; clinical
implications of, 20\u8211?21; downward arrow technique and, 252; identifying with
clients, 248\u8211?252; psychosocial history and, 250\u8211?251; thoughts
influenced by, 18\u8211?21; three types of, 18\par\pard\plain\hyphpar} {
Cycle of Avoidance diagram, 225\par\pard\plain\hyphpar} {
D\par\pard\plain\hyphpar} {
Daily Activities Schedule, 204\u8211?208\par\pard\plain\hyphpar} {
daily living activities, 209\par\pard\plain\hyphpar} {
depression: behavioral activation for, 196\u8211?221; CBT developed as treatment
for, 1; daily activity monitoring for, 204\u8211?208; diagram on cycle of, 197;
helping clients understand, 199\u8211?204; planning mood-boosting activities for,
209\u8211?215; relapse prevention for, 215; thoughts indicative of, 107\u8211?
108\par\pard\plain\hyphpar} {
Develop Effective Exposure Tasks exercise, 234, 277\par\pard\plain\hyphpar} {
Develop Mood-Boosting Activities for Anna exercise, 211\u8211?212,
275\par\pard\plain\hyphpar} {
Dewei Uses Marijuana Again exercise, 69\par\pard\plain\hyphpar} {
Diana Wants to Go to College exercise, 127\par\pard\plain\hyphpar} {
doorknob therapy, 67\par\pard\plain\hyphpar} {
downward arrow technique, 252\par\pard\plain\hyphpar} {
dysfunctional behaviors, 115\u8211?116\par\pard\plain\hyphpar} {
E\par\pard\plain\hyphpar} {
emotions. {\i
See} feelings\par\pard\plain\hyphpar} {
empathy, 25, 96\u8211?97\par\pard\plain\hyphpar} {
environment, in four-factor model, 8\par\pard\plain\hyphpar} {
Eulela Has a Very Bad Week exercise, 66\par\pard\plain\hyphpar} {
Evaluate Suzanne\u8217?s Homework exercise, 71\u8211?72,
268\par\pard\plain\hyphpar} {
evaluative thoughts, 103\u8211?105\par\pard\plain\hyphpar} {
Examine the Reality of Your Thoughts worksheet, 146, 170\par\pard\plain\hyphpar} {
Examples of Coping Thoughts handout, 190\par\pard\plain\hyphpar} {
exercise, physical, 209\par\pard\plain\hyphpar} {
exercises (practice), 4; for behavioral activation, 212; for developing helpful
goals, 55; for evaluating the Understand Your Reaction worksheet, 137; for
explaining consequences of thoughts, 189; for exploring images and thoughts, 131,
132; for exposure therapy, 226, 228, 232; for focusing on problems and strengths,
38; for helping clients reach their own conclusions, 162; for identifying cognitive
distortions, 113, 116; for identifying problems with thought records, 168; for
identifying specific behaviors, 95; for identifying the meaning of situations, 127;
for identifying thoughts about self, others, or the future, 106; for identifying
trigger situations, 87, 89; for problem solving, 178; for reviewing balanced
thoughts, 165; for using CBT theory to understand clients, 14, 15, 16, 18, 19, 20,
21; for weighing evidence against hot thoughts, 154; for working with depressed
clients, 201, 212; for working within a session structure, 66, 69, 72. {\i
See also} YOUR TURN! exercises\par\pard\plain\hyphpar} {
Explain CBT to Your Client handout, 39\par\pard\plain\hyphpar} {
Explain Goal Setting handout, 47\par\pard\plain\hyphpar} {
Explain the Structure of a Therapy Session handout, 61\par\pard\plain\hyphpar} {
exposure therapy, 222\u8211?245; effectiveness of, 228; explaining to clients,
230\u8211?231; fear hierarchy for, 231\u8211?232, 243, 244; homework assignments
on, 243\u8211?244; implementing exposure in, 232\u8211?238; negative predictions
about, 236\u8211?238; postexposure debriefing in, 238\u8211?242; preparing to do,
229\u8211?232; relapse prevention and, 242; tasks used in, 232\u8211?235, 238;
theory behind, 223\u8211?224; types of, 228\u8211?229\par\pard\plain\hyphpar} {
F\par\pard\plain\hyphpar} {
facts vs. thoughts, 87\u8211?88\par\pard\plain\hyphpar} {
false alarms, 158\par\pard\plain\hyphpar} {
fears: categories of, 229; exposure therapy for, 223\u8211?245; hierarchies of,
231\u8211?232, 243, 244; how avoidance maintains, 224\u8211?225. {\i
See also} anxiety\par\pard\plain\hyphpar} {
feedback, requesting from clients, 73\par\pard\plain\hyphpar} {
feelings: distinguishing thoughts from, 9, 91; empathy toward thoughts and, 25;
explanation of emotions and, 90; helping clients identify, 90\u8211?93; images
accompanying, 131; linking thoughts to, 135\u8211?137; physical reactions
distinguished from, 9; rating process for, 92\u8211?93, 98, 108\u8211?109; thoughts
related to, 12, 106\u8211?109, 127\u8211?128; worksheet for identifying, 138\u8211?
139\par\pard\plain\hyphpar} {
Fennell, Melanie, 203\par\pard\plain\hyphpar} {
filtering, 110\par\pard\plain\hyphpar} {
Find the Facts exercise, 89\par\pard\plain\hyphpar} {
flower analogy, 203\par\pard\plain\hyphpar} {
focus, during check-in, 64, 66\par\pard\plain\hyphpar} {
four-factor model, 7\u8211?11; homework assignments on, 21\u8211?22; self-
reflection exercise, 24; therapeutic use of, 81\u8211?83,
137\par\pard\plain\hyphpar} {
future: predictions about, 111; thoughts about, 104, 108,
119\par\pard\plain\hyphpar} {
G\par\pard\plain\hyphpar} {
goals, 46\u8211?58; defining problems and setting, 179; developing specific and
measurable, 48\u8211?55; examples of general vs. specific, 49; homework assignments
on, 56\u8211?57; introducing clients to, 46\u8211?48; prioritizing order of, 47,
55\par\pard\plain\hyphpar} {
Good Sleep Guidelines, 258\par\pard\plain\hyphpar} {
graded task assignments, 215\u8211?217\par\pard\plain\hyphpar} {
gratitude, expressing, 218\par\pard\plain\hyphpar} {
Greenberger, Dennis, 147, 155\par\pard\plain\hyphpar} {
Guidelines for an Effective Activity Plan handout, 210\par\pard\plain\hyphpar} {
Guidelines for Helpful Homework handout, 70\par\pard\plain\hyphpar} {
guilt, understanding, 108\par\pard\plain\hyphpar} {
H\par\pard\plain\hyphpar} {
habituation, 223\u8211?224\par\pard\plain\hyphpar} {
handouts, 4; Checklist of Common Problems with Thought Records, 168; Examples of
Coping Thoughts, 190; Explain CBT to Your Client, 39; Explain Exposure to Your
Clients, 230; Explain Goal Setting, 47; Explain the Structure of a Therapy Session,
61; Good Sleep Guidelines, 258; Guidelines for an Effective Activity Plan, 210;
Guidelines for Helpful Homework, 70; Identify Your Feelings, 90; Pleasurable
Activities List, 210; Questions for a Balanced Thought, 163; Questions to Assess
Your Client\u8217?s Safety Behaviors, 227; Questions to Develop Coping Thoughts,
189; Questions to Develop Helpful Goals, 51; Questions to Explore a Mood/Activity
Relationship, 205; Questions to Explore Problems, 26; Questions to Explore
Strengths, 33; Questions to Gather More Information about the Situation, 159;
Questions to Help Set an Agenda, 67; Questions to Identify Evidence Against
Negative Thoughts, 155; Questions to Identify Your Client\u8217?s Images, 131;
Questions to Identify Your Client\u8217?s Predictions During Exposure, 237;
Questions to Identify Your Client\u8217?s Thoughts, 134; Questions to Review the
Therapy Session, 72; Thinking Traps, 110. {\i
See also} worksheets\par\pard\plain\hyphpar} {
happiness, increasing, 218, 219\u8211?220\par\pard\plain\hyphpar} {
Help Cynthia Reach Her Own Conclusions exercise, 162, 273\par\pard\plain\hyphpar} {
Help Neale Identify a Specific Situation exercise, 86\u8211?
87\par\pard\plain\hyphpar} {
Help Raoul Develop Coping Thoughts exercise, 190\u8211?191\par\pard\plain\hyphpar}
{
Help Raoul Find New Solutions exercise, 182\u8211?183\par\pard\plain\hyphpar} {
Help Raoul Stay Focused During the Check-In exercise, 66\par\pard\plain\hyphpar} {
Help Suzanne Make Her Goals More Specific exercise, 53\u8211?
54\par\pard\plain\hyphpar} {
Help Suzanne Take a Close Look at the Facts exercise, 160\par\pard\plain\hyphpar} {
helpful questions, 124\u8211?129\par\pard\plain\hyphpar} {
history, psychosocial, 38\u8211?39\par\pard\plain\hyphpar} {
homework: developing helpful, 70\u8211?71; reviewing during check-in,
63\par\pard\plain\hyphpar} {
homework assignments: on behavioral activation, 219\u8211?220; on describing
specific situations and behaviors, 97\u8211?98; on exploring client problems,
41\u8211?42; on exposure therapy, 243\u8211?244; on identifying cognitive
distortions, 117\u8211?118, 120; on identifying stressors and strengths, 40, 43; on
looking for evidence, 169\u8211?170; on practicing CBT, 259\u8211?260; on problem
solving, 192\u8211?194; on rating your own feelings, 98; on setting specific goals,
56\u8211?57; on structuring therapy sessions, 74\u8211?76; on Understand Your
Reaction worksheet, 99\u8211?100; on using the four-factor model, 21\u8211?
22\par\pard\plain\hyphpar} {
hopes, thoughts as, 132\par\pard\plain\hyphpar} {
hot thoughts, 103, 145, 147, 155, 163\par\pard\plain\hyphpar} {
How Probable Are My Predictions? worksheet, 157\par\pard\plain\hyphpar} {
How Thoughts Influence Feelings and Behavior exercise, 12\u8211?14,
264\par\pard\plain\hyphpar} {
I\par\pard\plain\hyphpar} {
Identify a Client\u8217?s Stressors and Strengths worksheet, 34\u8211?
35\par\pard\plain\hyphpar} {
Identify Clients\u8217? Thoughts, Feelings, Physical Reactions, and Behavior
exercise, 15\u8211?16, 264\par\pard\plain\hyphpar} {
Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior exercise,
10\u8211?11, 263\par\pard\plain\hyphpar} {
Identify Specific, Measurable Goals exercise, 49\u8211?50,
267\par\pard\plain\hyphpar} {
Identify Suzanne\u8217?s Safety Behaviors exercise, 227\u8211?
228\par\pard\plain\hyphpar} {
Identify Suzanne\u8217?s Thoughts about Self, Others, and the Future exercise, 105,
270\par\pard\plain\hyphpar} {
Identify the Cognitive Distortion exercise, 112\u8211?113,
272\par\pard\plain\hyphpar} {
Identify Your Feelings handout, 90\par\pard\plain\hyphpar} {
if...then statements, 18\par\pard\plain\hyphpar} {
imagery, 129\u8211?131; exploring with clients, 130\u8211?131; practicing coping
thoughts using, 190; practicing new solutions using, 186; recreating situations
using, 129\u8211?130. {\i
See also} Practice in Your Imagination exercises\par\pard\plain\hyphpar} {
imaginal exposure, 229\par\pard\plain\hyphpar} {
in vivo exposure, 228\par\pard\plain\hyphpar} {
\u8220?Incorporating Imagery into Thought Records\u8221? (Josefowitz),
131\par\pard\plain\hyphpar} {
intermediary beliefs, 18\par\pard\plain\hyphpar} {
interpretations, alternative, 158\u8211?159, 171\par\pard\plain\hyphpar} {
Isabella Lists Her Worries exercise, 129\par\pard\plain\hyphpar} {
JKL\par\pard\plain\hyphpar} {
Jamar Is Feeling Depressed exercise, 212\par\pard\plain\hyphpar} {
Jim Forgets His Wallet exercise, 106\par\pard\plain\hyphpar} {
Josefowitz, Nina, 1, 131\par\pard\plain\hyphpar} {
journal writing, 218\par\pard\plain\hyphpar} {
Julie Has a Terrible Week exercise, 113\par\pard\plain\hyphpar} {
\u8220?Just Ask\u8221? questions, 122\par\pard\plain\hyphpar} {
kindness, practicing, 218\par\pard\plain\hyphpar} {
labeling feelings, 90\par\pard\plain\hyphpar} {
learning, active, 3\par\pard\plain\hyphpar} {
Lee Learns to Ask a Question exercise, 18\par\pard\plain\hyphpar} {
life, simple rules about, 18\par\pard\plain\hyphpar} {
Linehan, Marsha, 31\par\pard\plain\hyphpar} {
looking for evidence: against negative thoughts, 151\u8211?163; explaining to
clients the process of, 148; homework assignment on, 169\u8211?170; supporting
negative thoughts, 149\u8211?151; thought records and, 147\par\pard\plain\hyphpar}
{
M\par\pard\plain\hyphpar} {
magnifying problems, 111\par\pard\plain\hyphpar} {
Maia Was Attacked exercise, 228\par\pard\plain\hyphpar} {
Maria\u8217?s Symptom Maintenance Cycle exercise, 17, 265\par\pard\plain\hyphpar} {
Mary Treats Her Son Badly exercise, 95\par\pard\plain\hyphpar} {
memories, painful, 150\par\pard\plain\hyphpar} {
{\i
Mind Over Mood} (Greenberger & Padesky), 147\par\pard\plain\hyphpar} {
mind reading, 111\par\pard\plain\hyphpar} {
mindfulness, 210, 235\par\pard\plain\hyphpar} {
minimizing problems, 111\par\pard\plain\hyphpar} {
Miriam Wants a Better Marriage exercise, 55\par\pard\plain\hyphpar} {
mood: asking clients to rate, 63; planning activities to boost, 209\u8211?215;
related to thoughts, 133\u8211?134\par\pard\plain\hyphpar} {
mood-boosting activities, 209\u8211?215; examples of, 209\u8211?210; guidelines for
planning, 210\u8211?211; monitoring mood before/after, 212\u8211?214; overcoming
roadblocks to, 214\u8211?215\par\pard\plain\hyphpar} {
Mooney, Kathleen, 33\par\pard\plain\hyphpar} {
Myran, David, 1\par\pard\plain\hyphpar} {
N\par\pard\plain\hyphpar} {
Nasir Has a Busy Clinic exercise, 178\par\pard\plain\hyphpar} {
negative paths, 81\par\pard\plain\hyphpar} {
negative problem orientation, 175\par\pard\plain\hyphpar} {
negative thoughts: finding evidence against, 151\u8211?163; finding evidence
supporting, 149\u8211?151\par\pard\plain\hyphpar} {
Notice Raoul\u8217?s Change in Mood exercise, 133\u8211?134\par\pard\plain\hyphpar}
{
O\par\pard\plain\hyphpar} {
online materials, 3\u8211?4\par\pard\plain\hyphpar} {
optimism, 176, 218\par\pard\plain\hyphpar} {
Other Ways of Understanding the Situation worksheet, 161\par\pard\plain\hyphpar} {
others, thoughts about, 104, 107, 119\par\pard\plain\hyphpar} {
overgeneralizing, 110\par\pard\plain\hyphpar} {
P\par\pard\plain\hyphpar} {
Padesky, Christine, 33, 147, 155\par\pard\plain\hyphpar} {
painful memories, 150\par\pard\plain\hyphpar} {
patterns of limited thinking, 110\par\pard\plain\hyphpar} {
pause button, 82\par\pard\plain\hyphpar} {
personalizing, 111\par\pard\plain\hyphpar} {
Persons, Jackie, 155\par\pard\plain\hyphpar} {
perspectives, alternative, 158\u8211?159\par\pard\plain\hyphpar} {
physical reactions: feelings distinguished from, 9; helping clients identify, 94;
linking thoughts to, 135\u8211?137\par\pard\plain\hyphpar} {
pleasurable activities, 209\u8211?210\par\pard\plain\hyphpar} {
Pleasurable Activities List, 210\par\pard\plain\hyphpar} {
positive problem orientation, 175\u8211?177\par\pard\plain\hyphpar} {
positive psychology, 218\par\pard\plain\hyphpar} {
post-traumatic stress disorder (PTSD), 130\par\pard\plain\hyphpar} {
Practice in Your Imagination exercises, 4; for explaining a Daily Activities
Schedule, 204\u8211?205; for explaining exposure therapy, 231; for explaining goal
setting, 47\u8211?48; for explaining looking for evidence, 148; for explaining
problem solving, 180; for explaining session structure, 62; for exploring client
problems, 27; for reviewing sessions with clients, 73; for understanding your
reactions, 89\u8211?90\par\pard\plain\hyphpar} {
Predict Your Mood worksheet, 213\par\pard\plain\hyphpar} {
predictions: probability of negative, 156\u8211?158, 170; related to exposure
tasks, 236\u8211?238; thinking trap on making, 111\par\pard\plain\hyphpar} {
probing questions, 122\par\pard\plain\hyphpar} {
problem solving, 173\u8211?195; brainstorming solutions in, 180\u8211?183; choosing
a solution in, 184\u8211?187; developing coping thoughts for, 187\u8211?191;
explaining to clients, 179\u8211?180; homework assignments on, 192\u8211?194;
identifying problems for, 177\u8211?180; positive problem orientation for,
175\u8211?177; research on effectiveness of, 175; steps in process of, 174, 192;
theory behind, 174\par\pard\plain\hyphpar} {
Problem-Solving Worksheet, 174\par\pard\plain\hyphpar} {
problems: defining with clients, 177\u8211?178; how behaviors maintain, 16\u8211?
17; how thoughts maintain, 11\u8211?12; positive orientation to, 175\u8211?177;
prioritizing with clients, 31; process for understanding, 25\u8211?27, 28\u8211?30;
questions for exploring, 26\u8211?27, 28\u8211?30, 41\u8211?42; setting goals for
multiple, 47\par\pard\plain\hyphpar} {
prompting questions, 122\par\pard\plain\hyphpar} {
psychosocial history, 38\u8211?39, 250\u8211?251\par\pard\plain\hyphpar} {
Q\par\pard\plain\hyphpar} {
questions: asking helpful, 124\u8211?129; for assessing safety behaviors, 227; for
challenging hot thoughts, 155\u8211?156; for considering avoidance, 230; for
developing balanced thoughts, 163; for developing coping thoughts, 189; for
examining evidence against hot thoughts, 152; for exploring mood/activity
relationship, 205; for exploring problems, 26\u8211?27, 28\u8211?30, 41\u8211?42;
for exploring psychosocial history, 38; for exploring strengths, 33\u8211?34; for
finding new solutions, 181; for helping to define problems, 178; for identifying
images, 131; for identifying predictions about exposure, 237; for identifying
specific situations, 85\u8211?86; for identifying thoughts, 122, 124\u8211?129,
134\u8211?135; for reviewing therapy sessions, 72\u8211?73; for setting an agenda,
67; thoughts expressed as, 132\par\pard\plain\hyphpar} {
Questions for a Balanced Thought handout, 163\par\pard\plain\hyphpar} {
Questions to Develop Coping Thoughts handout, 189\par\pard\plain\hyphpar} {
Questions to Develop Helpful Goals handout, 51\par\pard\plain\hyphpar} {
Questions to Explore a Mood/Activity Relationship, 205\par\pard\plain\hyphpar} {
Questions to Explore Problems handout, 26\par\pard\plain\hyphpar} {
Questions to Explore Strengths handout, 33\par\pard\plain\hyphpar} {
Questions to Gather More Information about the Situation handout,
159\par\pard\plain\hyphpar} {
Questions to Help Set an Agenda handout, 67\par\pard\plain\hyphpar} {
Questions to Identify Evidence Against Negative Thoughts handout,
155\par\pard\plain\hyphpar} {
Questions to Identify Your Client\u8217?s Images handout,
131\par\pard\plain\hyphpar} {
Questions to Identify Your Client\u8217?s Predictions During Exposure handout,
237\par\pard\plain\hyphpar} {
Questions to Identify Your Client\u8217?s Thoughts handout,
134\par\pard\plain\hyphpar} {
Questions to Review the Therapy Session handout, 72\par\pard\plain\hyphpar} {
R\par\pard\plain\hyphpar} {
Raoul\u8217?s Boss Is Difficult exercise, 87\par\pard\plain\hyphpar} {
Raoul\u8217?s Cycle of Depression exercise, 201\par\pard\plain\hyphpar} {
Raoul\u8217?s Stressor\u8217?s and Strengths worksheet, 37,
266\par\pard\plain\hyphpar} {
rating feelings, 92\u8211?93, 98, 108\u8211?109\par\pard\plain\hyphpar} {
Raymond Drinks Too Much exercise, 116\par\pard\plain\hyphpar} {
reactions: worksheet for understanding, 82, 89\u8211?90, 99\u8211?100, 124, 136,
137, 139\u8211?140. {\i
See also} physical reactions\par\pard\plain\hyphpar} {
reassurance seeking, 226\par\pard\plain\hyphpar} {
reflective statements, 122\par\pard\plain\hyphpar} {
rehearsal, 226, 242\par\pard\plain\hyphpar} {
relapse prevention: behavioral activation and, 215; exposure therapy and,
242\par\pard\plain\hyphpar} {
Renee Tries to Catch Up at School exercise, 72\par\pard\plain\hyphpar} {
reviewing therapy sessions, 72\u8211?73, 76\par\pard\plain\hyphpar} {
Richard\u8217?s Boyfriend Wants to End the Relationship exercise,
106\par\pard\plain\hyphpar} {
Roger Doesn\u8217?t Want to Go to the Doctor exercise, 16\par\pard\plain\hyphpar} {
Ruda Attends Playgroup exercise, 38\par\pard\plain\hyphpar} {
S\par\pard\plain\hyphpar} {
safety behaviors, 226\u8211?228, 235, 243, 244\par\pard\plain\hyphpar} {
schemas. {\i
See} core beliefs\par\pard\plain\hyphpar} {
self: creating a new image of, 166\u8211?167; thoughts about, 104, 107,
119\par\pard\plain\hyphpar} {
self-assessment questions, 260\par\pard\plain\hyphpar} {
Separating Facts from Thoughts worksheet, 88, 269\par\pard\plain\hyphpar} {
session structure. {\i
See} therapy sessions\par\pard\plain\hyphpar} {
shame, understanding, 108\par\pard\plain\hyphpar} {
Sharon Is Invited for Coffee exercise, 15\par\pard\plain\hyphpar} {
should statements, 108, 111\u8211?112\par\pard\plain\hyphpar} {
Shula Eats Dessert example, 115\u8211?116\par\pard\plain\hyphpar} {
situations: examples of vague and specific, 85; four-factor model for
understanding, 8, 21\u8211?22; identifying specific and concrete, 84\u8211?87, 97;
identifying the meaning of, 124\u8211?127; recreating using imagery, 129\u8211?130;
separating facts vs. thoughts about, 87\u8211?88. {\i
See also} trigger situations\par\pard\plain\hyphpar} {
sleep guidelines, 258\par\pard\plain\hyphpar} {
social contact, 209, 218\par\pard\plain\hyphpar} {
Socratic questioning, 147, 162\par\pard\plain\hyphpar} {
solutions to problems: brainstorming, 180\u8211?183; choosing, 184\u8211?
187\par\pard\plain\hyphpar} {
Sophia Completes the Understand Your Reaction worksheet exercise,
137\par\pard\plain\hyphpar} {
strengths: exploring your own, 40; identifying client, 33\u8211?35,
43\par\pard\plain\hyphpar} {
stress management, 167\par\pard\plain\hyphpar} {
stressors: exploring your own, 40; identifying client, 32\u8211?33, 34\u8211?35,
43\par\pard\plain\hyphpar} {
SUDS ratings, 232, 235\par\pard\plain\hyphpar} {
Suzanne Avoids the Other Teachers exercise, 226\par\pard\plain\hyphpar} {
Suzanne Goes to the School Fair exercise, 189\par\pard\plain\hyphpar} {
Suzanne Is Asked to Be a Maid of Honor exercise, 162\par\pard\plain\hyphpar} {
Suzanne Is Upset with Her Husband exercise, 154\par\pard\plain\hyphpar} {
Suzanne Reviews Her Balanced Thought exercise, 165\par\pard\plain\hyphpar} {
Suzanne\u8217?s Stressors and Strengths worksheet, 34\u8211?
35\par\pard\plain\hyphpar} {
symptom maintenance cycle, 17\par\pard\plain\hyphpar} {
T\par\pard\plain\hyphpar} {
tasks, exposure, 232\u8211?235, 238\par\pard\plain\hyphpar} {
therapeutic relationship, 25, 96\par\pard\plain\hyphpar} {
Therapist Is Having a Bad Day exercise, 162\par\pard\plain\hyphpar} {
therapy sessions, 59\u8211?77; attitudes on structuring, 60, 75; basic components
of, 60; collaboratively setting an agenda for, 67\u8211?69; developing helpful
homework in, 70\u8211?72; explaining the structure of, 60\u8211?62; homework
assignments on structuring, 74\u8211?76; in Raoul\u8217?s therapy, 256\u8211?259;
requesting client feedback on, 73; reviewing with clients, 72\u8211?73, 76;
starting with a check-in, 62\u8211?66; in Suzanne\u8217?s therapy, 253\u8211?256;
working the agenda in, 69\par\pard\plain\hyphpar} {
thinking style, 110\par\pard\plain\hyphpar} {
thinking traps, 110\u8211?112; helping clients identify, 113\u8211?114, 120;
worksheet for identifying, 114, 117. {\i
See also} cognitive distortions\par\pard\plain\hyphpar} {
Thinking Traps handout, 110, 120\par\pard\plain\hyphpar} {
thought records, 145\u8211?147, 168\par\pard\plain\hyphpar} {
thoughts: automatic, 9, 18, 122\u8211?124, 248\u8211?249; balanced, 163\u8211?167;
as cognitive distortions, 109\u8211?116; coping, 187\u8211?191; distinguishing
feelings from, 9, 91; empathy related to, 25; evaluating self, others, or future,
103\u8211?106, 119; examining the reality of, 146; feelings related to, 12,
106\u8211?109, 127\u8211?128; four-factor model for understanding, 135\u8211?137;
hopes or questions as, 132; hot, 103, 145, 147, 155, 163; images accompanying, 131;
influence of core beliefs on, 18\u8211?21; looking for evidence about, 147, 148,
149\u8211?163; mood shifts related to, 133\u8211?134; problems maintained by,
11\u8211?12; questions for identifying, 122, 124\u8211?129, 134\u8211?135;
separating facts from, 87\u8211?88; worksheet for identifying, 138\u8211?
139\par\pard\plain\hyphpar} {
trigger situations, 83\u8211?89; facts vs. thoughts about, 87\u8211?88; identifying
specific and concrete, 84\u8211?87; worksheet for identifying, 83\u8211?
84\par\pard\plain\hyphpar} {
U\par\pard\plain\hyphpar} {
uncertainty, tolerance of, 158\par\pard\plain\hyphpar} {
Understand Janice\u8217?s Reactions exercise, 19\par\pard\plain\hyphpar} {
Understand Janice\u8217?s Vicious Cycle and Core Beliefs exercise,
20\par\pard\plain\hyphpar} {
Understand Mayleen\u8217?s Depression exercise, 203, 274\par\pard\plain\hyphpar} {
Understand Your Depression worksheet, 202, 220\par\pard\plain\hyphpar} {
Understand Your Reaction worksheet, 82, 89\u8211?90, 99\u8211?100, 124, 136, 137,
139\u8211?140\par\pard\plain\hyphpar} {
unless I\u8230?statements, 18\par\pard\plain\hyphpar} {
Use Graded Task Assignments exercise, 216\u8211?217, 276\par\pard\plain\hyphpar} {
V\par\pard\plain\hyphpar} {
video clips, 4; on brainstorming and choosing solutions, 186; on check-in and
agenda setting, 69; on creating balanced thoughts, 166; on defining problems and
setting goals, 180; on developing a fear hierarchy, 232; on developing coping
thoughts, 191; on explaining CBT to clients, 39; on explaining depression to
clients, 204; on exposure therapy, 236, 242; on identifying feelings, physical
reactions, and behavior, 96; on identifying thoughts, 128; on identifying trigger
situations, 89; on imagery for exploring thoughts, 131; on looking for evidence,
156; on monitoring mood before/after activities, 214; on planning mood-boosting
activities, 212; on probability of predictions, 158; on reviewing sessions and
asking for feedback, 73; on setting specific therapy goals, 55; on taking a close
look at the facts, 161; on understanding your client\u8217?s presenting problem,
31\par\pard\plain\hyphpar} {
virtual exposure, 228\u8211?229\par\pard\plain\hyphpar} {
W\par\pard\plain\hyphpar} {
web resources, 3\u8211?4\par\pard\plain\hyphpar} {
well-being, increasing, 218, 219\u8211?220\par\pard\plain\hyphpar} {
What Are My Feelings and Thoughts? worksheet, 138\u8211?139\par\pard\plain\hyphpar}
{
What Are My Thinking Traps? worksheet, 114, 117\par\pard\plain\hyphpar} {
What Is This Person Thinking? exercise, 14\par\pard\plain\hyphpar} {
What Is Your Trigger? worksheet, 83\u8211?84\par\pard\plain\hyphpar} {
What Thoughts Go with These Feelings? exercise, 109, 271\par\pard\plain\hyphpar} {
Wilson Feels Tense exercise, 72\par\pard\plain\hyphpar} {
worksheets: Are My Predictions Accurate?, 239\u8211?240; Benefits and Drawbacks of
My Solutions, 185; Examine the Reality of Your Thoughts, 146, 170; How Probable Are
My Predictions?, 157; Identify a Client\u8217?s Stressors and Strengths, 34\u8211?
35; Other Ways of Understanding the Situation, 161; Predict Your Mood, 213;
Problem-Solving, 174; Separating Facts from Thoughts, 88; Understand Your
Depression, 202, 220; Understand Your Reaction, 82, 89\u8211?90, 99\u8211?100, 136,
137, 139\u8211?140; What Are My Feelings and Thoughts?, 138\u8211?139; What Are My
Thinking Traps?, 114, 117; What Is Your Trigger?, 83\u8211?84. {\i
See also} handouts\par\pard\plain\hyphpar} {
worries: images associated with, 131; listing, 128\u8211?
129\par\pard\plain\hyphpar} {
XYZ\par\pard\plain\hyphpar} {
Yonas Asks a Question exercise, 127\par\pard\plain\hyphpar} {
YOUR TURN! exercises, 3; answers to, 263\u8211?277; on behavioral activation,
204\u8211?205, 211\u8211?212, 216\u8211?217; on exposure therapy, 227\u8211?228,
231, 241; for focusing on client problems and strengths, 27, 37; for helping
clients develop coping thoughts, 190\u8211?191; for helping clients reach their own
conclusions, 162; for identifying cognitive distortions, 112\u8211?113; for
identifying safety behaviors, 227\u8211?228; for identifying specific, measurable
goals, 49\u8211?50, 53\u8211?54; for identifying the meaning of situations,
125\u8211?126; for identifying thoughts about self, others, or the future, 105; for
identifying trigger situations, 86\u8211?87, 88; on looking for evidence, 148, 160;
on noticing mood shifts, 133\u8211?134; on problem-solving process, 180, 182\u8211?
183; on thoughts related to feelings, 109; for understanding a client\u8217?s
depression, 203; for understanding your reactions, 89\u8211?90; for using CBT
theory to understand clients, 10\u8211?11, 12\u8211?14, 15\u8211?16, 17; on working
within a session structure, 62, 66, 71, 73. {\i
See also} exercises (practice)\par\pard\plain\hyphpar} {
{\qc

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