South Central (Rural) MIRECC Clinical Education Product: A Therapist's Guide To Brief Cognitive Behavioral Therapy
South Central (Rural) MIRECC Clinical Education Product: A Therapist's Guide To Brief Cognitive Behavioral Therapy
South Central (Rural) MIRECC Clinical Education Product: A Therapist's Guide To Brief Cognitive Behavioral Therapy
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A THERAPISTS GUIDE TO
BRIEF COGNITIVE
BEHAVIORAL THERAPY
Published by the Department of Veterans Affairs, South Central Mental Illness Research,
Education, and Clinical Center (MIRECC), 2008.
Suggested citation: Cully, J.A., & Teten, A.L. 2008. A Therapists Guide to Brief Cognitive
Behavioral Therapy. Department of Veterans Affairs South Central MIRECC, Houston.
To request a copy of this manual, please contact Michael Kauth at [email protected]
ACKNOWLEDGMENTS
We would like to thank the multiple individuals and organizations that
supported this work. This project emanated from our passion for teaching
and our desire to increase the availability and quality of cognitivebehavioral therapies in health care settings. Our mentors and colleagues
were instrumental in their encouragement and feedback. We would like to
give special thanks to the following individuals: Evelyn Sandeen, PhD and
Melinda Stanley, PhD (expert consultants); Sparkle Hamilton, MA (project
assistant); and Heather Mingus (Graphic Artist); Anne Simons, PhD (past CBT
supervisor AT).
This work was supported by a Clinical Educator Grant from the South Central
0,5(&&
7+(%5,()&%70$18$/
This manual is designed for mental health practitioners who want to establish
a solid foundation of cognitive behavioral therapy (CBT) skills. Concepts
contained in the manual detail the basic steps needed to provide CBT
(Practicing CBT 101) with the intent that users will feel increasingly
comfortable conducting CBT. The manual is not designed for advanced
CBT practitioners.
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CBT builds a set of skills that enables an individual to be aware of thoughts and emotions;
identify how situations, thoughts, and behaviors influence emotions; and improve feelings
by changing dysfunctional thoughts and behaviors. The process of CBT skill acquisition is
collaborative. Skill acquisition and homework assignments are what set CBT apart from talk
therapies. You should use session time to teach skills to address the presenting problem and
not simply to discuss the issue with the patient or offer advice.
Brief CBT is the compression of CBT material and the reduction of the average 12-20 sessions
into four to eight sessions. In Brief CBT the concentration is on specific treatments for a
limited number of the patients problems. Specificity of the treatment is required because of
the limited number of sessions and because the patient is required to be diligent in using
extra reading materials and homework to assist in his or her therapeutic growth.
Brief CBT can range in duration from patient to patient and provider to provider. Although
variability exists, the following table shows an example session-by-session outline. You are
encouraged to think flexibly in determining length of treatment. Time-limited therapy may
offer additional incentive for patients and therapists to work efficiently and effectively.
However, the exact length of treatment will likely be determined by a host of factors
involving the therapist, patient, and treatment setting. As indicated in the following table,
you are not expected to rigidly adhere to a "set schedule" of progress or topics but rather
should be flexible and adaptive in approaching all brief CBT applications. For example, it is
often helpful to work within a "session-limited framework" where the patient receives four to
six sessions of "active" treatment, followed by one or more follow-up sessions that occur at
increasing intervals after the active-treatment phase (e.g., 2 weeks post treatment with an
additional booster 4 weeks after that).
Session 1
Session 2
Session Content
Orient the Patient to CBT.
Assess Patient Concerns.
Set Initial Treatment Plan/Goals.
Assess Patient Concerns (cont'd).
Set Initial Goals (cont'd)
Possible Modules
Module 5: Orienting the Patient
Module 4: Case Conceptualization
Module 6: Goal Setting
Module 4: Case Conceptualization
Module 6: Goal Setting
Or
Session 5
Session 6
Session 7
Session 8
When? (Indications/Contraindications)
Certain problems are more appropriate for Brief CBT than others. The following table
summarizes problems that may and may not be conducive to Brief CBT. Problems
amenable to Brief CBT include, but are not limited to, adjustment, anxiety, and depressive
disorders. Therapy also may be useful for problems that target specific symptoms (e.g.,
depressive thinking) or lifestyle changes (e.g., problem solving, relaxation), whether or not
these issues are part of a formal psychiatric diagnosis.
Brief CBT is particularly useful in a primary care setting for patients with anxiety and
depression associated with a medical condition. Because these individuals often face
acute rather than chronic mental health issues and have many coping strategies already in
place, Brief CBT can be used to enhance adjustment. Issues that may be addressed in
primary care with Brief CBT include, but are not limited to, diet, exercise, medication
compliance, mental health issues associated with a medical condition, and coping with a
chronic illness or new diagnosis.
Other problems may not be suitable for the use of Brief CBT or may complicate a
straightforward application of Brief CBT. Axis II disorders such as Borderline Personality
Disorder or Antisocial Personality Disorder typically are not appropriate for a shortened
therapeutic experience because of the pervasive social, psychological, and relational
problems individuals with these disorders experience. Patients exhibiting comorbid
conditions or problems also may not be appropriate because the presence of a second
issue may impede progress in therapy. For example, an individual with substance
dependence comorbid with major depression may not be appropriate because the
substance use requires a higher level of care and more comprehensive treatment than is
available in a brief format. However, Brief CBT could be used with Axis II and comorbid
patients in dealing with specific negative behaviors or in conjunction with more intensive
treatment.
Examples of Suitable and Unsuitable Problems for Brief CBT
Problem
Anxiety
Depression
Assertiveness
Diet
Exercise
Social Isolation
Specific Phobia
Grief/Bereavement
New Diagnosis of COPD
Coping with Chemotherapy
Caregiver Burden
Alcohol Dependence
Paranoid Personality Disorder
Crisis Intervention
Chronic PTSD
Divorce
Somatoform Disorder
Brief CBT?
Yes
Yes
Yes
Yes
Yes
Yes
Maybe
Yes
Yes
Yes
Yes
No
No
Maybe
No
Maybe
No
?
?
?
How? (Instructions/Handouts)
Therapist Considerations
It is important to be adequately skilled to evoke change in a patients life in a short amount
of time. You should periodically assess and seek supervision/consultation regarding your
capabilities in the process and content of Brief CBT.
The following are general therapist skills and abilities required for Brief CBT:
Supplemental Materials
Bond, F.W. & Dryden, W. (2002). Handbook of Brief Cognitive Behavioral Therapy. San
Francisco: Wiley.
Supervision is NOT
10
When? (Indications/Contraindications)
Ideally, supervision or consultation occurs on a regular basis. Typically, for therapists learning
CBT, supervision/consultation should occur every week or every other week. Monthly
consultation meetings may be appropriate for licensed practitioners in a more advanced
stage of psychotherapy training.
How? (Instructions/Handouts)
The following table outlines the most common formats for supervision. The usefulness of
each procedure will be determined by the goals of supervision and the supervisees level of
training and developmental needs. Exposure to multiple training modalities is seen as most
effective.
Format
Description
Advantages
Disadvantages
Verbal Report
- Less threatening to
therapists
- Allows for freeflowing discussion
between therapist
and supervisor
Process Notes
Audio/Video
Taping
- Less threatening to
clinicians
- Provides a more
detailed recount of
the session
(compared with
verbal report alone)
- Begins to identify
therapist issues during
session (process)
- Provides access to
objective and process
content of sessions
- Serves as an
excellent learning tool
- Subject to therapist
recollection (errors
and omissions)
- Limited ability for
supervisors to
monitor and provide
feedback on the
"process" of therapy
- Subject to therapist
focus and
recollection
- Limited ability to
monitor and provide
feedback on the
process of therapy
Group
Supervision
11
- Can be
threatening to
therapists (and
sometimes to
patients)
- Logistical issues
specific informed
consent for patients,
availability of
equipment
- Less individual
emphasis, not as
much time for each
therapist
Selecting a Supervisor/Consultant
The following are characteristics to seek out in selecting a CBT supervisor or consultant:
1) CBT knowledge and practice experience
o Ideally, CBT supervisors and consultants have received formal training in CBT
and use CBT in their daily practice settings.
2) Availability
o For those first learning how to apply CBT, it is highly recommended that you
identify supervisors/consultants who are available for weekly or bi-weekly
meetings that involve anywhere from 30 to 60 minutes per meeting. The
actual length of meetings can be determined by the number of cases being
reviewed.
o Consider logistical issues in scheduling. Would the supervisor/consultant be
available for in-person or telephone sessions (in-person is more effective)?
Consider proximity, travel, and availability of resources (e.g., audio/video
taping).
3) Experience with a patient population similar to those you will be serving.
Supplemental Readings
Bernard, J. M. & Goodyear, R.K. (2004). Fundamentals of Clinical Supervision 3rd
Edition. New York: Pearson.
Liese, B.S. & Beck, J.S. (1997). Cognitive Therapy Supervision. In Watkins, C.E. (Ed). In
Handbook of Psychotherapy Supervision. New York: Wiley; pp114-133.
12
13
facilitate more informed questions and better prepare the therapist for additional questions
and/or rapport development. Ultimately, the therapist has an added task of learning about
the culture of patients and appreciating life from their perspective.
Showing empathy to a patient helps to validate his or her experiences. Being critical, even
subtly, of what a patient is sharing in therapy often makes him or her feel judged and
unwilling to disclose additional information. Use validating responses to show empathy
towards a patient. Validating responses are simply statements of understanding of your
patients viewpoint. Validating responses usually entail the therapists describing what he or
she heard the patient say.
Genuineness
Genuineness is the ability to be authentic and free of dishonesty or hypocrisy. You can be
professional and express who you are at the same time. Genuineness helps build rapport
and solidify a therapeutic relationship by allowing the patient to view the therapist as a
human being. It also allows patients to access the genuineness of the therapist for credible
critical feedback about progress in their functioning.
Genuineness consists of wide variety of concepts ranging from nonverbal behaviors to overt
statements. Examples of factors related to genuineness include:
Supporting nonverbal behavior includes behaviors like keeping eye contact, giving
a patient your full attention, and nodding in agreement or understanding. Its
important that these nonverbal behaviors match what is going on in the
conversation, so as not to seem unnatural or fake.
Role behavior: CBT therapists encourage patients to be active and empowered
and subsequently attempt to facilitate this development through their behaviors in
therapy. Therapists that stress their authority in and between sessions with patients
14
15
necessary tool for all therapists. Clarification can be used to help simplify a message
that is being sent by the patient or to help confirm the accuracy of what the
therapist thinks he or she understood.
Patient:
Therapist:
Patient:
Therapist:
Patient:
Notice that the clarifying statement and question helped the therapist and patient
to more fully explore her feelings and thoughts. Given this new information, the
therapist is in a better position to explore in more detail the patient's concerns and to
set up targeted efforts and strategies for treatment.
Paraphrasing and Reflection: These techniques involve restating the patients main
thoughts in a different way or reflecting back the emotions the patient is currently
experiencing to gain depth or clarification.
Patient:
Therapist:
Patient:
Since my fianc's death, I feel like every day is a struggle, and I often
question whether my life will ever get better. I just miss him so much
that I think about him constantly. I don't know what to do, but the
pain is getting to be too much.
You are really struggling to feel better, and much of your pain comes
from the grief and loss you feel from losing your fianc. You may even
be questioning whether or not this pain will subside because it is
getting unmanageable.
Yes, that is correct. I do not want you to think that I think only about
the pain of losing him. The pain I feel comes from my intense feelings
of loss, but this pain is also because I miss all the things he meant to
me, and the joy he brought to my life. I am really struggling because I
do not want to let go of him, but holding on hurts so much.
In this example of paraphrasing, the therapist gives back to the patient what he or
she heard, which allows the patient to hear her own words and react with a more
detailed response. The use of paraphrasing in this example facilitated a deeper
understanding of the issue but also conveyed to the patient a feeling of being heard
and understood.
Listening for Themes and Summary Statements: Often, patients express thoughts,
feelings, and behaviors that become thematic across situations. Although novice
therapists may initially have difficulties identifying this thematic content, repetition
16
over time (e.g., across sessions) usually helps to create a clearer picture of the salient
therapeutic issues that require attention or focus. With experience, therapists
become more effective and efficient at identifying thematic content.
Once identified, thematic content can be a very powerful mechanism to influence
treatment outcomes. Summarization is the technique that brings thematic content
into the purview of the patient. Summarization is a condensed phrasing of the
patients responses over a specific period of time (e.g., across the session, since the
outset of treatment, since the onset of his/her current difficulties). You should
rephrase the themes, and repeat them back to the patient for clarification.
Barriers and Challenges to Building an Effective Therapeutic Relationship
Setting limits in an empathetic manner is an essential tool for new therapists. Many new
therapists desire to make it all better, in that they may coddle and console the patient
and are distracted from working on deeper issues. A therapist can create a holding
environment through empathetic words and active listening. A holding environment is a
setting in which the patient feels like he or she is being heard and that he or she is in a safe
and secure place to voice thoughts and feelings without judgment.
Moving from rapport and relationship building to assessment and goal setting can be
challenging. When therapist and patient are on the same page, this transition appears
seamless. Often, however, patients and therapists are not speaking the same language. For
example, a therapist may feel most comfortable when tackling a certain issue first; whereas
a patient may wish to focus on a different problem first. When the therapist and patient are
not in congruence regarding goals, the move between rapport building and goal setting is
strained. To overcome this issue, therapists are encouraged to use motivational interviewing
strategies (see Rollnick, Mason, Butler Chapters 3, 4, and 5). Primary techniques involve
listening to the patient, following the patient's lead and/or motivation, and setting
collaborative and mutually agreed-upon goals. A vital aspect to transitioning from rapport
to goal setting involves assessing the importance, confidence, and readiness of the patient
about specific treatment goals (see Goal Setting, Module 6).
Supplemental Readings
Beck, J. S. (1995). Cognitive therapy: Basics and beyond. Chapter 3. New York:
Guilford Press.
Cormier, W.H. & Cormier, L.S. (1991). Interviewing strategies for helpers: Fundamental
skills and cognitive behavioral interventions, 3rd edition. Chapters 2, 3, 4, 5. Pacific Grove,
CA: Brooks/Cole Publishing Company.
Rollnick S., Mason, P., & Butler, C. (1999). Health behavior change. A guide for
practitioners. Chapters 3, 4, 5. New York: Churchill Livingstone.
17
Conceptualization should begin during the first session and become increasingly
refined as treatment progresses.
An assessment of current difficulties and the creation of a problem list should occur
during the first session.
A treatment plan (including treatment goals) should be addressed early in treatment
(sessions 1, 2). Early conceptualization and treatment planning may require
modification as additional information becomes available.
Treatment plans and goals should be routinely revisited to ensure that the patient is
improving and agrees with the flow of the therapeutic work.
18
How? (Instructions/Handouts)
Case Conceptualization Step 1: Assessing Patient Concerns/Difficulties
The patient's presenting concerns and current functioning can be assessed in a number of
different ways. The following section outlines several possible avenues for identification of
problems/concerns.
A) Using established self-report symptom inventories. A common practice in CBT involves
the use of self-report symptom measures to assess baseline functioning as well as
therapeutic progress. Frequently used measures for depression and anxiety include Beck
Depression Inventory Second Edition, Patient Health Questionnaire (depression), Geriatric
Depression Scale, Beck Anxiety Inventory, and the State-Trait Anxiety Inventory.
Self-report measures are often completed by patients while in the waiting room and
evaluated by the clinician during the session. Often self-report measures can serve as a
routine agenda item during CBT sessions and can highlight important improvements and/or
continuing symptoms. Information obtained from these self-report inventories can also
provide insight into the way the patient thinks and behaves and factors that might be
important areas of need.
B) Problem lists. These are a common and useful strategy for identifying the psychological,
social, occupational, and financial difficulties faced by patients. Therapists who used
problem lists typically elicit a list of five to 10 difficulties from the patient during the first part
of session 1. Problems are best identified using open-ended questions (e.g., What brings
you to this clinic? What issues would you like to focus on in our work together?). Problems
are best described in terms of symptom frequency (How often does the symptom occur?),
intensity (How mild or severe is it?) and functional impact (What influence does the
symptom have on daily functioning or general distress?).
Some patients may describe their difficulties or goals in vague or abstract ways, such as, I
want to improve my life, or I want to be happy again. Problems and subsequent goals are
best described in specific terms to maintain clinical focus. For example, specific problems
are listed in the following table.
Problem
Socially
Isolated
Frequency
Stay at home 6
out of 7 days
Severity
Limited social contacts;
moderate-to-severe isolation
Pain
Experience
pain each hour
Occur 3 out of 7
days
Feelings of
Worthlessness
Fatigue
Occurs almost
constantly
19
Impact
Highly distressing; socially
debilitating; estranged
family/friends
Pain leading to decreased
activity level, inability to work
Highly distressing; influences
work, social, and intimate
relationships
Decreased activity level,
frequent naps, inability to
complete daily tasks
C) Assessing cognitions. Within the CBT model, it is often helpful to examine the patient's
thoughts especially as they are perceived by the patient. A commonly used, structured way
to examine these factors is to assess (ask questions related to) how the patient perceives
him-/herself, others, and the future. For example, a patient might describe him- or herself as
incapable, not useful, or a burden. He or she may generally perceive others to be critical or
hard to please. And his/her view of the future might be largely pessimistic and contain
beliefs that the future will include only more losses and disappointments (see also Thought
Records in Modules 9 and 10).
D) Assessing behaviors and precipitating situations. Precipitating situations are events,
behaviors, thoughts, or emotions that activate, trigger, or compound patient difficulties.
The Antecedents, Behavior, Consequences (ABC) Model is a formalized model for
examining behavior (symptoms) in a larger context. It postulates that behaviors are largely
determined by antecedents (events that precede behavior/thoughts/mood) and
consequences (events that follow the behavior/thoughts/mood).
The ABC model (see worksheet) is used in a functional assessment. It follows the premise
that behavior (B) is shaped by antecedents (A) and consequences (C). The antecedent
occurs before a behavior and may be a trigger for a particular reaction in the patient.
Behavior is any activity (even a thought or feeling) that the patient exhibits in response to
an antecedent. Consequences are events that occur after the behavior and direct the
patient to either continue or discontinue the behavior. Two kinds of consequences are
examined in a functional assessment: short-term and long-term consequences.
Antecedents: Antecedents, or events that occur before a behavior, typically elicit
emotional and physiological responses. Antecedents may be affective (an emotion),
somatic (a physiological response), behavioral (an act), or cognitive (a thought). They are
also subject to contextual (situational) and relational (interpersonal) factors. For example, a
patient who reports depression (behavior) may feel bad when he or she is alone at home
late at night (contextual antecedent) or better when he or she is around family (relational
antecedent). Alternatively, he or she may feel depressed by thinking, I will always be
alone (cognitive antecedent). Its important to remember that antecedents can both
increase and decrease a particular behavior.
To help your patient identify antecedents, teach him or her to pinpoint conditions that
affect his or her behavior.
What were you feeling right before you did that? (Affective)
What happens to you physically before this happens? Do you feel sick? (Somatic)
How do you normally act right before this happens? (Behavioral)
What thoughts go through your mind before this happens? (Cognitive)
Where and when does this usually happen? (Contextual)
Do you do this with everyone, or just when you are around certain people? (Relational)
Behaviors: A behavior is anything the patient does, feels, or thinks immediately following the
antecedent. Each behavior that your patient displays could potentially include an affective
component (feelings or moods), a somatic component (bodily sensations such as rapid
20
When completing a functional assessment, both short- and long-term consequences are
examined. Short-term consequences tend to be behavioral reinforcers, while long-term
consequences tend to be negative outcomes. In the case of addiction, the short-term
consequence of using a substance is intoxication, or escape from a negative mood; the
long-term consequence may be legal trouble, family problems, or a hangover.
Understanding the positive and negative consequences of a behavior for a patient helps
design the timing and nature of intervention. For example, in the case above, an
intervention would need to follow a noxious antecedent to offset the negative mood it
causes. Treating the negative mood would then decrease the need for escape through
substance use. A variety of questions may be used to elucidate a short-term consequence:
Does this behavior get you attention in some way?
What good things happen as a result of this behavior?
Does this help you in some way?
Do you feel a certain rush from doing this?
Does this behavior help you avoid something you dont want to do?
21
Case conceptualization in Brief CBT is much the same as with longer forms of
treatment with the following exceptions:
o Brief therapy leaves little room for delays in case formulation.
o The time constraints of brief therapy must be considered in all treatment/goalsetting endeavors. Treatment goals should be reasonable, measurable and as
simple as possible.
o Because of limited time, the focus of treatment in Brief CBT also generally limits
the depth of cognitive interventions. For example, it is quite frequent to
address automatic thoughts and intermediate beliefs as foci of treatment,
while addressing core beliefs is often difficult. If core beliefs are addressed, this
usually occurs indirectly through more surface-level intervention techniques or
at a time when the patient is particularly ready for such work.
22
23
Behaviors
(What did you do?)
Short-Term Consequences
(What was the result 1 second and 1
hour following behavior?)
24
Long-Term Consequences
(What were the lasting results?)
28
The cognitive model challenges this subjective experience and suggests, instead, that it is
the thoughts we have about situations that give rise to emotions. Individuals who are
depressed or anxious tend to display patterns of dysfunctional or inaccurate thinking. In
the cognitive elements of CBT, the therapist trains the patient in specific skills that help the
patient learn to improve his/her mood and change behavior by modifying the way hr or
she thinks about situations. A key tool in identifying and examining the associations between
thoughts, feelings, and situations is the thought record, which we will discuss in detail in
Module 10: Challenging Automatic Thoughts.
The behavioral aspect of CBT addresses how behaviors influence mood. The therapist works
with the patient to increase behaviors to improve mood and reduce behaviors associated
with negative mood. As depicted in the figure below, changing behaviors can change
feelings as well as thoughts. The associations among behaviors, thoughts, and feeling in CBT
are captured by social learning theory, which suggests that the likelihood of a behavior is
determined by its consequences. For example, social learning theory implies that a positive
behavior, such as exercise, will occur more frequently if a patient experiences pleasure and
a sense of satisfaction after completing physical activity. This is the premise of behavioral
activation (see Module 11).
29
Avoidance and escape are particular learned behavioral patterns targeted in CBT. For
example, not going to class because someone fears large crowds is an avoidance
behavior. If someone leaves class because of anxiety over a large crowd, it is an escape
behavior.
Initial Session
To prepare for the initial session, you are encouraged to thoroughly review all intake
information. You need the intake information to form an initial conceptualization and
formulation of a therapeutic plan. Using the patients presenting problems, symptoms,
current level of functioning, and history helps in developing the therapeutic plan. From the
intake information, it is also imperative that you assess the patients suicidality. This can be
done by asking about the patients suicidal ideation, intent, or plan and determining his or
her level of hopelessness, as well as the reasons for hopelessness. If the patients suicidality
seems high, then crisis intervention is above all other therapeutic considerations. In the case
of an acutely suicidal patient, you are encouraged to seek supervision or consultation and
follow approved clinic procedures for managing a suicidal patient (e.g., contact on-call
psychiatrist for evaluation).
Patient Expectations for Treatment
You should inquire about what the patient knows about how therapy is conducted.
Orienting your patient to therapy includes describing the cognitive-behavioral model and
answering any questions he/she might have about the progression of therapy. Using the
patients examples to help explain the cognitive-behavioral model will assist him/her in
being able to see how the model can work and how it has worked for other patients with
problems similar to his or hers. Often patients think therapy is a place where they will come
and be lectured and told what to do or a place to vent without a focus on behavior
change. It is essential in Brief CBT that the patient understands that therapy is a partnership
between the therapist and the patient, in which they work together so that the patient can
better understand feelings and solve problems.
Negotiating the amount of time the patient will need to be in therapy is also important. For
Brief CBT, patients typically attend weekly individual sessions for 4-8 weeks. However, the
amount of time in therapy and the number of days a week can be reassessed periodically
and adjusted to meet the needs of the patient.
Discussing Symptoms and Diagnostic Issues with the Patient
Most patients want to know how they have been diagnosed. Explain the disorder in terms of
cognitive and behavioral symptoms, to clarify how CBT will directly address their problems.
Giving patients descriptions of common symptoms of their disorder can also be helpful.
Example: There are cognitive and behavioral aspects of feeling depressed.
Cognitive characteristics of depression include having negative thoughts
about yourself, such as I am no good, or Things are not going to get
better. Behavioral characteristics are ways your body tells you youre
depressed, such as changes in your appetite or sleep patterns.
30
Feedback
The collaborative piece of CBT involves asking a patient for feedback on the session (e.g.,
What did you think about our session today? Did we leave out anything you think is
important to discuss?) and on how he/she feels about the cognitive-behavioral model
(Do you feel you have at least a basic understanding of the model, or should we be sure
to review it in detail again next week?) at the end of the first and subsequent sessions.
Encouraging the patient to offer feedback strengthens the rapport and trust within the
therapeutic relationship and indicates to the patient that they are an active member of the
therapeutic process. It shows that the therapist cares about what the patient thinks and
feels and values his/her input. This is also a time to resolve misunderstandings about the
cognitive model or things that occurred in the session (Was there anything that bothered
you about the session, or anything that youd like to change?). Getting feedback from the
patient shows how important it is to work as a team and also helps you work on sharpening
your abilities in therapy. It also allows you to attend to and repair any real or perceived
therapeutic fissures or needed treatment modifications in a timely way.
Important Introductory Elements
Introduce Processes of Psychotherapy
o Transparent
o Collaborative
o Time-Limited
Introduce Cognitive-Behavioral Model
o Research Basis
o Association between behaviors, thoughts, feelings, and
situations
o Use of examples from patients past week to clarify associations
Educate the patient about his/her disorder
o Describe patients problems in cognitive and behavioral terms
Instill hope and empowerment
o Request for feedback
o Creation of a warm, collaborative therapeutic environment
31
32
Example
Goal: Learn two cognitive and two behavioral strategies for coping with stress.
Operational Cognitive Goals
o Learn and use thought testing and problem solving to manage
anxious thoughts/situations
Operational Behavioral Goals
o Plan and complete one pleasant or social activity per week
33
seems to have trouble understanding the assignments, focus on more concrete and
behavioral skills.
34
35
36
37
38
[This worksheet is to be completed by the patient prior to beginning the session (e.g., in the
waiting room) to prepare for therapy and assist in collaboratively selecting agenda items.]
BRIDGING SESSIONS
1. What main points did we reach in our last session? What did you learn from last
session? Did anything come to mind in the past week about our last session that
youd like me to know or that youd like to discuss?
2. Were you uncomfortable about anything we talked about in our last session? Is there
anything you wish we had discussed that we didnt?
3. How is your mood? (How is your physical health?) Compared with last week, is it
better or worse?
4. What treatment goals would you like to work on today? What problems would you
like to put on the agenda?
5. What homework did you attempt or complete for last session? What did you learn
from doing it?
39
Module 8: Homework
Objectives
To understand how homework is introduced and used in Brief CBT
To understand techniques for increasing homework utility and compliance
What is homework, and why is it a central part of CBT?
Homework is an essential and effective component of Brief CBT. Because of the condensed
number of sessions in Brief CBT, assignments such as readings, behavior monitoring, and
practicing new skills should be given to the patient to practice and use outside sessions.
Homework assignments facilitate patient skill acquisition, treatment compliance, and
symptom reduction by integrating the concepts learned in sessions into daily life.
Homework is a key mechanism for facilitating between-session work and progress.
When? (Indications/Contraindications)
Give homework assignments throughout treatment. The nature and frequency of
assignments is left to your discretion. Consider patient characteristics when assigning
homework, specifically reading ability, cognitive functioning, level of distress, and
motivation. During the beginning stage of therapy, suggest homework; but, as therapy
progresses, encourage the patient to generate between-session activities. This helps the
patient to continue to use skills outside therapy and after the end of treatment. Some
patients may be hesitant to participate in homework assignments, so it is your responsibility
to be open to patient feedback about assignments, give reasons for each task, and
personalize homework assignments for each patient.
How? (Instructions/Handouts)
Seven Tips for Setting Homework
1. One Size Does Not Fit All.
Always tailor assignments to patients. Their reading level, desire to change, cognitive
functioning, and, even, stage of life determine how much and what type of homework
assignment fits them best. For example, a single, working mother who is also a full-time
student may not have time to read a complete book as a bibliotherapy assignment.
Assigning her a small part of the book or an article may be more reasonable. Breaking
assignments down into smaller parts is also useful. Always consider the patients diagnosis
and presenting problem when assigning homework and ask yourself
Can the patient handle this homework, and will it be beneficial to his/her growth?
Could there be a negative result from this assignment; and, if so, is the patient
prepared to handle it outside session?
2. Explain In Detail.
Knowing the reason for an assignment and how it relates to overall treatment goals helps
the patient understand why he/she is doing the assignment and also may encourage
him/her to complete it. Most patients are interested in how certain activities may improve
their situation or relieve their symptoms. Explain assignments in the context of treatment
goals and the cognitive model to enhance patient buy-in to the tasks.
40
41
42
the right answer, and that they should concentrate on recording real feelings and
thoughts and not concern themselves with spelling, grammar, or appearance of the
assignment.
Therapist Cognition Problems
Although completion of homework is primarily the patients responsibility, sometimes your
thoughts about an assignment or approach to homework plays a role in noncompliance.
Check your own thoughts about assigning homework, and determine whether there is
anything you can adjust in your approach that could better encourage the patient. Ask
yourself, Is the assignment too difficult?, Did I explain the assignment thoroughly?, or
Have I led the patient to believe that homework is unimportant to therapy?
Sample Homework Assignments
Examples of homework that could be assigned for each cognitive and behavioral skill are
included in each module. Examples of tailoring a homework assignment to a specific case
are included in Appendix B.
Supplemental Readings
Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press;
Chapter 14.
Burns, D.D. (1999). Feeling good handbook. New York: Plume Books (Penguin USA).
Cormier, W.H. & Cormier, L.S. (1991). Interviewing strategies for helpers: Fundamental
skills and cognitive behavioral interventions, 3rd ed. Pacific Grove, CA: Brooks/Cole
Publishing Company; Chapters 12, 16, & 19.
Greenberg, D. & Padesky, C.A. (1995). Mind over mood: Change the way you feel
by changing the way you think. New York: Guilford Press; Chapters 3, 6, 7, 8.
Rollnick S., Mason, P., & Butler, C. (1999). Health behavior change. A guide for
practitioners. Chapters 3, 4, 5. New York: Churchill Livingstone.
43
An automatic thought is a brief stream of thought about ourselves and others. Automatic
thoughts largely apply to specific situations and/or events and occur quickly throughout the
day as we appraise ourselves, our environment, and our future. We are often unaware of
these thoughts, but are very familiar with the emotions that they create within us.
Maladaptive automatic thoughts are distorted reflections of a situation, which are often
accepted as true. Automatic thoughts are the real-time manifestations of dysfunctional
beliefs about oneself, the world, and the future that are triggered by situations or
exaggerated by psychiatric states, such as anxiety or depression.
Intermediate beliefs are attitudes or rules that a person follows in his/her life that typically
apply across situations (not situation specific as with automatic thoughts). Intermediate
beliefs can often be stated as conditional rules: It x , then y. For example, If I am thin,
then I will be loved by others. Individuals create these assumptions by categorizing the
information they receive from the world around them. These rules guide thoughts and
subsequently influence behaviors.
Dysfunctional core beliefs drive dysfunctional rules and automatic thoughts. For example,
the belief, I am unlovable, may be driving the conditional rule, If I am thin, then I will be
loved by others, which may drive obsessive thinking about ones appearance, excessive
exercise, or disordered eating habits. Core beliefs are often formed in childhood and
44
solidified over time as a result of ones perceptions of experiences. Because individuals with
psychological disorders tend to store information consistent with negative beliefs but ignore
evidence that contradicts them, core beliefs tend to be rigid and pervasive. Although
automatic thoughts are often tied to a specific situational trigger, intermediate and core
beliefs are more global and cut across domains. Beck suggests that individuals tend to have
core beliefs that involve either interpersonal (Im unlovable) or achievement issues (Im
incompetent).
When? (Indications/Contraindications)
Identifying maladaptive automatic thoughts is the first step in the cognitive component of
therapy. The focus of intervention in Brief CBT is the dysfunctional automatic thought.
Patients must master identifying and challenging thoughts to be able to grasp the concept
and techniques of challenging beliefs. Because of the interrelated nature of thoughts and
beliefs, an intervention targeting automatic thoughts may also change underlying beliefs
(depicted below). Therefore, Brief CBT can result in belief modification, even if the target of
treatment was automatic thoughts.
Because patients progress through treatment at different rates, you may be able to identify
and challenge some beliefs late in brief therapy (sessions 5-8) for some patients. For other
patients, work will be limited to automatic thoughts.
Because skill building to alleviate symptoms and prevent relapse is a
central focus of CBT, mastery of skills is paramount. Focus on building a
skill set with the patient that he or she can generalize to different
situations, thoughts, or beliefs. It is less important to identify and modify
deep-seated childhood beliefs. For most patients in Brief CBT, this will not
be necessary for symptom reduction. However, some patients may
benefit from this work.
45
Although you may not discuss beliefs directly with the patient, as part of the case
conceptualization, he/she should constantly be forming hypotheses about what beliefs
may be driving the thoughts (see Module 4: Case Conceptualization and Treatment
Planning).
In identifying thoughts and beliefs, ask yourself several questions.
After an automatic thought or belief is identified, it is challenged using the skills in Module 9.
How? (Instructions/Handouts)
Explaining Automatic Thoughts to Your Patient
It is important for the patient to understand the rationale for identifying automatic thoughts
before acquiring the skill of addressing his/her own thoughts. Using the situationthought
feeling triangle introduced in Module 5 (Orienting the Patient to Brief CBT) can be helpful in
explaining automatic thoughts. Completing the triangle with the patients recent or current
automatic thoughts can facilitate his/her understanding.
Therapist:
Pamela:
Therapist:
Pamela:
Therapist:
Using the patient's example, describe the association between thoughts and feelings to
build awareness of the connection. This is a good time for the patient to write down the
thought and begin using the cognitive-behavioral model.
Therapist:
Pamela:
Therapist:
Pamela:
Therapist:
Pamela:
So, lets write down this automatic thought that you are having. I will never
get married. Your going to your cousins wedding was the situation that
triggered the thought, I will never get married.
Yes, thats true.
When you were at the wedding and that thought came to you, how did you
feel?
I felt really sad and hopeless.
So, can you see how our thoughts can affect our mood and change the way
we are feeling?
Yeah, I guess if I hadnt had that thought, I wouldnt have felt so bad.
46
Therapist:
Patient:
47
Example continued:
Therapist:
Lets take a look at that line of thinking and the feelings it creates. It seems
that when that thought entered your mind, your mood changed very quickly.
Did you notice that?
Patient:
Yeah, I guess it did upset me pretty fast.
You usually will also need to use specific questions to elicit an automatic hot thought. These
questions are found on p. 48-49 and in Module 10.
Automatic Thoughts Between Sessions
In Brief CBT, a principal characteristic is the work the patient does outside of session.
Because identifying automatic thoughts is a novel concept to many, practicing outside of
session will facilitate movement and change in therapy. In fact, Burns and Nolen-Hoeksema
(1992) found that patients who completed homework had significantly better treatment
outcomes than those who did not. Practicing key skills between sessions allows session time
to be used for new skill acquisition and troubleshooting. Initially, when a specific situation is
brought up in session, always ask, What was going through your mind at that moment?
This helps the patient build awareness of his/her automatic thought, both within and outside
of session.
Because automatic thoughts may occur outside awareness, asking for a more detailed
description of the situation is also helpful in pinpointing maladaptive thoughts. For example,
you could "take the patient back" to when it happened, using imagery (e.g., Where were
you when this happened? What time of day was it?). If the patient reverts to past tense,
remind him/her to tell the story in present tense to help bring back the thoughts and feelings
that occurred in this situation.
With continued questioning, it is possible that there may be more than one automatic
thought associated with a problematic situation. Elicit and record all automatic thoughts
given for a particular situation.
Therapist:
Craig:
Therapist:
Craig:
Therapist:
Craig:
Craig, what else were you thinking during this phone call
with your wife?
I was thinking that she knows how bad I feel for not coming
to the party and she wants me to feel even worse.
So you werent thinking only that they were using you. You
were also thinking that they knew you felt bad, and they
wanted you to feel worse?
Yes.
So, that is really three different thoughts that you were
having that were creating feelings of anger?
I guess so.
Remember that a patients automatic thoughts should be the actual words or images that
go through his or her mind. Patients (or therapists) may often interpret or rephrase thoughts;
however, the goal is to get unprocessed thoughts verbatim.
48
Look for an intermediate belief that comes in the form of a patients automatic
thought.
Provide the first part of an assumption (If x), and enlist the help of the patient to
complete it.
Elicit a rule or an attitude from the patient, and change it into an assumption.
Look for themes in the patients automatic thoughts. Either come up with a
hypothesis, or ask the patient to identify a theme.
Ask the patient directly about his or her beliefs.
Have the patient complete a questionnaire or inventory that will help identify his/her
beliefs (e.g., Dysfunctional Attitudes Scale).
49
Core Beliefs
Throughout therapy, hypothesize core beliefs that may be underlying dysfunctional
behaviors and thoughts. These hypotheses aid development of the case conceptualization
and treatment plan (see Module 5). A belief that is likely to be core will appear in several
different areas of the patients life (i.e., relationships, work, parenting).
If time permits in Brief CBT, after you have collected enough evidence to support the
alleged core belief, present and discuss it with the patient.
Ive heard you say several times that you either didnt do a good
job, or that someone else put in more time and energy. It seems to
me that you feel inadequate a lot of the time. Is that right?
At this point, you can also elicit childhood experiences consistent with the belief. This helps
identify the possible origin of the belief and helps you explain it to the patient.
In educating the patient about core beliefs, make several things clear:
Core beliefs are only ideas. Feeling them strongly does not make them true.
These beliefs started developing during childhood. The patient believes them today
because he/she has stored evidence to support them and rejected evidence to
contradict them.
These beliefs can be tested and changed through use of the techniques that will
be taught in therapy.
50
THOUGHT RECORD
(1) Situation
Out of breath when I
played in the park
with my
granddaughter
(2) Automatic
Thought(s)
Im too old to play with
her.
Sad
I cant be her
caregiver.
Sad
What actually
happened? Where?
What? How? When?
(4) Evidence to
Support Thought
(6) Alternative
Thought
(7) Rate
Mood
Now
What is
another way to
think of this
situation?
0-100
Disappointed
Hopeless
Hopeless
Worthless
Hopeless (80)
Worthless (90)
What
emotion(s) did
you feel at the
time? Rate how
intense they
were (1-100).
51
Helpful Questions
Situational
Questions
Feeling
Questions
Thought
Questions
52
Cognitive Distortions
1. All-or-nothing thinking: Viewing situations on one extreme or another instead of on a
continuum.
Ex. If my child does bad things, its because I am a bad parent.
2. Catastrophizing: Predicting only negative outcomes for the future.
Ex. If I fail my final, my life will be over.
3. Disqualifying or discounting the positive: Telling yourself that the good things that happen
to you dont count.
Ex. My daughter told her friend that I was the best Dad in the world, but Im sure
she was just being nice.
4. Emotional reasoning: Letting ones feeling about something overrule facts to the
contrary.
Ex. Even though Steve is here at work late every day, I know I work harder than
anyone else at my job.
5. Labeling: Giving someone or something a label without finding out more about it/them.
Ex. My daughter would never do anything I disapproved of.
6. Magnification/minimization: Emphasizing the negative or playing down the positive of a
situation.
Ex. My professor said he made some corrections on my paper, so I know Ill
probably fail the class.
7. Mental filter/tunnel vision: Placing all ones attention o, or seeing only, the negatives of a
situation.
Ex. My husband says he wishes I was better at housekeeping, so I must be a lousy
wife.
8. Mind reading: Believing you know what others are thinking.
Ex. My house was dirty when my friends came over, so I know they think Im a
slob.
Ex. My daughters boyfriend got suspended from school. Hes a loser and wont
ever amount to anything.
9. Overgeneralization: Making an overall negative conclusion beyond the current situation.
Ex. My husband didnt kiss me when he came home this evening. Maybe he
doesnt love me anymore.
10. Personalization: Thinking the negative behavior of others has something to do with you.
Ex. My daughter has been pretty quiet today. I wonder what I did to upset her.
11. Should and must statements: Having a concrete idea of how people should behave.
Ex I should get all As to be a good student.
53
54
55
patients will generate new emotions from the alternative thought. However, it is most
important first to re-rate the old mood before generating new emotions.
The same strategy of generating an alternative thought for a dysfunctional thought is used
when challenging a core belief. Once the belief is identified, the evidence is weighed and
a new more balanced belief is generated.
56
There will not always be an immediate change to a patients mood after a thought record
is completed. It might be necessary to assess why there is no change. It could be attributed
to the patients deeply rooted belief in the automatic thought, to an unchanged underlying
core belief, or to additional automatic thoughts that have not been evaluated. It is
necessary to ask: Why was there no mood change after completion of the Thought
Record? These other questions will also be helpful.
If thought/belief testing is ineffective in reducing negative mood, you can also explore the
advantages and disadvantages of maintaining a thought/belief. As we know, there are
many disadvantages to negative beliefs we have, but there are also advantages. The
patients perceptions of the advantages may be obstructing the change process.
Understanding the function of the thought/belief for the patient may be useful in clarifying
why certain thoughts/beliefs are resistant to modification. The therapist should evaluate
both the advantages and disadvantages of a patients assumptions and beliefs, but in
doing so work to diminish the advantages and highlight the disadvantages.
Often, when working to modify thoughts and beliefs, the patient may find evidence that
supports the negative belief instead of evidence that contradicts it. If there is a good
amount of evidence to support that negative core belief, then problem solving, rather then
thought testing, is an appropriate strategy (see Module 12).
Seven Tips for Effective DTRs
1.
You must have mastered the use of DTR before introducing it to patients.
2.
Reinforce and make sure that the patient believes in the cognitive model being used.
3.
Teach the DTR in two sections: (1) The first three columns; Situation, Automatic
thought(s), and Emotion(s), and (2) the last four columns; Evidence for and against
thought, Alternative response, and New rating of emotion.
4.
Use the patients exact words when recording thoughts and feelings. Working with
thoughts verbatim preserves the emotions or personal meaning for each thought.
5.
The patient should be able to adequately complete the first three columns of the DTR
before learning about the last four columns.
6.
Completing a DTR is a skill and, like other Brief CBT skills, requires practice. Success
depends on the patients understanding of the steps. Encourage the patient to take
time with the skill and work through any frustration.
7.
If the patient is not collaborative in completing the DTR in session or does not complete
DTR homework, it is possible that he or she might have automatic thoughts about this
type of exercise. Ask the patient to create a thought record of the DTR experience.
57
58
(1) Situation
Out of breath
when I played in
the park with my
granddaughter
(2) Automatic
Thought(s)
(3) Emotion(s)
Defeated
I cant do what I
used to do.
Sad
I cant be her
caregiver.
Sad
I have nothing to
offer my family
anymore.
Disappointed
Hopeless
I am a burden to my
family.
Hopeless
Worthless
I am no good to my
family.
Hopeless (80)
Worthless (90)
What
emotion(s) did
you feel at the
time? Rate how
intense were
they?(1-100)
THOUGHT RECORD
(4) Evidence to
Support Thought
My family has to
look in on me more
often than they
used to.
(6) Alternative
Thought
(7) Rate
Mood Now
Because of my
COPD and
because I am
getting older, I
have more
physical
limitations than
I used to, and I
do need my
familys help
from time to
time, but I am
able to offer
them many
valuable
things and
contribute to
my grandkids
lives.(80)
Hopeless
(10)
I contribute to my family
in new ways, such as
offering advice and
support.
I still live independently.
What actually
happened?
Where? What?
How? When?
I am able to do many
things physically, though I
do have more limitations
than I used to.
What has
happened to make
you believe the
thought is true?
59
What is
another way to
think of this
situation?
Worthless (5)
0-100
60
The use of behavioral activation for anxiety conditions requires a little more detail. Patients
with anxiety symptoms often avoid situations out of fear of negative consequence
occurring in response to engaging in a particular activity. Although behavioral activation
can aid these patients, you must also understand that the activity itself is not reinforcing
(pleasant) but rather feared. It is only the resulting completion of the task that may
generate positive affect (e.g., I faced my fear, and nothing terrible happened). This
response differs from depression in that depressed patients will often look at behavioral
activation as a positive outcome in and of itself (e.g., "exercising is enjoyable" or "I love
talking with my grand-daughter"). To effectively apply behavioral activation with anxious
patients, it is important to monitor anxiety and combine behavioral activation with relaxation
techniques to increase patient comfort and control. Similarly, be careful not to allow
behavioral activation procedures to further aid in the patients avoidance of fearful
situations (e.g., presenting problem is avoiding interpersonal difficulties with spouse, and
patient chooses to shop or be on the internet for pleasure but specifically when spouse is in
the house to avoid confrontation/talking about issues).
How? (Instructions/Handouts)
Step #1: Provide patient with rationale for behavioral activation.
It is important to educate the patient as to what behavioral activation is and how it can be
useful for improving depression and anxiety. Let him/her know that when feeling a little
down or having a bad day and not feeling well physically can make it more likely that he or
she will stop doing many activities that used to be pleasurable. When this happens, the
patient can get into the habit of avoiding pleasant activities that might actually help
him/her feel better. It is also important for the patient to understand the connection
between what he or she does and how he/she feels, both mentally and physically. You are
encouraged to explain to the patient that increasing activity and/or taking action, even
when we do not feel like it, help one to feel better physically, as well as decrease
depression.
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
Patient:
Therapist:
I would like to talk a little about what your day looked like yesterday. Walk me
through your day (e.g., what did you do in the morning, afternoon, evening)
Well, in the morning I woke up at 10 am and ate breakfast. I watched TV until
noon. Then I ate lunch. Around 2:30 I took a shower. At 3:00 I went for a walk with
my dog.
Okay, thanks. How did you feel in the morning?
Tired. I just couldn't get motivated and did not want to do anything. I guess I was
feeling sorry for myself depressed, I guess.
You say you were feeling depressed. If you had to rate that feeling on a scale of 0
to 100 (100 is worst depression) what would you say your depression was?
65.
What about in the afternoon after your shower and walk? How would you rate your
depression?
20.
To what do you attribute this change in your depression?
I guess I just got off my couch and started moving which helped me feel better.
That would be my guess as well. (subsequently, explain the connections between
mood and behavior and encourage use of behavioral activation).
61
The figure below visually describes the connection between mood and behavior and can
be an effective aid in communicating with patients. To maximize the utility of the figure, you
are encouraged to use the patient's own examples. For example, you and the patient can
work together to complete a daily activity log (see handout). From this activity log, you
might highlight activities that appeared to raise or lower the patient's mood.
If depressed persons increase their activities on a daily basis, it improves mood and
decreases symptoms of depression.
62
For patients who have difficulty identifying activities, you can introduce a behavioral
activity checklist (see Appendix).
Before completing the next steps (e.g., setting a plan), it is important to discuss the potential
importance of the behavior with the patient. If he/she reports low importance, encourage
the patient to find another, more meaningful activity.
Step #3: Setting an Action Plan.
Once the patient has identified a meaningful activity to focus on, help shape this work into
a meaningful therapeutic goal. Action plans are one mechanism of creating meaningful
behavioral goals for therapy. Action plans in their most basic form stipulate the specific goal
to be obtained, defined in terms of observable and measurable characteristics and a
timeframe for monitoring progress.
Example:
Goal: To read at least three times per week (a minimum of 30 minutes per
reading session).
Timeframe: Patient will complete three reading sessions over the next week.
63
meaningful activities related to the prior occupation. In this case, the patient might benefit
from volunteering at a university, providing consultation (e.g., over email or telephone calls),
or volunteering for a local school, youth or church organization (e.g., talking about
engineering).
2) It is also helpful and supportive to look for ways that others can help. Family or other
social networks that the patient has not yet fully engaged might exist, which might assist the
patient in moving forward on goals.
3) Pleasant activities are the best first step. Pleasant activities are doubly beneficial to the
patient, as they increase activity and feelings of pleasure. Activities designed to overcome
avoidance or increase a sense of accomplishment should be entertained as the first goals
only if highly important to the patient or apparently salient to the attainment of future goals.
Summary of Steps
Step 1.
Step 2.
Step 3.
Step 4.
Step 5.
64
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Thursday
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66
reacting to emotions (e.g., depression). This problem may be better served using
another skill (e.g., maladaptive thoughts module).
How? (Instructions/Handouts)
Problem-Solving Therapy (PST)
In problem-solving therapy, it is important that you first educate the patient about the
problem-solving strategies that will be used during sessions. To enable the patient to use the
strategies after therapy ends, teach him/her to carefully examine a problem, create a list of
solutions, and make decisions about which strategies are appropriate for a variety of
problems.
General guidelines for using problem-solving strategies are as follows:
67
Emotional/Social/Relationship Problems
Managing Mood
Difficulty Communicating
Marital Stress
Family Stress
**To effectively use the SOLVED technique, problems may need to be more specific than those
listed above.
68
Other examples of problem-solving worksheets are listed at the end of this module. These
worksheets expand the common pros and cons lists to help a patient consider multiple
perspectives and outcomes before making a decision.
Homework Examples:
1. Create a list of possible solutions to your identified problem (brainstorm).
2. Implement your identified solution, assess it effectiveness, and modify as
necessary.
Supplemental Readings
Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press;
Chapter 6.
Cormier, W.H. & Cormier, L.S. (1991). Interviewing strategies for helpers: Fundamental
skills and cognitive behavioral interventions, 3rd ed. Pacific Grove, CA: Brooks/Cole
Publishing Company; Chapter 13.
69
pecific Problem:_________________________________________________
_________________________________________________________________________________________
_______________________________________
ist
PROS
AND
CONS
1.
2.
3.
4.
] YES
70
] NO
_____
71
72
73
comfortable with certain recommendations (e.g., unfolding arms) but may be uncertain or
uncomfortable with others (e.g., closing their eyes). The following list of options can be used
to create an effective atmosphere for relaxation-based interventions.
Setting up the room:
- Comfortable chair (a high-backed chair to support the patients neck, if possible)
- Safe and relaxing room (e.g., temperature, noise, and lighting)
The following sections of this module addresses three specific techniques: progressive
muscle relaxation, deep breathing, and imagery. You largely determine selection of a
specific technique, but you should select it with the patient's expressed interests and
learning preferences/abilities in mind. For example, patients who are largely somatically
focused may prefer muscle relaxation or deep breathing. Other patients, especially those
who appreciate the association between thoughts and mood, might be best served using
guided imagery procedures. However, the ultimate decision of which procedure to use
may relate to exposure to all three techniques and a trial-and-error approach.
Progressive Muscle Relaxation (PMR)
PMR consists of learning how to tense and then relax various groups of muscles all through
the body in a sequential fashion, while paying close attention to the feelings associated
with both tension and relaxation. Although muscle relaxation has been around for many
years, it has become more popular recently for dealing with different anxiety and panic
disorders. With this procedure, the patient learns how to relax and how to recognize and
pinpoint tension and relaxation in the body to identify tension and reduce its influence
before each reaches high levels/impairment.
In teaching patients muscle relaxation, you should first explain the reason for using muscle
relaxation and how it will benefit the patient (rationale). You should also give a full
explanation and demonstration of how it is done.
Step #1: PMR Increases Control.
Introduce PMR principles and procedures. PMR begins by letting the patient know that
he/she can create sensations of relaxation and that this process of inducing relaxation
begins by being able to identify and discriminate between sensations of tension and
relaxation.
Step #2: Note the Incongruence of Tension and Relaxation.
Inform the patient that sensations of tension and relaxation cannot occur at the same time.
No muscles in the body can be tensed and relaxed at the same time. This principle is
74
critical, and you should ensure that patients fully understand how this applies to their current
difficulties.
Step #3: Identify States of Tension.
Explain to the patient that tension often builds gradually without conscious awareness.
Learning to detect the initial signs of an increase is an important step towards avoiding a
full- blown occurrence of tension. Inform the patient that, no matter the level of intensity, he
or she can stop and reverse the tension using knowledge of PMR in essence, it is never too
late to reduce tension. Over time patients become increasingly skilled at identifying stress
earlier and earlier (e.g., their awareness increases).
Step #4: Tense Muscle Groups.
A brief word of caution: If at any point during the technique a patient experiences
pain, alter or completely discontinue the technique. If the patient experiences
chronic pain in any part of the body, it is best to avoid the tensing component for
muscles in that area; just do the relaxing component when the patient gets to those
muscle groups.
PMR asks the patient to tense and release different muscle groups in sequence, moving
from the arms to the face, neck, chest and shoulders, torso, and legs. For each specific
muscle group, its important to try to tense only that muscle group during the tensing part of
the exercise. Throughout the procedure, it is important to concentrate on the sensations
produced by the different exercises. Asking the patient to describe bodily sensations is very
important for the learning process. Statements or phrases from you might include: What
are you noticing about your body right now? These questions help the patient to focus on
the way the body feels when tense and relaxed.
Tensing Instructions
Model each tension procedure. Ask the patient to practice, and provide feedback. Check
to be sure that the patient can identify tension in each group before moving on to the next.
a. Dominant arm. Make a fist and tense biceps; pull wrist upward, while pushing
elbow down against the arm of chair or bed.
b. Nondominant arm. Same as above.
c. Forehead, lower cheeks and jaw. Lift eyebrows as high as possible, bite teeth
together, and pull corners of mouth tightly.
d. Neck and throat. Pull chin down toward chest; at the same time, try to prevent
it from actually touching the chest. Counterpose muscles in front part of neck
against those in the back part of neck.
e. Shoulders, chest, and upper back/abdomen. Take a deep breath and hold it.
At the same time, pull the shoulder blades back and together, trying to make
them touch. Try to keep your arms as relaxed as possible while tensing this
muscle group. At the same time make the stomach hard by pressing it out, as if
someone were going to hit you in the stomach.
f. Dominant leg. Lift foot off the floor and push down on the chair with thigh.
g. Nondominant leg. Same as above.
75
Step #5: Ask the patient to continue slow, even, deep breaths. To pace the patient, you
might suggest that he/she say the words in and out slowly, while taking breaths. Inhalations
and exhalations should build to approximately 3 seconds in duration.
76
Step #6: Ask the patient if he or she notices any changes in breathing and feelings of
relaxation. Ask for general feedback about the technique.
Step #7: Repeat the breathing exercise three or more times until the patient reports skill
understanding and benefit.
Step #8: Ask the patient if he or she can identify situations when deep breathing might be
appropriate.
Step #9: Continue practice outside of session. Work with the patient to set a homework
assignment that encourages application of deep breathing to situations when the patient
feels stress.
Other tips for deep breathing:
1)
2)
3)
4)
5)
6)
Imagery
Imagery is a nonphysiological (cognitive) relaxation technique that can be used to ease
stress and promote an overall sense of well-being. Imagery focuses on increasing cognitive,
emotional, and physical control by changing the focus of an individuals thoughts. We all
have daydreamed about pleasant things that have distracted us and made us feel better.
Imagery uses much the same process but encourages positive adaptive dreaming that
distracts and relaxes the individual. Imagery is highly effective for depression and anxiety, as
well as specific situations that require clarity, focus, distraction, or feelings of mastery. The
following are examples:
Topic
Focused Topic
Image
Outcome
Depression
Negative Selfworth
Increased self-confidence;
reduced negative thoughts;
distraction from negative
mood
Anxiety/Worry
Public Speaking
Medical
Anxiety
Fear of
Procedure (e.g.,
needles)
Relaxation; peacefulness;
pain-free environment
Sports
Performance
Focused efforts
during golf
game
77
78
79
80
A garden where you watch big, beautiful clouds in a blue sky, while you
inhale the scent of flowers and feel a gentle breeze on your skin as the
sunshine warms you.
A mountain scene where you feel calm and relaxed as you look out over the
valley. Just you and the vegetation and you dip your feet into a cool
mountain stream; and let your foot rest on a big, slippery stone as the sunshine
warms you and the wind blows through the trees.
81
82
Relapse-Prevention Questions
1) When I feel (symptom), I will (tool learned in therapy).
2) If _(stressor)___, I will (tool learned in therapy).
Example:
When I feel sad for 2 days, I will go for a walk and call a friend to have lunch.
When I feel depressed for a month, I will schedule an appointment with my primary
care physician/mental health provider.
If my boyfriend breaks up with me, I will do a thought record to evaluate any
dysfunctional thoughts.
83
Discuss questions or concerns the patient might have about the transition.
Review treatment goals and maintenance of treatment gains.
Supplemental Readings
Allsop, S. & Saunders, B. (1991). Reinforcing robust resolutions: Motivation in relapse
prevention with severely dependent problem drinkers. In Miller, W.R. & Rollnick, S. (Eds.).
Motivational interviewing: Preparing people to change addictive behavior. New York:
Guilford Press, pp. 236-247.
Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press;
Chapter 15.
84
Mood Check
a. List five emotions you are feeling right now, and rate their intensity from 0100%.
b. List three emotions you have felt this past week, and rate their intensity from 0100%.
II.
III.
85
REFERENCES
88
APPENDIX A:
PATIENT HANDOUTS
92
BRIDGING SESSIONS
1. What main points did we reach in our last session? What did you learn
from last session? Did anything come to mind in the past week about our
last session that youd like me to know or that youd like to discuss?
4. What treatment goals would you like to work on today? What problems
would you like to put on the agenda?
5. What homework did you attempt or complete for last session? What did
you learn from doing it?
93
Cognitive Distortions
1. All-or-Nothing Thinking: Viewing situations on one extreme or another instead of on a
continuum.
Ex. If my child does bad things, its because I am a bad parent.
2. Catastrophizing: Predicting only negative outcomes for the future.
Ex. If I fail my final, my life will be over.
3. Disqualifying or Discounting the Positive: Telling yourself that the good things that happen
to you dont count.
Ex. My daughter told her friend that I was the best Dad in the world, but Im sure
she was just being nice.
4. Emotional Reasoning: Feeling about something overrules facts to the contrary.
Ex. Even though Steve is here at work late everyday, I know I work harder than
anyone else at my job.
5. Labeling: Giving someone or something a label without finding out more about it/them.
Ex. My daughter would never do anything I disapproved of.
6. Magnification/Minimization: Emphasizing the negative or downplaying the positive of a
situation.
Ex. My professor said he made some corrections on my paper, so I know Ill
probably fail the class.
7. Mental Filter/Tunnel Vision: Placing all your attention on the negatives of a situation or
seeing only the negatives of a situation..
Ex. My husband says he wished I was better at housekeeping, so I must be a
lousy wife.
EX. My daughters boyfriend got suspended from school. Hes a loser and wont
ever amount to anything.
8. Mind Reading: Believing you know what others are thinking.
Ex. My house was dirty when my friends came over, so I know they think Im a
slob.
9. Overgeneralization: Making an overall negative conclusion beyond the current situation.
Ex. My husband didnt kiss me when he came home this evening. Maybe he
doesnt love me anymore.
10. Personalization: Thinking the negative behavior of others has something to do with you.
Ex. My daughter has been pretty quiet today. I wonder what I did to upset her.
11. Should and Must Statements: Having a concrete idea of how people should behave.
Ex. I should get all As to be a good student.
94
THOUGHT RECORD
(1) Situation
(2) Automatic
Thought(s)
What
emotion(s) did
you feel at the
time? How
intense were
they?(1-100)
Rate your
mood.
(4) Evidence to
Support Thought
95
(5) EvidenceThat
Doesn't Support
Thought
(6) Alternative
Thought
(7) Rate
Mood
Now
Rate
from 1 to100
(worst to
best)
Helpful Questions
Thought
Questions
Feeling
Questions
Situational
Questions
96
THOUGHT RECORD
(1) Situation
(2) Automatic
Thought(s)
What
emotion(s) did
you feel at the
time? How
intense were
they? (1-100)
Rate your
mood.
(4) Evidence to
Support Thought
97
(6) Alternative
Thought
(7) Rate
Mood
Now
Rate
from 1
to100
(worst to
best)
Behaviors
(What did you do?)
Short-Term Consequences
(What was the result 1 second, 1
hour following behavior?)
98
Long-Term Consequences
(What were the lasting results?)
For depressed persons, increasing their activities on a daily basis improves mood
and decreases symptoms of depression.
99
Activities Checklist
EXCURSIONS/COMMUNITY
2. Visiting a neighbor
5. Going shopping
6. Going fishing
PHYSICAL ACTIVITY
2. Eating healthier
4. Gardening or planting
SPIRITUAL, RELIGIOUS,
AND KIND ACTS
1. Going to a place of worship
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101
Thursday
Friday
Saturday
pecific Problem:_________________________________________________
_________________________________________________________________________________________
_______________________________________
ist
PROS
AND
CONS
1.
2.
3.
4.
] YES
102
] NO
_____
103
104
Tensing Instructions
105
Deep-Breathing Technique
Step #1: Put one hand on your abdomen, with the little finger about 1 inch above the
navel, and place one hand on your chest.
Step #2: Pay attention to your breathing (pause for several seconds to assess your
breathing). Ideally, the hand on the abdomen should be moving, while the hand over the
chest remains still. This ensures that the breaths are deep.
Step #3: Take deeper breaths by getting the hand over the stomach to move, while
having little movement of the hand over the chest.
NOTE: If you have a lung or heart condition and you are having difficulty with this exercise,
slow the process down to your comfort level.
Step #4: Continue your slow, even, deep breaths. To pace yourself, you can say the words in
and out slowly while taking breaths. Inhalations and exhalations should build to
approximately 3 seconds in duration.
106
107
A garden where you watch big, beautiful clouds in a blue sky, while you inhale the
scent of flowers and feel a gentle breeze on your skin as the sunshine warms you.
A mountain scene where you feel calm and relaxed as you look out over the
valley. Just you and the vegetation, and you dip your feet into a cool mountain
stream, and let your foot rest on a big, slippery stone as the sunshine warms you
and the wind blows through the trees.
108
Rating Moods
Describe a recent event. Rate the intensity of your mood at the time the event
occurred on a scale of 0-100 (There is a list of different moods at the bottom if you need
help).
1.
Event:_______________________________________________________________________________
_____________________________________________________________________________________
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
2.
Event:_______________________________________________________________________________
_____________________________________________________________________________________
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
3.
Event:_______________________________________________________________________________
_____________________________________________________________________________________
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
4.
Event:_______________________________________________________________________________
_____________________________________________________________________________________
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
Mood:_____________: 0
10
20
30
40
50
60
70
80
90
100
109
Mood Check
a. List five emotions you are feeling right now, and rate their intensity from 0100%.
b. List three emotions you have felt this past week, and rate their intensity from 0100%.
II.
III.
110
APPENDIX B:
SAMPLE TREATMENT OUTLINES
114
Session 4
Check Mood.
Review Behavioral Activation,
Introduce Three-Column Thought Record and Idea of Hot Thought.
Practice Three Column With Event From Past Week.
Homework: 1 behavioral activation
1 three-column thought record
Receive Feedback From Maria.
Session 5
Check Mood.
Discuss Progress of Therapy and Termination.
Review Homework.
Introduce Cognitive Distortions.
Complete Three-Column in Session, and Have Maria Identify Hot Thought.
Introduce Concept of Challenging Hot Thought.
Homework: 1 behavioral activation
1 three-column thought record
Receive Feedback From Maria.
Session 6
Check Mood.
Review Homework.
Introduce Challenging Thoughts and Seven-Column Thought Record.
Complete Seven-Column in Session.
Introduce Concept of Challenging Hot Thought.
Homework: 1 behavioral activation
1 three-column thought record
Receive Feedback From Maria.
Session 7
Check Mood.
Review Homework.
Complete Seven-Column in Session (With Maria Writing and Talking Through asSshe
Completes It)
Homework: 1 behavioral activation
1 seven-column thought record
Receive Feedback From Maria.
Session 8
Check Mood.
Review Homework.
Review Progress of Treatment.
Complete Relapse Prevention.
Introduce and Schedule Self-Management Sessions.
Homework: Self-Management Session
115
116
Session 4
Check mood.
Review imagery.
Introduce three-column thought record and idea of hot thought.
Practice three-column with event from past week.
Homework: 1 relaxation technique
1 three-column thought record
Receive feedback from James.
Session 5
Check mood.
Discuss progress of therapy and termination.
Review homework.
Introduce cognitive distortions.
Complete three-column in session, and have James identify hot thought.
Introduce concept of challenging hot thought.
Homework: 2 relaxation techniques
1 three-column thought record
Receive feedback from James.
Session 6
Check mood.
Review homework.
Introduce challenging thoughts and seven-column thought record.
Complete seven-column in session.
Introduce concept of challenging hot thought.
Homework: 2 relaxation techniques
1 three-column thought record
Receive feedback from James.
Session 7
Check mood.
Review homework.
Complete seven-column in session.
Homework: 2 relaxation techniques
1 seven-column thought record
Receive feedback from James.
Session 8
Check mood.
Review homework.
Review progress of treatment.
Complete relapse prevention.
Introduce and schedule self-management sessions.
Homework: self-management session
117