1. 使用CBT理论理解你的来访

PART 1 CBT FoundationCHAPTER 1 Use CBT Theory to Understand Your Clients Let’s get started with laying our foundation. In this chapter, you’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. 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’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?

Set the Agenda 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’ problems. I have four agenda items that are related to learning basic CBT theory. Agenda Item #1: CBT building blocks: thoughts, feelings, physical reactions, and behavior Agenda Item #2: How thoughts maintain problems Agenda Item #3: How behaviors maintain problems Agenda Item #4: How core beliefs influence thoughts

Work the Agenda The third step in a CBT session is to work the agenda, or address your clients’ problems; in our case, this means learning the information and skills related to each agenda item. 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 ques- tions 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’s problems in a way that leads to helpful interventions? To answer these questions, you need a good theory—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 “do” CBT, it is important to understand the underlying theory of CBT.

Agenda Item #1: CBT Building Blocks: Thoughts, Feelings, Physical Reactions, and Behavior 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’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’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 back- pack 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 under- standing their reactions, they often start to feel less overwhelmed and believe change is more possible. 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, “Whew—what a relief!” Let’s see what happens when we unpack her backpack and sort Rose’s reaction into the four factors. Situation: Another rejection letter Rose’s Thoughts: I will never get a job, I am such a failure. Rose’s Feelings: Depressed and hopeless. Rose’s Physical Reactions: Stomach hurts and is exhausted. Rose’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. 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. Padesky and Mooney (1990) include a fifth factor—the environment—in their model of how the factors influence each other, as shown in figure 1.1.

Figure 1.1. Five-part model to understand life experiences.

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’ 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.

WHAT IS A SITUATION? The four-factor model separates thoughts, feelings, physical reactions, and behavior from the situ- ation. The situation is what actually occurred, or the objective reality without any interpretation. For example, an upcoming test is a situation; a “hard” upcoming test is a situation and an interpretation— the interpretation is that the test will be hard. Let’s take another example of a situation: your client tells you that a kid at school approached him in the hallway and said, “You’re ugly.” This is a situation. If your client adds, “That kid is mean and trying to show off,” this is your client’s interpretation.

WHAT IS THE DIFFERENCE BETWEEN FEELINGS AND THOUGHTS? 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, “I feel like he doesn’t like me,” when what we really mean is, “I think he doesn’t like me.” 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. In CBT we refer to the thoughts we have in specific situations as automatic thoughts. Our auto- matic 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 He is part of a pickpocket scam, you will also think, He’s dangerous; I want to get away. However, if your initial thought is He’s a tourist, you may also think, How can I help him? I want to be friendly. Automatic thoughts are words or images that go through our head. Many of our automatic thoughts are about very ordinary things, such as I wonder if it will rain today? or, as you leave the house, Do I have my shopping list? We don’t have strong emotional reactions to these kinds of thoughts, and in CBT we usually don’t pay much attention to them. In CBT, we are more interested in thoughts that are con- nected 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 am stupid, while a thought about others might be My mother is inconsiderate, and a thought about the future might be Everyone will laugh at me. These thoughts are usually just below your awareness, but if you ask yourself, What was I thinking? you can usually identify them. Automatic thoughts are spontaneous and rapid; we have a lot of them, and they come and go so quickly that we often don’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 behav- iors also change.

WHAT IS THE DIFFERENCE BETWEEN FEELINGS AND PHYSICAL REACTIONS? 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’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. 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?

WHAT ABOUT BEHAVIOR? 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’s behav- ior and also look at the consequences of your client’s behavior. When we look at symptom maintenance cycles later in the chapter, we will focus on how a client’s behavior can maintain his symptoms.

YOUR TURN! Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior Throughout this book you will come across YOUR TURN! exercises. This is an opportunity to prac- tice what you just learned. I think you will find them interesting! Try this first one. 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. Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior Situation, Thought, Feeling, Physical Reaction, or Behavior? Staying up late and studying No matter what I do, no one likes me. I feel tense all over. Even if I study hard, I will still fail. I am so happy. My boss hates my work. I am late for work.

Agenda Item #2: How Thoughts Maintain Problems We’ve talked about the importance of sorting out your client’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’ problems. Let’s start with understanding the role of thoughts. 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 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 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. Feelings Situation Thoughts Behavior Physical Reactions Figure 1.2. Our thoughts influence our feelings, physical reactions, and behavior. Let’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’t pay much attention to his barking; I think, He’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, He’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’s and my different thoughts can lead to very different feelings and behavior. Feelings Nina's Thoughts Shadey will stop barking. He is so cute. Situation Happy Behavior Pats Shadey Physical Reactions Mildly excited Shadey barks. Feelings Alicia's Thoughts Shadey will jump on me. Dogs are unpredictable. Anxious and unhappy Physical Reactions Behavior Tries to avoid Shadey Tense Figure 1.3. Shadey the dog barks.

YOUR TURN! How Thoughts Influence Feelings and Behavior Two friends, Maria and Jane, work in the same company. They are both going to a conference, where they won’t know anyone. Maria is anxious and dreading the conference. When she imagines going, she thinks, This will be awful. No one will talk to me. Everyone will think I’m stupid, and she gets a sick feeling in her stomach. Jane meanwhile thinks, 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’t wait for the conference to begin. When we examine their thoughts, we can begin to understand why their reactions are so different. 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’s and Jane’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.

Maria and Jane attend a conference. Situation Physical Reactions Feelings Physical Reactions Figure 1.4. Maria and Jane attend a conference. Jane's Thoughts Maria's Thoughts Feelings Behavior Behavior

This is the first additional practice exercise you will find at http://www.newharbinger.com /38501. You will find many more throughout the book. Exercise 1.1: What Is This Person Thinking? Practice understanding how thoughts can influence feelings. 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 reac- tions, 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’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. 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, “I am so down and depressed. I have a really hard math test tomorrow. It’s too hard for me. I’ve had a splitting headache all day. I’m really anxious about this test. I haven’t started studying. I’m going to fail anyhow. I’m just going to go home and play computer games. I don’t know what’s wrong with me. Why don’t I study?” Let’s look at figure 1.5 and see how using the four-factor model can help us understand Alfred’s problems. Imagine that his therapist says to him, “Sounds like you’re having a tough time; let’s make sure we understand what’s going on for you. I want to start with separating out your thoughts from your feelings, physical reactions, and behavior. Let’s see if once we understand your reaction, we can under- stand why it’s so hard for you to study.” Feelings SituationThoughts Math test tomorrowTest is too hard for me; I'm going to fail anyhow Down, depressed anxious Physical Reaction Behavior Does not study; plays computer games Headache

Figure 1.5. Alfred has a math test tomorrow. Was it helpful to look at Alfred’s reaction in terms of the four factors? Did identifying Alfred’s thoughts help explain his feelings and behavior?Use CBT Theory to Exercise 1.2: Sharon Is Invited for Coffee Practice identifying the four factors.

YOUR TURN! Identify Clients’ Thoughts, Feelings, Physical Reactions, and Behavior 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 thera- pist and see if you can identify the four factors in Sara’s reaction. Therapist: What’s it like for you when your boyfriend comes half an hour late without con- tacting you? Sara: I am just so depressed at how he is treating me. Therapist: How did you react? 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. Therapist: It is hard for you to know what else you could do. Sara: That’s right. Therapist: What is that like for you? Sara: I hate it. He treats me as if he doesn’t care about me. He takes me for granted. It makes me feel worthless. In this type of dialogue the client’s thoughts, feelings, physical reactions, and behavior are a jumble; it is hard to know how best to continue therapy. Let’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’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. Situation: Sara’s Thoughts: Sara’s Feelings: Sara’s Physical Reactions: Sara’s Behavior: How did identifying Sara’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. Exercise 1.3: Roger Doesn’t Want to Go to the Doctor Practice identifying the four factors from a therapy dialogue.

Agenda Item #3: How Behaviors Maintain Problems To understand how your clients’ behaviors maintain their problems, you want to understand how their behavior influences their thoughts, feelings, and physical reactions. Start by looking at the conse- quences of your client’s behavior. Let’s examine first how the consequences of a behavior can reinforce your client’s thoughts, and second, how the consequences of a behavior can influence the situation so as to reinforce the client’s original thoughts or interpretation. Let’s go back to Alfred, my seventeen-year-old client in the earlier example with the math test. Here is a summary of Alfred’s reaction using the four-factor model. Alfred thinks, The test is too hard for me and I’m going to fail anyhow. He feels anxious and he gets a headache. His behavior is to go home and play computer games. How do the consequences of Alfred’s behavior reinforce his thoughts and the situation? Alfred did not study, he failed the test. When Alfred failed the test he thought, The test really was too hard for me since I failed, and I was going to fail anyhow. Failing the test becomes evidence that the test is “too hard.” 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’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 “fail anyhow.” Now, let’s now look at how the consequences of Alfred’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’s behavior can reinforce his thoughts and influence the situation. Alfred is caught in what CBT therapists call a symptom maintenance cycle.

Feelings SituationThoughts Difficult math testTest is too hard for me; I'm going to fail anyhow Down, depressed anxious Behavior Plays computer games Physical Reaction Headache When fails, next test is harder When fails, thoughts are confirmed Consequences Fails test Figure 1.6. Alfred’s symptom maintenance cycle. YOUR TURN! Maria’s Symptom Maintenance Cycle Let’s return to the example of Maria, who had to attend a conference where she would not know anyone. Let’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. Maria’s Situation: Attending a conference where she does not know anyone Maria’s Thoughts: This will be awful. No one will talk to me. Everyone will think I am stupid. Maria’s Feelings: Anxious Maria’s Physical Reaction: Sick stomach Maria’s Behavior: Sits by herself in a corner Consequences: What are the consequences of Maria’s behavior? Ask yourself: If she is sitting by herself, will people talk to her? Do you think she will enjoy herself? How do the consequences of her behavior reinforce her thoughts? (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?) How do the consequences of her behavior influence the situation? (Hint: Maria started the confer- ence not knowing anyone. If she sits in a corner, how many people will she know at the end of the conference?) Exercise 1.4: Lee Learns to Ask a Question Practice using a symptom maintenance cycle.

Agenda Item #4: How Core Beliefs Influence Thoughts 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 situ- ations and influence automatic thoughts. (Some CBT books use the term schema; core beliefs and schemas are virtually identical.) There are generally three types of core beliefs (Clark, Beck, & Alford, 1999): 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’s emotional well-being. Examples might be: •Be polite to strangers. •To succeed in life, get a good education. •Always wear a life jacket in a boat. Intermediary beliefs and assumptions. These are rules for living that often take the form of if…then statements or unless I… statements. These rules play an important role in determining feelings and behaviors. Examples might be: •Unless I am perfect, I will fail. •If I yell, then people will listen to me. •If people see the real me, then they will reject me. 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: •Core beliefs about self: I am smart, I am lovable, I am selfish, I am incompetent, I am unlovable. •Core beliefs about others: Others are kind, others will take care of me, others are mean, others will take advantage of me. •Core beliefs about the world: The world is just, the world is stable, the world is dangerous, the world is unjust. Although an individual’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’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 “stupid.” All of the girls she previously played with refused to play with her, and school became a night- mare. She did not tell her parents until late in the year, and had no support from her parents or teach- ers. Let’s look at how this experience affected her core beliefs. Maria’s Core Beliefs: •Self: I am stupid and unlikable. •Others: People will be critical and mean to me. •World: The world is unpredictable. The power of core beliefs is their capacity to influence how you react to a variety of different situ- ations. For example, when Maria meets a new neighbor, she will likely think, We will not get along. When her supervisor does not comment on her last report, she thinks, He probably thought it was ter- rible. 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 did something wrong, I will be punished, this is terrible, or (b) I wonder what they want, it will probably be fine, if there is a problem I can explain myself to them. Figure 1.7 is a diagram of how core beliefs influence automatic thoughts. Core Beliefs Self: I am stupid and unlikable. Others: People will be critical and mean to me. World: The world is unpredictable. Meet new neighbor. Thought: We will not get along; she will not like me. Supervisor does not comment on report. Thought: He probably thought it was terrible. HR department asks for meeting. Thought: I did something wrong, I will be punished, this is terrible.

Figure 1.7. Maria’s core beliefs influence her automatic thoughts. Exercise 1.5: Understand Janice’s Reactions

Practice understanding the relationship between core beliefs and automatic thoughts.

Let’s look at the situation where Maria meets her new neighbor in more detail. When Maria thinks, 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’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. Core Beliefs Self: I am stupid and unlikable. Others: People will be critical and mean to me. World: The world is unpredictable. Consequences reinforce thoughts and core belief Meets new neighbor. Thought: We will not get along; she will not like me. ConsequencesBehavior Maria’s neighbor thinks she is unfriendly and avoids Maria.Maria avoids her neighbor. Figure 1.8. Maria’s vicious cycle also influences her core beliefs. Exercise 1.6: Understand Janice’s Vicious Cycle and Core Beliefs Practice understanding how vicious cycles can involve core beliefs. Clinical Implications. CBT therapists usually start with focusing on clients’ automatic thoughts and behavior as this teaches clients basic CBT skills and can lead to fairly rapid improvement in clients’ 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. It is helpful to start hypothesizing about your client’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’s automatic thoughts provides clues to his core beliefs.

Clients either don’t notice information that contradicts their core beliefs, or they minimize the information. How would you expect Maria to react when her neighbor says, “I am so happy to see you”? Would she think, She’s just saying that to make me feel good, or would she think, She really likes me? Hypothesizing about your client’s core beliefs can help you notice what types of information your client is likely to ignore or minimize.

Homework: Practice CBT At the end of each chapter I list the additional exercises that are mentioned in the chapter and avail- able 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. Apply What You Learned to Clinical Examples Complete the following exercises. Exercise 1.1: What Is This Person Thinking? Exercise 1.2: Sharon Is Invited for Coffee  Exercise 1.3: Roger Doesn’t Want to Go to the Doctor Exercise 1.4: Lee Learns to Ask a Question Exercise 1.5: Understand Janice’s Reactions Exercise 1.6: Understand Janice’s Vicious Cycle and Core Beliefs Apply What You Learned to Your Own Life 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? Homework Assignment #1 Use the Four-Factor Model to Understand Your Own Situation 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? Situation: Thoughts: Feelings: Physical Reactions: Behavior: Apply What You Learned to Your Therapy Practice Let’s see if applying the four-factor model to your own clients can help you understand their prob- lems differently. Homework Assignment #2 Use the Four-Factor Model to Understand a Client’s Situation Think of a situation involving a current client. Try to complete the four-factor model below using the situation you selected. Don’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? Situation: Thoughts: Feelings: Physical Reactions: Behavior:

Let’s Review At the end of a CBT session, the therapist and client spend a few moments reviewing what was covered in the session. Similarly, let’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. Agenda Item #1: CBT building blocks: thoughts, feelings, physical reactions, and behavior • Why is it helpful to divide your client’s reactions into thoughts, feelings, physical reactions, and behavior? Agenda Item #2: How thoughts maintain problems • How do thoughts lead to feelings, physical reactions, and behavior? Agenda Item #3: How behaviors maintain problems • What do we mean by symptom maintenance cycles? Agenda Item #4: How core beliefs influence thoughts • What are core beliefs? What Was Important to You? 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. What idea(s) or concepts would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.) What was it like to review? Did it help consolidate what you learned?