12. 苏珊和罗尔的治疗

注意自动思维中的模式

核心信念基本上是一种信息处理过滤器；它们影响你注意到的信息、赋予事件的意义以及你记住的内容。你可以把核心信念想象成大磁铁，四处吸引和挑选确认核心信念的信息。人们要么不注意与核心信念相矛盾的信息，要么最小化这些信息。例如，在苏珊娜开始治疗之前，如果一个老师在课间休息时走到她面前说你好，你会预期她会怎么反应？她会认为（A）我开始交朋友了；这个老师喜欢我，还是（B）这只是偶然；我确信她明天不会和我说话？我猜是B。当她晚上回家，丈夫问她一天的情况时，她会记住那个老师走过来和她说话，还是会记住她大部分时间都是一个人在课间休息？我猜她会记住她是独自一人。我们可以寻找来访感到压力的情境类型和导致来访痛苦的自动思维类型的模式。一旦我们识别了这些模式，就可以开始假设来访的核 心信念。

我发现将关于自我的核心信念分为三个领域是有帮助的：（1）对自身能力的判断，包括无助、不聪明或无能的信念；（2）对自身是否可爱或不可爱的判断，包括不吸引人、不喜欢、脆弱或不同的信念；（3）对自身基本价值或无价值的判断，涉及一种基本的好感或一种深刻的感觉，即自己有问题。与无价值相关的核 心信念通常是严重童年虐待的结果。注意哪个类别对来访最具触发性，可以帮助你关注与来访痛苦中心相关的情境和思维。当我寻找来访自动思维的模式时，我会问自己这三个类别中哪一个对来访最相关。

苏珊娜的核心信念

让我们来思考苏珊娜。她生活中的主要压力源是一所新学校，这扰乱了她的友谊和家庭关系；她最好的朋友搬走了；以及婆婆的疾病。根据你所知道的，你会预期她的核心信念集中在能力、可爱性还是无价值上？在我看来，导致她压力的情境主要是社交性的。

苏珊娜的负面思维经常集中在不被喜欢或感觉不被接受上。在烧烤和课间休息时，她的思维都与老师们不喜欢她或不想成为她的朋友有关。当她的丈夫没有给儿子洗澡时，她其中一个想法是“他不在乎我”。在暴露任务中，她不期待人们对她的友好举动有积极的反应。你会假设苏珊娜的核心信念是什么？当我们考察她感到压力的情境类型和自动思维的模式时，我会假设她的核心信念如下：

• 关于自我的核心信念：我不可爱。
• 关于他人的核心信念：人们不会喜欢我，也不会友好。
• 关于世界的核心信念：世界是不安全的。

劳尔的核心信念

根据你对劳尔的了解，你会猜测他的核心信念是什么？错过晋升触发了他的困难。我会假设成功对劳尔非常重要。这使我假设他的核心信念更多集中在能力上，而不是可爱性上。我怀疑他关于自我的一个核心信念可能是“只有我取得成就才有价值”，或者“如果我失败了，这就证明我是愚蠢的”。我也怀疑有一个潜在的核心信念：“我是无能的。”

关于他人的核心信念呢？我注意到他不信任老板或同事的支持和帮助。然而，他与妻子和孩子的关系很好。我怀疑他关于他人的一个核心信念可能是“你不能信任家庭以外的人”。关于他对世界的核 心信念呢？劳尔对错过晋升非常不满，觉得这是不公平的。我会怀疑他是否认为世界是不公平的，而不仅仅是这次经历。这些都会是初步的假设；我希望能够了解更多情况。鉴于我对劳尔核心信念的假设，你认为他可能会忽略关于自己和他人的哪些信息？

临床意义

一旦我对来访的核 心信念有了假设，我特别注意她如何驳回或最小化挑战她核心信念的信息。让我们举个例子。苏珊娜告诉治疗师，一位老师问她是否愿意志愿加入负责冬季节日聚会的委员会。苏珊娜会怎么想：（A）这是融入学校的一个好开始；我可以更好地了解一些老师，还是（B）我肯定无法融入？我猜是B。作为她的治疗师，我特别注意她如何解释可能挑战她核心信念的社交情境。我特别注意收集关于情境的事实，因为我知道苏珊娜会最小化他人友好或喜欢她的迹象。我还知道苏珊娜很难记住与她核心信念相矛盾的例子，回顾这些例子将非常重要。

识别来访心理社会史中的主题

核心信念通常在童年时期形成，是家庭和更大社会环境中的经历的结果，尽管后来生活中的经历也会影响核心信念。我知道许多害羞、社交焦虑的儿童和青少年在营地、学校、工作或大学中有积极的经历后，变成了外向的年轻人。这些年轻人经历了一系列积极的社交体验，改变了他们的核心信念，从“别人不会喜欢我”变为“别人会对我的友好做出积极回应”。创伤经历也会改变核心信念。在创伤后，许多人开始相信世界是危险的，如果创伤涉及其他人，他们对别人的信念会变成“别人会伤害你”。经历过创伤的人常常还会发展出关于自我的核心信念，如“我是脆弱的或弱小的”或“我在创伤后受到了某种损害”。

记得在第二章中，我们谈到在获取心理社会史时要注意事件的意义吗？当我获取历史时，我会倾听来访关于自己、他人和世界的核 心信息。让我们来看看苏珊娜和劳尔的心理社会史，看看我们能否推测他们的核心信念。

苏珊娜的历史

苏珊娜是四个兄弟姐妹中的长女。她的父母勤劳，家里的经济状况能够满足家庭的基本需求，但没有多余的开支。苏珊娜描述她的父母冷酷且严格。他们对苏珊娜有很高的期望，要求她在学校表现良好，还要帮忙照顾家务和三个弟弟。他们明确表示更偏爱男孩，这让苏珊娜担心如何取悦他们，做到足够好。苏珊娜在学校表现很好，这是唯一一个母亲不批评她的领域；除此之外，母亲对她非常挑剔，苏珊娜认为这是“为了她好”。她的母亲也是一个非常焦虑的女人，几乎没有朋友，总是担心自己是否能融入群体，是否有人喜欢她。

苏珊娜形容自己是一个“好孩子”，没有任何问题。她在学校几乎没有朋友，因为她经常需要在家帮忙，没有时间与同龄人相处。她在高中时确实交了一些朋友，但在拒绝让家里举办饮酒派对后，大多数同学都反对她。她高中毕业后进入师范学院学习，是家中第一个上大学的人，对此她非常自豪。她嫁给了她的初恋男友，两人在高中时就是情侣。

回想一下，通过考察她感到压力的情境类型和自动思维的模式，我假设她的核心信念是“我不可爱”，“人们不会喜欢我，也不会友好”，“世界是不安全的”。她的心理社会史与这些核心信念的发展一致。

劳尔的历史

劳尔的家人在他两岁时移民到美国。他住在离姨妈和舅舅很近的地方，长大在一个大家庭中。劳尔描述自己有一个快乐的童年，直到八岁时父亲去世，此后生活变得更加艰难。他的母亲有两份工作，他经常独自在家。他继续与大家庭保持联系，但非常想念父亲。在学校，他觉得老师不尊重他和他的家庭，他们的经济状况不如许多其他家庭。他还有一些轻微的学习障碍，直到高中才被诊断出来。虽然他在学校很努力，但老师经常向他的母亲抱怨他没有充分发挥潜力。他记得在学校因答不出问题或考试成绩差而感到羞辱。唯一表现良好的科目是数学。他还是足球队的一员，非常喜欢这项运动。高中毕业后，他的叔叔资助了他的大学教育，他获得了会计学位。大学毕业后，他遇到了妻子，两人拥有美满的婚姻。

劳尔的心理社会史支持我们之前怀疑的核心信念。我们假设他关于自我的一个核心信念是“只有我取得成就才有价值”，或者“如果我失败了，这就证明我是愚蠢的”。我们还怀疑有一个潜在的核心信念：“我是无能的”。他学习不佳和有学习障碍的历史支持了这一假设，即他关于自我的一个核心信念是“我是无能的”。他的心理社会史也支持我们之前识别的关于他人和世界的核 心信念：“你不能信任家庭以外的人”和“世界是不公平的”。鉴于我对劳尔核心信念的假设，你认为他可能会忽略关于自己和他人的哪些信息？

第4次和第5次会话

第4次会话

苏珊娜在第4次会话中带来了《理解你的反应》工作表，针对两个其他情境：一是课间休息时独自一人，二是教职工会议上她发表了一条评论但无人回应。她惊讶于自己经常想到“没有人会想和我做朋友”和“其他老师不会喜欢我”。苏珊娜还想讨论与丈夫在家的一个情境，她因为丈夫没有给孩子洗澡而生气。

苏珊娜希望大部分时间谈论烧烤会的邀请，尽管我们也花了一些时间探讨在家的情境。我解释了寻找证据和创建平衡思维的概念。我们继续处理烧烤会的邀请，并寻找她热认知“没有人会想和我做朋友”的证据。我们还创建了一个平衡思维。（详见第8章，关于我如何寻找证据并帮助苏珊娜创建平衡思维。）然后，我们探讨了我们收集的证据是否适用于她在家庭作业中识别的其他两个情境，这些情境中的热认知相同或几乎相同。在会话结束时，苏珊娜决定她想参加烧烤会。

我问苏珊娜她认为什么作为家庭作业会有帮助。她建议每天早上上学前复习我们完成的思维记录。我认为这是一个非常好的主意，因为我希望她在开始上课时，平衡思维能在她的脑海中保持新鲜。我还建议她为另外两个情境完成完整的思维记录。

第5次会话

在第5次会话中，我们首先回顾了苏珊娜作为家庭作业完成的两个思维记录。她发现这些记录很有帮助，并自发提到她想知道是否对新学校的其他老师不公平。第5次会话的议程项目是她对下周参加烧烤会的焦虑和持续的抑郁情绪。

我们讨论了如何处理烧烤会，并制定了应对思维。（详见第9章，摘录了这次会话的部分内容。）由于苏珊娜提到了她的抑郁情绪，我认为这是一个介绍行为激活的好机会。我们使用《理解你的抑郁》工作表探讨了她的抑郁情绪，她觉得这很有道理。然后，我解释了了解她一周的时间安排以及不同活动对情绪的影响会有所帮助。我介绍了每日活动计划表，并在时间用完前填写了前一天的一半。我让她作为家庭作业完成下一周的每日活动计划表。

第6至第9次会话

每日活动计划

苏珊娜完成了作为家庭作业的《每日活动计划表》。我们使用《探索情绪/活动关系的问题》进行了回顾。（您可以在第10章找到我们所做的工作。）接下来的几次会话主要集中在行为激活、解决问题障碍和发展应对思维上。我们特别关注她早晨和放学后的在家时间，因为这是她一天中情绪最低落的时段。我们仔细规划了她可以做的活动，以提升她的情绪，并使用问题解决和应对思维来应对任何障碍。在这几次会话的过程中，随着她重新与朋友见面、更多地与孩子们玩耍、以及与丈夫共度高质量时间，她的情绪逐渐好转。

与丈夫沟通的问题

我们考虑了许多活动来改善她早晨和放学后的情绪，其中许多活动涉及要求她的丈夫在照顾孩子和家务方面更加积极。我之前没有机会详细讨论这个问题，所以现在让我花些时间解释我是如何处理的。

苏珊娜对与丈夫讨论他在家务和育儿方面的缺乏参与感到焦虑。她的负面思维包括：“他会反应消极并心怀怨恨”、“他会生气，因为照顾孩子是我的责任”、“即使我要求，他也不会提供更多帮助”、“我是一个不合格的母亲，因为有困难”。

在第6至第9次会话中，我们大约每会话用一半的时间来增加愉快的活动，另一半时间来检查这些想法。我让苏珊娜列出她对与丈夫讨论这些问题的具体担忧，并查看这些结果的可能性有多大。（在第7章和第8章中，我帮助苏珊娜列出了她对参加烧烤会的担忧，然后我们查看了每个担忧的概率。我们对她在育儿和家务方面与丈夫沟通的担忧采用了类似的干预措施。）

当苏珊娜开始查看证据时，她意识到丈夫不太可能因为被要求更多参与孩子事务而心怀怨恨，也不太可能认为照顾孩子只是她的责任。苏珊娜认为，考虑到他的工作时间，他可能有一定的实际限制，但她认为提出这个话题是值得的。我们进行了问题解决和角色扮演，以找到最佳的沟通方式，苏珊娜也在想象中练习了这些技巧。

早晨准备孩子的困难

苏珊娜发现早晨让孩子起床非常困难。我建议我们做一个思维记录。她最初将情境定义为“因为早晨孩子不起床而对他们发怒，所以我是一个坏母亲”。在第5章中，我们讨论了将情境的事实与其意义分开的重要性。我帮助苏珊娜明确了情境的事实：她的孩子早晨不愿意起床。然后我们确定了她的想法：“我是一个坏母亲”，以及她的感受：“愤怒”。一旦苏珊娜能够将她的想法与情境分开，我们就可以评估她认为自己是一个坏母亲的想法。

接下来，我们列出了成为好母亲的标准。苏珊娜的标准包括表达爱和关心、花时间与孩子在一起、提供经济支持、组织他们的生活、以及给他们读书。然后我们根据她制定的标准评估了她的行为。起初，我不得不引导苏珊娜注意到她是好母亲的证据，但我小心地没有直接告诉她这些证据。例如，我问她在周末做了什么，为孩子的生日做了什么，即使早晨很难，她是否给他们准备早餐并让他们准备好上学。当她描述了与孩子做的事情时，我问她这些是否是好母亲的一部分。最终，她能够认识到自己是一个好母亲。

我们还检查了她的信念，即如果她在早晨让孩子准备好上学有困难，就意味着她是一个不合格的母亲。我试图帮助苏珊娜从另一个角度看待问题。（在第8章中我们讨论了换位思考。）让我问你，除了是一个不合格的母亲，还有哪些其他解释可以说明苏珊娜在早晨让孩子准备好上学有困难？我知道当我的孩子小时候，他们也喜欢磨蹭、赖床和玩耍，而不是按紧张的日程准备上学。当我们查看所有事实时，苏珊娜认为大多数母亲都会发现让年幼的孩子按时穿衣、吃饭和准备好上学是一项挑战。从不同的角度来看待早晨与孩子的困难，帮助苏珊娜减少了压力，并考虑了不同的处理方式。她开始以更好的心情去上班，并对自己的批评减少了很多。

第10至第16次会话

第10至第16次会话

到第10次会话时，苏珊娜的情绪已经显著改善。她在学校经常使用思维记录，当她与丈夫和孩子发生争执时，也会在家里使用。然而，她在学校仍然非常内向。我认为她陷入了这样一个负面循环：她越是内向，就越难与其他老师建立关系，从而导致她更加内向。苏珊娜同意我的看法，认为她陷入了恶性循环，并认为与同事建立社交关系是个好主意。然而，每当她想到要开始与同事建立友谊时，她都会感到非常焦虑，不知道从哪里开始。在第10至第16次会话中，我们使用了暴露疗法来帮助苏珊娜克服社交焦虑，并开始在学校结交朋友。（在第11章中可以看到苏珊娜的暴露疗法片段。）

在暴露任务中，她的负面思维“没有人会想和我做朋友”经常被触发。苏珊娜利用暴露任务中的积极体验作为额外的证据来挑战这一思维。例如，当苏珊娜在集会上与坐在她旁边的一位同事交谈时，他们发现彼此小时候曾就读同一所学校。集会上的对话自然地引申到一起吃午饭，他们在课间休息时也开始互相交谈。这些经历成为了反驳“没有人会想和我做朋友”这一思维的证据。我们开始记录那些挑战这一信念的情境。

第17和第18次会话

第17和第18次会话

在第17次会话中，苏珊娜开始考虑是否应该结束治疗。她已经不再抑郁，丈夫在家帮忙更多，他们的关系有所改善，她对自己的感觉也更好了。当孩子表现不佳时，她能够将其视为正常行为并应对，而不是责怪自己。她在新学校也开始结交一些朋友，也不再那么介意通勤；她甚至在开车时开始听有声书。苏珊娜和我回顾了她的目标，她已经实现了所有目标或接近实现。

当我们开始讨论结束治疗时，苏珊娜意识到她担心没有治疗的情况下能否应对。我们决定两周后再见面，看看苏珊娜的情况如何。苏珊娜取消了下一次会面，所以我们三周后才再次见面。我们回顾了她生活的改变和学到的东西。苏珊娜认为思维记录和行为激活对她帮助最大。我们讨论了继续在社交场合面对恐惧的问题。苏珊娜认为治疗非常有帮助，虽然她会想念我，但她已经准备好结束了。我告诉她随时欢迎回来进行巩固会话。

我通常在结束治疗时告诉来访与他们合作的愉快经历。如果来访给我表扬，我会接受表扬，但会补充说我们合作得很好，建立了良好的关系。这样我们可以共同分享表扬，强调我们关系的重要性。

议程项目 #3：劳尔的治疗

虽然我们在书中一直跟随劳尔的治疗过程，但我使用的干预顺序与书中的顺序有所不同。我从问题解决和分级任务分配开始，然后进行行为激活，仅在治疗后期使用认知干预。

第1次和第2次会话

劳尔比苏珊娜更难参与治疗，他对治疗是否有效持怀疑态度。最初，劳尔很难识别自己的感受和想法，我相信他会更容易接受行为干预。从一开始就假设他的核心信念与成功有关。我始终留意与受尊重或被重视相关的思维。我还努力注意他何时低估了自己受到尊重的证据。

让我们来看看劳尔的目标：

• 更好地应对工作，特别是集中精力完成工作并在规定时间内完成项目。
• 与同事像以前那样社交，包括与人交谈、在食堂吃午饭、外出就餐和在走廊闲聊。
• 不要在老板每次与他谈话时感到焦虑。
• 重新喜欢上工作。

第3次和第4次会话

在前两次会话之后，我有些不确定从哪里开始。我担心劳尔的抑郁情绪，考虑从行为激活开始。另一方面，他的第一个目标是更好地应对工作并按时完成项目。我希望解决对他来说立即相关的问题。我还担心如果劳尔继续拖延，他会收到另一个差评。这可能会在工作中造成实际困难，并加重他的抑郁情绪。我决定首先解决他的拖延和其他与工作相关的问题。

我们从识别进行顺利的项目和他拖延的项目开始。我们还评估了他的拖延可能带来的最严重后果。我们发现劳尔大部分工作都能按时完成，并且达到了令他满意的水平。我利用这些信息质疑他整体上的负面判断，即他在工作中无法应对。由于我假设他的一个核心信念是不被尊重，我还确保询问其他人是否尊重他工作的这一方面。

第3次和第4次会话的大部分时间都用于探讨他拖延的项目。我们使用了问题解决（见第9章）和分级任务分配（见第10章末尾）。劳尔发现将项目分解成小块非常有帮助，这使任务变得更加可管理。我们还查看了他的日程安排，指定了他每天完成每个任务块的时间。

劳尔喜欢开发应对思维的想法。我们探讨了他如何处理进行顺利的项目，并将这些策略应用于他遇到困难的项目。我们开发了一系列应对思维，包括“一步一步来”、“这只是个任务，完成它”和“打球”。劳尔高中时是一名成功的橄榄球运动员。我们探讨了他在感到沮丧或难以集中注意力时如何应对作为运动员的情况。他回答说，他只是专注于任务，停止比赛不是选项。我在想他如何将这种策略应用到当前的工作中。“打球”这句话提醒他将当前的工作视为一场橄榄球比赛——没有选择，只能打！

当劳尔开始减少拖延时，他开始感觉稍微好一些，但他仍然感到抑郁。在第4次会话结束时，我介绍了行为激活的概念。在会话中，我们完成了前一天的《每日活动计划表》。劳尔同意尝试在接下来的一周内完成《每日活动计划表》作为家庭作业。

第5至第8次会话

第5至第8次会话

劳尔完成了《每日活动计划表》，我们使用《探索情绪/活动关系的问题》来了解他的一天以及他的活动如何影响他的情绪。劳尔没有意识到自己已经与家人和朋友疏远了多少。鉴于社会关系对提升和维持积极情绪的重要性，我重点关注让他增加与妻子、孩子和朋友的社交活动。接下来的几次会话涉及行为激活、问题解决和应对思维的组合。几周后，他的情绪开始好转。

在查看他的《每日活动计划表》时，我们还发现劳尔没有一个好的睡眠习惯。这与他未抑郁时的情况大不相同。对于长期经历睡眠困难的来访，可能需要看专门治疗失眠的认知行为疗法（CBT-I）的治疗师（Edinger & Carney, 2014）。然而，对于许多来访，遵循基本的睡眠卫生指南就足以显著改善睡眠。以下是我在治疗中使用的《良好睡眠指南》，您可以在 http://www.newharbinger.com/38501 下载该指南的手册版本。

1. 保持规律的作息时间，无论是入睡还是起床。
2. 将午睡时间限制在每天20分钟以内，并且只在下午早些时候进行。
3. 在睡前两小时内不要进行剧烈运动。
4. 避免接触强光，确保卧室黑暗；有些人发现睡前使用电脑会影响睡眠。
5. 避免在睡前吃重餐或饮酒。
6. 避免在睡前摄入咖啡因或酒精。

当劳尔查看他的《每日活动计划表》时，他注意到自己下班回家后，看电视并立即睡至少一个小时。然后他在凌晨1点到2点之间上床睡觉，早上感到非常疲惫。周末他醒来时感到疲倦，躺在床上直到上午9点或10点，希望能弥补睡眠不足。

我们一起回顾了《良好睡眠指南》。劳尔决定尝试建立一个规律的睡眠时间表。他希望下班回家后去散步而不是看电视和午睡，并尝试在晚上11点上床睡觉。

在下一次会话中，劳尔报告说放弃在电视前午睡非常困难。他喜欢下班回家后散步的想法，但在现实中从未做到。我们探讨了他可以做的其他活动，他建议可以帮助妻子做饭、给孩子们打电话和处理电子邮件。在下一次会话中，劳尔报告说这个计划效果更好。当他停止午睡后，更容易在较早的时间上床睡觉，他的睡眠随着更规律的作息时间表开始改善。

第9至第16次会话

第9至第16次会话

我们继续结合使用行为激活、问题解决、分级任务分配和应对思维。劳尔开始带着越来越多他想要解决的议程项目来到治疗。一旦劳尔不再拖延，他开始提出与工作中的社交关系相关的问题。我们列出了他因抑郁而停止的社交活动，并逐渐引入那些最容易实施的活动。我总是确保劳尔有一个具体可行的计划。劳尔开始与同事在食堂共进午餐，在会议上发言，与老板讨论他参与的一些项目，总体上更像他过去的自己。（您可以在第9章看到部分工作。）

通常，劳尔预期这些社交活动不会让他感到愉快，也不会进行得顺利。然而，他发现这些活动通常进行得很顺利，一旦他做了这些活动，他感觉更好。我们强调了按照计划行事而不是根据抑郁情绪行事的重要性。

在尝试与同事和老板建立联系的过程中，劳尔经常想：“他们不尊重我”或“他们不重视我的意见。”（请参阅第7章了解我是如何识别劳尔的思维的。）他提到的情况包括他认为老板在会议上批评了他（见第5章），以及他邀请一位同事共进午餐但对方很忙的情况。在这两种情况下，劳尔都能够考虑其他可能的、更温和的解释。我建议劳尔，他倾向于灾难化（见第6章的认知扭曲列表），他也同意这一点。我们经常使用灾难化作为一种简短的方式，检查是否有其他更温和的解释。

到第9次会话时，劳尔已经开始自发地将我们在工作中使用的干预措施应用到个人生活中。例如，一位朋友告诉他不能去保龄球馆。通常劳尔会认为这意味着朋友不尊重他，尤其是如果朋友临时取消。然而，他能够考虑其他解释。

在第14次会话中，劳尔告诉我他已经完成了六个月的评估，一切似乎都在正轨上。我们讨论了他自从开始治疗以来取得的进步。劳尔想知道是否可以跳过下一次会话，因为他有一个办公室社交活动想去。他通常期待我们的会话，但这次他似乎对安排下一次会话相当随意。我问他关于继续治疗的感受。劳尔解释说我是一个非常好的女士，但他认为自己不再需要治疗了。劳尔的经历非常常见。随着来访状况的好转，治疗对他们来说变得不那么重要，而他们的生活其他方面变得更重要。我建议我们在两周后再进行一次会话，以确保一切顺利，如果一切顺利，我们再安排最后一次会话来结束治疗。

第17次会话

在我们的最后一次会面中，我们回顾了劳尔在治疗中取得的成就，并查看了他的原始目标。劳尔惊讶地发现自己取得了多大的进步，因为他已经忘记了第一次来时的感觉。他的睡眠更加规律，不再抑郁。他和妻子重新开始社交，与朋友和家人见面。我强调了继续与妻子、家人和朋友进行愉快活动的重要性。我们花了一些时间探讨对他最有帮助的部分。他认为将大项目分解成小块真的很有帮助，他说他经常这样做，甚至教给了其他同事。他还认为不灾难化也很有帮助。正如我对苏珊娜所说的那样，我告诉劳尔，如果他需要巩固会话，我随时欢迎他回来，我也很享受与他合作的过程。

家庭作业：练习认知行为疗法 (CBT)

我希望你在阅读这本书的过程中觉得家庭作业很有价值。我知道，对我来说，在写作过程中，我发现很多认知行为疗法 (CBT) 的干预措施非常有用。我重新发现了积极心理学，并一直在努力停下来享受每一个时刻。在整个写作过程中，我特别感谢以下几位 CBT 朋友，没有他们，这本书不可能完成。

• 议程设置：你帮我保持了组织性。每天写作结束时的回顾帮助我记得自己确实完成了一些事情！
• 四因素模型：每当我卡住时，你帮助我暂停并找出我的想法。我注意到自己的消极自动思维，寻找证据，通常能够回到任务上来。
• 应对思维：你让我保持专注。
• 行为激活：我想我的整个家庭都想感谢你。有一段时间我除了写书什么都没做；你让我安排了每天的散步和有趣的时间。
• 问题解决：当我发现自己盯着电脑屏幕沉思时，我进行了问题解决。我最喜欢的一个解决方案是把困扰我的段落发给一位同事或学生，然后问丈夫回家后的意见；他们都给出了很好的建议。
• 分级任务分配：没有你，这本书不可能完成。无论我多么感到不知所措，你总是在那里帮助我把任务分解成可管理的小块。我认为你是这本书的英雄。

将所学应用到你的生活中

花点时间思考我们所涵盖的一切。你如何将这些知识应用到自己的生活中？你做出了哪些改变？你想要继续做什么？我希望你有机会亲身体验到 CBT 的帮助。记住，数据清楚地表明，如果你将 CBT 应用到自己的生活中，你会成为一个更好的 CBT 治疗师。

将所学应用到你的治疗实践中

在我们道别之前，让我们以自我评估结束。在阅读这本书的过程中，你的治疗实践发生了哪些变化？你尝试了哪些新的技能和干预措施？你是否设置了议程？是否识别了来访的思维？是否寻找证据并创建平衡的思维？你有没有机会尝试问题解决、行为激活或暴露疗法？你需要做些什么来继续学习和提高你的 CBT 技能？你可以设定一两个专业目标并制定学习计划吗？

结束时刻

亲爱的读者，我们已经到了这本书的结尾。此时此刻，是否使用你所学的知识取决于你。我真诚地希望你会使用。如果你已经在治疗实践中或自己的生活中做出了一些改变，请花点时间承认你所做的工作，并给自己一个应得的掌声。改变对我们和我们的来访来说都是困难的。

通过阅读这本书，就好像你参加了一门完整的 CBT 课程，包括检查、回顾、议程设置、行动计划、家庭作业和不断的练习。我希望你能更容易地将这种结构应用到你的治疗实践中，你和你的来访都能从你所付出的努力中受益。能成为你的引导者是我的荣幸。

本章知识点阐述

进一步阐述知识点

自动思维中的模式

核心信念是信息处理的过滤器，影响你注意到的信息、赋予事件的意义以及你记住的内容。识别自动思维中的模式可以帮助我们推测来访的核 心信念。具体步骤如下：

1. 注意问题情境：观察来访在哪些情境中感到压力。
2. 识别自动思维的模式：记录来访在这些情境中的自动思维，找出其中的模式。
3. 假设核心信念：根据模式推测来访的核 心信念。

核 心信念的分类

核 心信念可以分为三个领域：

1. 关于能力的判断：包括无助、不聪明或无能的信念。
2. 关于可爱性的判断：包括不吸引人、不喜欢、脆弱或不同的信念。
3. 关于价值的判断：涉及基本的好感或深刻的感觉，即自己有问题。

苏珊娜的核心信念

苏珊娜的生活中的主要压力源是社交性的，她的负面思维集中在不被喜欢或感觉不被接受上。通过分析她的自动思维和压力情境，可以推测她的核心信念：

• 关于自我的核心信念：我不可爱。
• 关于他人的核心信念：人们不会喜欢我，也不会友好。
• 关于世界的核心信念：世界是不安全的。

劳尔的核心信念

劳尔的核心信念更多集中在能力上，而不是可爱性上。他的自动思维和压力情境表明：

• 关于自我的核心信念：只有我取得成就才有价值，或者如果我失败了，这就证明我是愚蠢的。
• 关于他人的核心信念：你不能信任家庭以外的人。
• 关于世界的核 心信念：世界是不公平的。

临床意义

一旦对来访的核 心信念有了假设，治疗师需要特别注意来访如何驳回或最小化挑战核 心信念的信息。具体做法包括：

• 关注事实：收集关于情境的事实，帮助来访认识到与核 心信念相矛盾的信息。
• 回顾例子：帮助来访回顾与核 心信念相矛盾的例子，强化正面信息。

通过本章的学习，你可以更好地理解如何识别自动思维中的模式，如何分类核 心信念，以及如何在临床实践中应用这些知识。这些方法可以帮助来访更有效地应对焦虑，提高生活质量。

进一步阐述知识点

识别来访心理社会史中的主题

核心信念通常在童年时期形成，是家庭和更大社会环境中的经历的结果。通过识别来访心理社会史中的主题，可以帮助我们推测来访的核心信念。具体步骤如下：

1. 获取心理社会史：详细了解来访的家庭背景、成长经历和重要生活事件。
2. 识别核心信息：倾听来访在这些经历中学到的关于自己、他人和世界的核 心信息。
3. 推测核心信念：根据这些核心信息，推测来访的核心信念。

苏珊娜的核心信念

苏珊娜的心理社会史与以下核心信念的发展一致：

• 关于自我的核心信念：我不可爱。
• 关于他人的核心信念：人们不会喜欢我，也不会友好。
• 关于世界的核 心信念：世界是不安全的。

劳尔的核心信念

劳尔的心理社会史支持以下核心信念的发展：

• 关于自我的核心信念：只有我取得成就才有价值，或者如果我失败了，这就证明我是愚蠢的。潜在的核心信念是：我是无能的。
• 关于他人的核心信念：你不能信任家庭以外的人。
• 关于世界的核 心信念：世界是不公平的。

临床意义

一旦对来访的核 心信念有了假设，治疗师需要特别注意来访如何驳回或最小化挑战核 心信念的信息。具体做法包括：

• 关注事实：收集关于情境的事实，帮助来访认识到与核 心信念相矛盾的信息。
• 回顾例子：帮助来访回顾与核 心信念相矛盾的例子，强化正面信息。

通过本章的学习，你可以更好地理解如何识别来访心理社会史中的主题，如何推测来访的核心信念，以及如何在临床实践中应用这些知识。这些方法可以帮助来访更有效地应对焦虑，提高生活质量。

进一步阐述知识点

寻找证据和创建平衡思维

在第4次会话中，苏珊娜和治疗师一起探讨了她的热认知“没有人会想和我做朋友”，并通过寻找证据和创建平衡思维来处理这一认知。具体步骤如下：

1. 选择热认知：选择一个具体的负面自动思维。
2. 寻找证据：列出支持和反对该热认知的证据。
3. 创建平衡思维：结合证据，创建一个更加平衡和现实的思维。

家庭作业的重要性

家庭作业在认知行为治疗中起着关键作用，帮助来访在日常生活中应用所学的知识。苏珊娜的家庭作业包括：

1. 复习思维记录：每天早上上学前复习已完成的思维记录，保持平衡思维的新鲜感。
2. 完成新的思维记录：为其他情境完成完整的思维记录，进一步巩固技能。

处理焦虑和抑郁

在第5次会话中，治疗师和苏珊娜一起处理了她对参加烧烤会的焦虑和持续的抑郁情绪。具体步骤如下：

1. 问题解决：讨论如何处理烧烤会，制定应对策略。
2. 行为激活：介绍行为激活的概念，使用《理解你的抑郁》工作表探讨抑郁情绪。
3. 日常活动计划：使用每日活动计划表，了解不同活动对情绪的影响。

临床意义

通过这些会话，治疗师帮助苏珊娜逐步克服了她的焦虑和抑郁情绪。具体做法包括：

• 寻找证据和创建平衡思维：通过具体的情境和证据，帮助来访建立更现实的思维。
• 家庭作业：通过家庭作业，帮助来访在日常生活中应用所学的技能。
• 行为激活：通过了解来访的日常活动，帮助来访增加积极的活动，改善情绪。

通过本章的学习，你可以更好地理解如何在认知行为治疗中使用寻找证据和创建平衡思维的方法，如何设计有效的家庭作业，以及如何在临床实践中处理来访的焦虑和抑郁情绪。这些方法可以帮助来访更有效地应对心理问题，提高生活质量。

进一步阐述知识点

行为激活和情绪管理

在第6至第9次会话中，治疗师和苏珊娜主要通过行为激活、问题解决和应对思维来改善她的情绪。具体步骤如下：

1. 行为激活：规划愉快的活动，以提升情绪。
2. 问题解决：解决实施活动中的障碍。
3. 应对思维：发展应对负面思维的策略。

与丈夫沟通的技巧

苏珊娜在与丈夫沟通家务和育儿问题时感到焦虑。治疗师通过以下步骤帮助她：

1. 列出具体担忧：详细列出与丈夫沟通的具体担忧。
2. 评估可能性：查看这些担忧的实际可能性。
3. 角色扮演：通过角色扮演和想象练习，帮助苏珊娜练习沟通技巧。

处理早晨准备孩子的困难

苏珊娜在早晨让孩子准备好上学时感到困难。治疗师通过以下步骤帮助她：

1. 分离事实与意义：明确情境的事实，而不是立即赋予其负面意义。
2. 评估负面思维：通过标准评估自己的行为，认识到自己是一个好母亲。
3. 换位思考：从其他角度看待问题，减少压力并找到不同的处理方式。

临床意义

通过这些会话，治疗师帮助苏珊娜逐步克服了她的焦虑和抑郁情绪，改善了她的情绪和生活质量。具体做法包括：

• 行为激活：通过增加愉快的活动，提升情绪。
• 问题解决：解决实施活动中的障碍，确保活动的有效性。
• 应对思维：发展应对负面思维的策略，减少焦虑和抑郁。
• 沟通技巧：通过角色扮演和想象练习，帮助来访有效沟通。
• 分离事实与意义：通过分离事实与意义，帮助来访更客观地看待问题。
• 换位思考：通过换位思考，帮助来访减少压力并找到不同的解决方案。

通过本章的学习，你可以更好地理解如何在认知行为治疗中使用行为激活、问题解决和应对思维的方法，如何帮助来访有效沟通，以及如何处理日常生活中的具体问题。这些方法可以帮助来访更有效地应对心理问题，提高生活质量。

进一步阐述知识点

暴露疗法

在第10至第16次会话中，治疗师使用了暴露疗法来帮助苏珊娜克服社交焦虑。具体步骤如下：

1. 识别负面思维：识别苏珊娜在社交场合中的负面思维，如“没有人会想和我做朋友”。
2. 暴露任务：设计一系列逐步增加难度的社交任务，帮助苏珊娜面对她的恐惧。
3. 记录积极体验：利用暴露任务中的积极体验作为证据，挑战负面思维。
4. 持续记录：记录那些挑战负面信念的情境，帮助苏珊娜逐步建立自信。

社交焦虑的处理

苏珊娜在尝试与同事建立友谊时感到非常焦虑。治疗师通过以下步骤帮助她：

1. 逐步暴露：从简单的社交任务开始，逐步增加难度。
2. 正面反馈：利用每次成功的社交互动作为正面反馈，增强她的信心。
3. 记录进展：记录每次成功的社交互动，帮助她看到自己的进步。

临床意义

通过这些会话，治疗师帮助苏珊娜逐步克服了社交焦虑，改善了她的人际关系和生活质量。具体做法包括：

• 暴露疗法：通过逐步增加难度的社交任务，帮助来访克服恐惧。
• 记录积极体验：利用积极的社交体验作为证据，挑战负面思维。
• 持续记录：记录每次成功的社交互动，帮助来访看到自己的进步。

通过本章的学习，你可以更好地理解如何在认知行为治疗中使用暴露疗法来处理社交焦虑，如何帮助来访逐步建立自信，以及如何记录和评估来访的进展。这些方法可以帮助来访更有效地应对社交焦虑，改善人际关系和生活质量。

进一步阐述知识点

结束治疗

在第17和第18次会话中，苏珊娜和治疗师讨论了结束治疗的问题。具体步骤如下：

1. 回顾目标：回顾苏珊娜的治疗目标，确认她已经实现或接近实现。
2. 讨论担忧：讨论苏珊娜对结束治疗的担忧，帮助她建立信心。
3. 巩固会话：安排巩固会话，确保苏珊娜能够在需要时获得支持。
4. 正面结束：通过正面的结束语，强调治疗的积极成果和双方的良好关系。

建立信心

苏珊娜在结束治疗时感到担忧，治疗师通过以下步骤帮助她建立信心：

1. 回顾成就：回顾苏珊娜在治疗中的成就，帮助她看到自己的进步。
2. 讨论应对策略：讨论如何在没有治疗的情况下应对未来的挑战。
3. 巩固会话：安排巩固会话，确保苏珊娜在需要时可以寻求支持。

临床意义

通过这些会话，治疗师帮助苏珊娜顺利结束了治疗，确保她能够独立应对未来的挑战。具体做法包括：

• 回顾目标：回顾治疗目标，确认来访的进展。
• 讨论担忧：讨论来访的担忧，帮助他们建立信心。
• 巩固会话：安排巩固会话，确保来访在需要时可以获得支持。
• 正面结束：通过正面的结束语，强调治疗的积极成果和双方的良好关系。

通过本章的学习，你可以更好地理解如何在认知行为治疗中处理结束治疗的问题，如何帮助来访回顾成就、建立信心，并确保他们在未来能够独立应对挑战。这些方法可以帮助来访顺利完成治疗，提高生活质量。

进一步阐述知识点

初始阶段的挑战

劳尔在治疗初期表现出较大的抵触情绪和怀疑态度。治疗师通过以下步骤帮助他：

1. 行为干预：由于劳尔难以识别自己的感受和想法，治疗师选择从行为干预开始。
2. 核心信念：假设劳尔的核心信念与成功和受尊重有关，关注这些方面的思维。
3. 目标设定：明确劳尔的治疗目标，帮助他集中精力应对具体问题。

解决拖延问题

在第3次和第4次会话中，治疗师和劳尔重点解决了拖延问题。具体步骤如下：

1. 项目分类：识别进行顺利的项目和拖延的项目。
2. 评估后果：评估拖延可能带来的最严重后果。
3. 问题解决：使用问题解决策略，将大任务分解成小任务，使其更易于管理。
4. 应对思维：开发应对思维，帮助劳尔更好地应对工作中的挑战。
5. 行为激活：在减少拖延后，引入行为激活，帮助劳尔改善情绪。

临床意义

通过这些会话，治疗师帮助劳尔逐步克服了拖延问题，改善了他在工作中的表现，并开始减少抑郁情绪。具体做法包括：

• 行为干预：从行为干预开始，帮助来访更容易参与治疗。
• 目标设定：明确治疗目标，帮助来访集中精力应对具体问题。
• 问题解决：使用问题解决策略，将大任务分解成小任务，使其更易于管理。
• 应对思维：开发应对思维，帮助来访更好地应对工作中的挑战。
• 行为激活：在减少拖延后，引入行为激活，帮助来访改善情绪。

通过本章的学习，你可以更好地理解如何在认知行为治疗中处理来访的抵触情绪和拖延问题，如何帮助来访设定明确的治疗目标，以及如何使用问题解决和应对思维的方法来改善来访的工作表现和情绪状态。这些方法可以帮助来访更有效地应对工作和生活中的挑战，提高生活质量。

进一步阐述知识点

行为激活和社会活动

在第5至第8次会话中，治疗师和劳尔重点增加了他的社交活动。具体步骤如下：

1. 完成《每日活动计划表》：通过《每日活动计划表》了解劳尔的日常活动及其对情绪的影响。
2. 增加社交活动：鼓励劳尔增加与家人和朋友的社交活动，以提升情绪。
3. 行为激活：通过行为激活，帮助劳尔逐步恢复正常的社交活动。

改善睡眠质量

劳尔的《每日活动计划表》显示他的睡眠习惯存在问题。治疗师通过以下步骤帮助他改善睡眠：

1. 评估睡眠习惯：通过《每日活动计划表》评估劳尔的睡眠习惯。
2. 提供《良好睡眠指南》：向劳尔提供《良好睡眠指南》，帮助他建立规律的睡眠时间表。
3. 制定具体计划：帮助劳尔制定具体的计划，如下班后散步、帮助妻子做饭等。
4. 逐步实施：逐步实施计划，逐步改善睡眠质量。

临床意义

通过这些会话，治疗师帮助劳尔逐步改善了他的情绪和睡眠质量。具体做法包括：

• 行为激活：通过增加社交活动，帮助来访提升情绪。
• 评估和改善睡眠习惯：通过评估和提供《良好睡眠指南》，帮助来访建立规律的睡眠时间表。
• 制定具体计划：帮助来访制定具体的计划，逐步实施，改善睡眠质量。

通过本章的学习，你可以更好地理解如何在认知行为治疗中使用行为激活来增加来访的社交活动，如何评估和改善来访的睡眠习惯，以及如何制定具体的计划来帮助来访逐步改善睡眠质量。这些方法可以帮助来访更有效地应对抑郁情绪，提高生活质量。

进一步阐述知识点

继续行为激活和应对思维

在第9至第16次会话中，治疗师和劳尔继续结合使用行为激活、问题解决、分级任务分配和应对思维。具体步骤如下：

1. 行为激活：继续增加社交活动，帮助劳尔逐步恢复正常的社交生活。
2. 问题解决：解决实施社交活动中的障碍，确保活动的有效性。
3. 分级任务分配：将大项目分解成小块，逐步实施。
4. 应对思维：发展应对负面思维的策略，减少焦虑和抑郁。

处理社交焦虑

劳尔在尝试与同事和老板建立联系时感到焦虑。治疗师通过以下步骤帮助他：

1. 识别负面思维：识别劳尔在社交场合中的负面思维，如“他们不尊重我”或“他们不重视我的意见”。
2. 替代解释：考虑其他可能的、更温和的解释，减少灾难化的倾向。
3. 逐步实践：通过逐步实践，帮助劳尔建立自信，改善社交关系。

自发应用干预措施

到第9次会话时，劳尔开始自发地将治疗中学到的干预措施应用到个人生活中。具体例子包括：

1. 将大项目分解成小块：将大项目分解成小块，逐步实施，提高效率。
2. 不灾难化：避免过度悲观，考虑其他可能的解释，减少焦虑。

结束治疗

在第17次会话中，劳尔和治疗师讨论了结束治疗的问题。具体步骤如下：

1. 回顾成就：回顾劳尔在治疗中的成就，确认他的进步。
2. 讨论担忧：讨论劳尔对结束治疗的担忧，帮助他建立信心。
3. 巩固会话：安排巩固会话，确保劳尔在需要时可以获得支持。
4. 正面结束：通过正面的结束语，强调治疗的积极成果和双方的良好关系。

临床意义

通过这些会话，治疗师帮助劳尔逐步克服了拖延和社交焦虑，改善了他的情绪和生活质量。具体做法包括：

• 行为激活：通过增加社交活动，帮助来访逐步恢复正常的社交生活。
• 问题解决：解决实施社交活动中的障碍，确保活动的有效性。
• 分级任务分配：将大项目分解成小块，逐步实施，提高效率。
• 应对思维：发展应对负面思维的策略，减少焦虑和抑郁。
• 自发应用干预措施：鼓励来访将治疗中学到的干预措施应用到个人生活中。
• 结束治疗：通过回顾成就、讨论担忧、安排巩固会话和正面结束，帮助来访顺利结束治疗。

通过本章的学习，你可以更好地理解如何在认知行为治疗中继续使用行为激活、问题解决、分级任务分配和应对思维的方法，如何帮助来访处理社交焦虑，如何鼓励来访自发应用干预措施，以及如何处理结束治疗的问题。这些方法可以帮助来访更有效地应对抑郁情绪，改善社交关系和生活质量。

进一步阐述知识点

家庭作业的价值

作者强调了家庭作业在学习和应用 CBT 中的重要作用。具体来说：

1. 议程设置：帮助保持组织性和目标导向，每天回顾有助于确认成就。
2. 四因素模型：在遇到困难时，帮助识别和挑战消极自动思维，回归任务。
3. 应对思维：保持专注，减少分心。
4. 行为激活：通过安排日常活动，提高生活质量，减少抑郁情绪。
5. 问题解决：通过具体步骤解决实际问题，寻求外部支持。
6. 分级任务分配：将大任务分解成小块，逐步完成，减少压力和焦虑。

个人应用

作者鼓励读者将所学应用到自己的生活中。具体步骤包括：

1. 反思：回顾所学内容，思考如何应用到自己的生活中。
2. 改变：识别并实施具体的改变，如增加积极活动、减少消极思维。
3. 持续：继续保持这些有益的习惯和思维方式。

治疗实践应用

作者建议读者将所学应用到治疗实践中。具体步骤包括：

1. 自我评估：回顾治疗实践的变化，识别新的技能和干预措施。
2. 技能提升：设定议程、识别来访的思维、寻找证据、创建平衡的思维。
3. 尝试新方法：尝试问题解决、行为激活、暴露疗法等新方法。
4. 制定计划：设定专业目标，制定学习计划，持续提升 CBT 技能。

临床意义

通过本书的学习，读者不仅可以在个人生活中受益，还能在治疗实践中更好地应用 CBT 技能。具体做法包括：

• 家庭作业：通过家庭作业巩固所学知识，提高实践能力。
• 个人应用：将 CBT 知识应用到个人生活中，改善情绪和生活质量。
• 治疗实践：在治疗实践中应用 CBT 技能，提升治疗效果。
• 持续学习：设定专业目标，制定学习计划，不断提升 CBT 技能。

通过本章的学习，你可以更好地理解如何在个人生活和治疗实践中应用 CBT 知识，如何通过家庭作业巩固所学，以及如何设定专业目标并制定学习计划。这些方法可以帮助你成为更有效的 CBT 治疗师，同时改善自己的生活质量。

PART 4 CBT in Action

CHAPTER 12 Suzanne’s and Raoul’s Therapy In the last chapter we covered exposure therapy. Did you notice your own or one of your client’s safety behaviors? Did you identify any clients who you thought might benefit from exposure? What about explaining exposure or developing a fear hierarchy? If you did not have a chance to do the homework, think of a situation you are currently avoiding, and try to develop a plan to face your fear. Set the Agenda Although Suzanne and Raoul are composites of a number of clients, they are based on my clinical experience. I want to give you a sense of how their therapy unfolded and how I used the various inter- ventions we covered in the book. The preceding chapters were too short to cover everything we did in Suzanne’s and Raoul’s therapy, so I’ve included some of the additional interventions in this final chapter. However, I want to start with discussing core beliefs. Agenda Item #1: Identify Suzanne’s and Raoul’s core beliefs. Agenda Item #2: Suzanne’s therapy Agenda Item #3: Raoul’s therapy Work the Agenda Up to now we have focused on automatic thoughts and behavior. I want to look at how we can use core beliefs to understand Suzanne and Raoul. Agenda Item #1: Identify Suzanne’s and Raoul’s Core Beliefs Automatic thoughts are situation specific and are just below consciousness. This means that it is fairly easy to teach people to notice their automatic thoughts and then to evaluate and modify them.

Core beliefs are stable, deeply held beliefs that affect how you feel and behave in many different situa- tions. It is much harder to identify and modify core beliefs than automatic thoughts. Most CBT focuses on modifying automatic thoughts and behaviors. In chapter 1 we talked about how we all have core beliefs about the self, others, and the world. Core beliefs can be negative or positive. Examples of core beliefs about one’s self might be I am lovable or I am incapable; examples of core beliefs about others might be People do not care about me or People will try to help me; and examples of core beliefs about the world might be The future will be good or The world is unpredictable. I want to go over three approaches for identifying core beliefs: (1) noticing patterns in problematic situations and automatic thoughts, (2) identifying themes in a client’s psychosocial history, and (3) the downward arrow technique. NOTICING PATTERNS IN AUTOMATIC THOUGHTS Core beliefs are basically an information-processing filter; they influence what you notice, the meaning you give to events, and what you remember. You can think of core beliefs as large magnets that go around attracting and picking up information that confirms the core belief. People either don’t notice information that contradicts their core beliefs or minimize the information. For example, before Suzanne started therapy, how would you expect her to react if a teacher came up to her at recess and said hello? Would she think (A) I am starting to make friends; this teacher likes me or (B) This is a fluke; I am sure that she won’t talk to me tomorrow? I would guess B. What about when she gets home at night and her husband asks her about her day? Will she remember the teacher who came up to her, or will she remember that a lot of the time she was alone at recess? I would guess she will remember that she was alone. We can look for patterns in the types of situations that are stressful for our clients and pat- terns in the types of automatic thoughts that cause our clients’ distress. Once we identify these pat- terns, we can start to hypothesize about our clients’ core beliefs. I find it helpful to think of core beliefs about the self as falling into three areas: (1) judgments about how competent or incompetent one is; this includes beliefs related to being helpless, unintelligent, or incapable; (2) judgments about how lovable or unlovable one is; this includes beliefs related to being unattractive, unlikable, vulnerable, or different; and (3) judgments about how basically worthy or worthless one is; this involves a very deep sense of being basically an okay person or a deep sense of something being horribly wrong with you. Core beliefs related to worthlessness often are the result of severe childhood abuse. Noticing which category is the most triggering for your client can help you focus on situations and thoughts that are central to your client’s distress. When I look for patterns in my client’s automatic thoughts, I ask myself which of the three categories seems the most relevant to my client. Suzanne’s core beliefs. Let’s think about Suzanne. The major stressors in her life have been a new school, which has disrupted her friendships and family relationships; her best friend moving away; and her mother-in-law’s illness. From what you know, would you expect her core beliefs to center on com- petence, lovability, or worthlessness? It seems to me that the types of situations that caused her stress were social. Suzanne’s negative thoughts frequently center on not being liked or feeling accepted. At both the barbecue and recess, her thoughts are related to the other teachers not liking her or not wanting to be her friend. When her husband didn’t give their son a bath, one of her thoughts was He doesn’t care about me. During the exposure tasks, she didn’t expect people to react positively to her friendly overtures. What would you hypothesize were Suzanne’s core beliefs? When we examine the type of situations that she found stressful and the pattern to her automatic thoughts, I would hypothesize that these were her core beliefs: Core belief about self: I am not lovable. Core belief about others: People will not like me and will not be friendly. Core belief about the world: The world is not safe. Raoul’s core beliefs. From what you know of Raoul, what would you guess were his core beliefs? Being passed over for a promotion triggered his difficulties. I would hypothesize that being successful is very important to Raoul. This leads me to hypothesize that his core beliefs would center more on being competent than on being lovable. I wondered if one of his core beliefs about self was I am only valuable if I achieve, or maybe, If I fail, this is proof that I am stupid. I also wondered if there was an underlying core belief: I am incompetent. What about his core beliefs about others? I noticed that he doesn’t trust his boss or colleagues to be supportive and helpful. However, he has a good relationship with his wife and children. I wondered if one of his core beliefs about others was You can’t trust people outside the family. What about his core belief about the world? Raoul was very upset about being passed over and felt that it was unfair. I would wonder if he sees the world as unfair, and not just this one experience. These would all be initial hypotheses; I would want to know more information. Given my hypothesis of Raoul’s core beliefs, what kinds of information do you think he might ignore about himself and others? Clinical implications. Once I have a hypothesis of my client’s core beliefs, I am particularly attuned to how she dismisses or minimizes information that would challenge her core belief. Let’s take an example. Suzanne tells her therapist that one of the teachers asked her if she would volunteer to be on the com- mittee that was responsible for the winter holiday assembly. Will Suzanne think: (A) This is a good start to being more part of the school; I will get to know some of the teachers better or (B) I am sure I will not fit in? I would guess B. As her therapist, I am especially attuned to how she interprets social situations that might challenge her core belief. I pay particular attention to gathering facts about the situation because I know that Suzanne will minimize indications that others are friendly or like her. I also know that Suzanne will have a hard time remembering examples that contradict her core belief and that review- ing them will be very important. IDENTIFY THEMES IN A CLIENT’S PSYCHOSOCIAL HISTORY Core beliefs generally develop during childhood and are a consequence of experiences in one’s family and the larger social world, though experiences in later life can also influence core beliefs. I know of many shy, socially anxious children and teens who developed into outgoing young adults after positive experiences at camp, school, work, or college. These young people had a series of positive social experiences that changed their core belief from Others will not like me to Others will respond positively to me. Traumatic experiences can also change core beliefs. Subsequent to trauma, many people start to believe that the world is dangerous, and if the trauma involved another person, their belief about others becomes Other people can hurt you. Often individuals who experience trauma also develop core beliefs about the self, such as I am vulnerable or weak or I am somehow damaged after the trauma. Remember in chapter 2 we talked about listening for the meaning of events when you take a psy- chosocial history? When I take a history, I am listening for the core messages my client learned about herself, others, and the world. Let’s look at Suzanne’s and Raoul’s psychosocial history and see if we can hypothesize what their core beliefs might be. Suzanne’s history. Suzanne was the eldest of four siblings. Her parents were hard-working people who had enough money for the family’s needs, but there was no extra. Suzanne described her parents as cold and strict. They had very high standards for Suzanne, expecting her to do well at school and help take care of the household and her three younger brothers. They made it clear that they preferred boys, and she worried about pleasing them and being good enough. Suzanne did well in school, the one area where her mother did not criticize her; otherwise, her mother was very critical of her, which Suzanne thought was “for her own good.” Her mother was also a very anxious woman who had few friends and worried about whether she would fit in and whether people would like her. Suzanne described herself as a “good kid” with no problems. She had very few friends at school, which she attributed to often being needed at home and having no time to be with her peers. She did make some friends in high school, but after she refused to let her house be used for a drinking party, most of the class turned against her. She graduated from high school and attended a teacher’s college. She was the first person in her family to go to college and was very proud of her accomplishment. She is married to her first boyfriend, who was her high school sweetheart. If you remember, from examining the types of situations that she found stressful and the pattern to her automatic thoughts, I had hypothesized that her core beliefs were I am unlovable, People will not like me and will not be friendly, and The world is not safe. Her psychosocial history is consistent with the development of these core beliefs. Raoul’s history. Raoul’s family had immigrated to the United States when he was two years old. He lived close to his aunt and uncle and grew up in a large extended family. Raoul described having a happy childhood until age eight when his father died, after which his life became more difficult. His mother had two jobs, and he was often home alone. He continued to see his extended family, but he missed his father. In school he felt that the teachers did not respect him or his family, who had less money than many of the other families. He also had a slight learning disability, which was not diag- nosed until high school. Though he tried hard at school, his teachers often complained to his mother that he was not working up to his potential. He remembers being humiliated at school when he could not answer questions or did poorly on a test. The one area where he did well was math. He was also on the football team, which he loved. After high school, his uncle paid for his college education and he obtained a degree in accounting. He met his wife after college, and they have had a good marriage. Raoul’s psychosocial history supports the development of the core beliefs we wondered about earlier. We hypothesized that one of his core beliefs about self was I am only valuable if I achieve, or maybe, If I fail, this is proof that I am stupid. We wondered if there was an underlying core belief: I am incompetent. His history of not doing well in school and having a learning disability would support the hypothesis that one of his core beliefs about self was I am incompetent. His psychosocial history also supports his core beliefs about others and the world that we identified earlier: You can’t trust people outside the family and The world is unfair. Given my hypotheses of Raoul’s core beliefs, what kinds of information do you think he might ignore about himself and others?

DOWNWARD ARROW TECHNIQUE The downward arrow technique involves starting with an automatic thought and tracing it back to the core belief. Because you are accessing very deep beliefs about the self, others, and the world, you don’t want to use this approach until you have worked with your client for a while, have established a solid relationship, and know that she is strong enough to find this kind of work helpful. As in all therapy, it is important to use a gentle tone and caring curiosity. The therapist starts with the automatic thought, usually a thought that is (1) a negative prediction, such as My new date will not call back; (2) a fact, such as I did not get the promotion; (3) a “what if” state- ment, such as What if my mother gets angry at me?; (4) a prediction of the future, such as No one will talk to me at the party; or (5) a thought about self, such as I did not study hard enough to get good grades. The therapist then asks, “If the thought was true, what would that mean?” Additionally, I sometimes ask, “What would that mean about you?” or, “If that was true, how would that be a problem for you?” Let’s look at a brief example. One of Suzanne’s thoughts at the barbecue was I will stand there looking awkward. Let’s see what happens when we use the downward arrow technique. Look at figure 12.1. Suzanne’s therapist starts with the thought I will stand there looking awkward, which is a prediction about the future. The therapist then asks what it would mean if that was true. After all, you could think that if I stand there looking awkward, if the principal is a good host, she will come up and talk to me. Suzanne’s therapist uses the downward arrow technique to discover Suzanne’s core belief: I am not a likable person. You can see from the example how this technique can lead to important but painful cognitions and how vital it is to have a good therapeutic relationship before using this technique. Suzanne:I will stand there looking awkward. Therapist:If that was true, how would that be a problem for you? Suzanne:No one would talk to me. Therapist:And if that was true, what would that mean? Suzanne:I guess it would mean that none of the teachers likes me. Therapist:(gently) And if it was true that none of the teachers liked you, what would that mean about you? Suzanne:(softly) That I am not a very likable person (looking sad). Therapist:And do you think that sometimes? Suzanne:Yes, often. Figure 12.1. Suzanne’s therapist uses the downward arrow technique.

Agenda Item #2: Suzanne’s Therapy This book has roughly followed the order of Suzanne’s therapy. After completing the assessment and setting goals, we started with thought records, moved on to problem solving and coping thoughts, then worked on behavioral activation, and lastly I introduced exposure therapy. SESSIONS 1 AND 2 In the first two sessions, I focused on understanding Suzanne’s problems, taking a history, and identifying her goals. Suzanne was easy to connect with, and from the first session we started to form a good relationship. From the very beginning, I noticed Suzanne’s strengths and started thinking about which interven- tions might make sense. I also started to hypothesize about her core beliefs. SESSION 3 If one of my clients is suffering from depression, I usually start with behavioral activation. However, at the start of session 3, Suzanne’s main agenda item was the barbecue she had just been invited to. I had to decide whether to focus on the barbecue or introduce behavioral activation. Although Suzanne was depressed, she was in the moderate range. I was concerned that if we did not start with the barbe- cue, she might think that therapy would not address the problems that she identified and that our relationship would be negatively affected. If she had been significantly depressed, I might have started with behavioral activation, as the evidence is clear that for severely depressed clients, behavioral activa- tion is an essential component of treatment. We started by exploring Suzanne’s reaction to the barbecue using the four-factor model, and we completed the Understand Your Reaction worksheet. Suzanne found it helpful to see the links between her thoughts and feelings, and it started making sense to her that she found the decision about the barbecue so difficult. Her homework was to use the Understand Your Reaction worksheet to try and identify her thoughts, feelings, physical reactions, and behavior in two other situations in the coming week. (Some of the work we did was described in chapters 6 and 7.) SESSIONS 4 AND 5 Suzanne came to session 4 having completed the Understand Your Reaction worksheet for two other situations: one, being alone at recess, and two, a staff meeting where she had made a comment and no one had responded. She was surprised at how often she thought, No one will want to be my friend and, The other teachers will not like me. Suzanne also wanted to focus on a situation at home with her husband, where she had gotten angry that he had not bathed their son. Suzanne wanted to spend most of the time talking about the invitation to the barbecue, though we spent some time exploring the situation at home. I explained the idea of looking for evidence and creat- ing balanced thoughts. We continued working on the invitation to the barbecue and looked for evi- dence for her hot thought No one will want to be my friend. We also created a balanced thought. (See chapter 8 for how I looked for evidence and helped Suzanne create a balanced thought.) We then explored whether the evidence we had collected was relevant to the other two situations she had identified in her homework, where her hot thoughts were the same or almost the same. At the end of the session Suzanne had decided she wanted to attend the barbecue. I asked Suzanne what she thought would be helpful as homework. She suggested reviewing the thought record we had completed every morning before she went to school. I thought this was an excel- lent idea, as I wanted her balanced thought to be fresh in her mind when she started school. I also suggested that she complete an entire thought record for two other situations. In session 5, we started by going over the two thought records Suzanne had completed as home- work. She had found them helpful and spontaneously mentioned that she wondered if she was being unfair to the other teachers at her new school. Her agenda items for session 5 were her anxiety about attending the barbecue the next week and her continuing depression. We problem solved how to handle the barbecue and developed coping thoughts. (See chapter 9 for excerpts of this session.) Since Suzanne had mentioned her depression, I thought this was a good opening to introduce behavioral activation. We explored her depression using the Understand Your Depression worksheet, and it made sense to her. I then explained that it would be helpful for us to understand how she spends her week and whether her mood fluctuates with the different activities. I introduced the Daily Activities Schedule, and we filled in half of the previous day before our time was up. I asked her to complete the Daily Activities Schedule as homework for the following week. SESSIONS 6–9 Suzanne had completed the Daily Activities Schedule for homework. We reviewed it using Questions to Explore a Mood/Activity Relationship. (You can find the work we did in chapter 10.) The next few sessions were focused on a combination of behavioral activation, problem-solving obstacles, and developing coping thoughts. We focused on her early morning schedule as well as the time at home after school, as these were the lowest times of her day. We carefully planned activities that she could do to boost her mood and used problem solving and coping thoughts to address any obstacles. Over the course of these few sessions, her mood improved as she started seeing friends again, playing with her children more, and spending quality time with her husband. Many of the activities we considered to improve her mood in the morning and after school involved asking her husband to be more active with the children and housework. I did not have a chance to address this issue earlier in the book, so let me spend some time explaining how I dealt with it. Suzanne was anxious about talking to her husband about his lack of participation in household chores and childcare. Her negative thoughts included He will react negatively and be resentful; He will be angry, as it is my job to take care of the children; Even if asked, he will not help more; and I am an inadequate mother for having difficulties. Over sessions 6 through 9 we spent about half of each session on increasing pleasurable activities and the other half on examining these thoughts. I asked Suzanne to list her specific worries about what would happen if she raised the issue with her husband, and we looked at the evidence for how likely these outcomes were. (In chapters 7 and 8 I helped Suzanne list her worries about going to the barbe- cue, and then we looked at the probability of each worry. We did a similar type of intervention for her worries around raising issues of childcare and housework with her husband.) When Suzanne started looking at the evidence, she realized that it was unlikely that her husband would resent being asked to be more involved with the children, and it was unlikely that he would think that it was only her job to take care of the children. Suzanne thought that there were probably realistic limits to what he could do, given his work schedule, but she thought it was worthwhile to raise the topic. We problem solved and role-played how best to raise the subject, and Suzanne also practiced in her imagination. Suzanne found getting the children ready in the morning very difficult. I suggested we do a thought record. She initially identified the situation as “I am a bad mother for being angry at the kids in the morning when they don’t get up.” In chapter 5 we talked about the importance of separating the facts of a situation from the meaning of the situation. I helped Suzanne specify the facts of the situation: her children refusing to get up in the morning. We then identified her thought: I am a bad mother, and her feelings: anger. Once Suzanne was able to separate her thoughts from the situation, we could then evaluate her thought that she was a bad mother. Next we made a list of criteria for being a good mother. Suzanne’s criteria included expressing love and affection, spending time with your children, providing for them financially, organizing their lives, and reading to them. We then evaluated her behavior in relation to the criteria she had developed. Initially, I had to draw Suzanne’s attention to evidence that she was a good mother, though I was careful not to tell Suzanne about the evidence. For example, I asked her what she did with the children on the weekend. What had she done for their birthdays? And even though the mornings were difficult, did she give them breakfast and get them ready for school? When she described what she did with the children, I asked her if that was part of being a good mother. Eventually she was able to recognize that she was a good mother. We also examined her belief that if she is having difficulty getting her four- and six-year-old chil- dren ready in the morning, this meant she is an inadequate mother. I tried to help Suzanne take another perspective. (In chapter 8 we covered taking another perspective.) Let me ask you, besides being an inadequate mother, are there any other explanations that could account for Suzanne having difficulty getting her four- and six-year-old children ready in the morning? I know when my children were little, they wanted to dawdle, stay in bed, and play rather than get ready for school on a tight schedule. When we looked at all the facts, it seemed to Suzanne that most mothers would find it a challenge to get young children dressed, fed, and ready on time every morning. Taking a different per- spective on her morning difficulties with her children helped Suzanne be less stressed and consider different ways of handling the children. She started leaving for work in a better mood and was less criti- cal of herself. SESSIONS 10–16 By session 10 Suzanne’s mood had significantly improved. She was regularly using thought records at school and often at home when she was upset with her husband and children. However, she remained very withdrawn at school. I thought she was caught in a negative cycle where the more she withdrew, the harder it was for her to get to know the other teachers, and the more she then withdrew. Suzanne agreed with me that she was caught in a vicious cycle and thought it would be a good idea to engage socially with the other teachers. However, she felt very anxious whenever she thought of starting to make friends with them and did not know where to begin. In sessions 10 through 16 we used exposure therapy to help Suzanne overcome her social anxiety and start to make friends at school. (In chapter 11 you can see excerpts from Suzanne’s exposure therapy.) Often during the exposure tasks her thought No one will want to be my friend was triggered. Suzanne used the positive experiences from the exposure tasks as additional evidence to challenge this thought. For example, when Suzanne talked to her colleague sitting next to her in assembly, they discovered they had gone to the same school as children. The talk in assembly led naturally to having lunch together, and they started talking to each other at recess. This became evidence against her thought No one will want to be my friend. We started a written log of situations that challenged this belief. SESSIONS 17 AND 18 At session 17 Suzanne wondered if it was time to end therapy. She was no longer depressed, her husband was helping more at home, their relationship had improved, and she was feeling better about herself. When her children were difficult, she was able to see their behavior as normal and cope rather than blame herself. She was developing some friends at her new school, and she no longer minded the commute as much; she had even started listening to books on tape during the drive. Suzanne and I reviewed her goals, and she had met all of them or was well on her way. When we started talking about ending, Suzanne realized she was worried about being able to cope without therapy. We decided that we would meet in two weeks and see how Suzanne had managed. Suzanne had to cancel our next meeting, so it was three weeks before we met. We went over all the ways her life had changed and what she had learned. Suzanne found the thought records and behav- ioral activation the most helpful. We talked about continuing to face her fears in social situations. Suzanne thought that therapy had been very helpful. While she would miss me, she was ready to end. I told her that she was welcome to come back for a booster session any time. I usually end therapy with telling my clients how much I have enjoyed working with them. If a client gives me a compliment, I accept the compliment but add that we worked well together and had a good relationship. That way we share the compliment, and the importance of our relationship is central. Agenda Item #3: Raoul’s Therapy Although we have followed Raoul throughout the book, the order of the interventions I used was different than the order of the book. I started with problem solving and graded task assignments. We then did behavioral activation and used cognitive interventions only in the latter part of therapy. SESSIONS 1 AND 2 Raoul was harder to engage in therapy than Suzanne was, and he was much more skeptical about whether therapy would work. Initially, Raoul had a hard time identifying his feelings and thoughts, and I believed that he would have an easier time with behavioral interventions. From the beginning I hypothesized that his core beliefs were related to being successful. I consistently listened for thoughts related to being respected or valued. I also made an effort to notice any times he minimized evidence that he was respected. Let’s look at Raoul’s goals: •Cope better at work, particularly concentrate on my work and get my projects done on time. •Socialize with people at work the way I used to. This includes talking to people, having lunch in the lunchroom, going out for lunch, and chatting in the hallways. •Not get anxious every time the boss talks to me. •Start to like work again.

SESSIONS 3 AND 4 After the first two sessions I was somewhat unsure where to start. I was concerned about Raoul’s depression and considered starting with behavioral activation. On the other hand, his first goal was to cope better at work and get his projects done on time. I wanted to address an issue that was immedi- ately relevant to him. I was also concerned that if Raoul continued to procrastinate, he would receive another poor evaluation. This would potentially cause real difficulties at work, and also add to his depression. I decided to first address his procrastination and other work-related difficulties. We started with identifying projects that were going well and projects where he was procrastinat- ing. We also assessed where his procrastination might have the most negative consequences. We dis- covered that Raoul was accomplishing the majority of his work on time and at a level he was satisfied with. I used this information to question his global negative judgment that he was not coping at work. Since I had hypothesized that one of his core beliefs centered on not being respected, I also made sure to ask if other people respected this aspect of his work. We spent most of sessions 3 and 4 looking at the projects where he was procrastinating. We used a combination of problem solving (see chapter 9) and graded task assignments (see the end of chapter 10). Raoul found it very helpful to break the projects down into chunks, as it made the tasks more manageable. We also looked at his schedule and specified the time during the day when he could com- plete each chunk. Raoul liked the idea of developing coping thoughts. We examined how he approached the projects that were going well and applied these strategies to the projects he was struggling with. We developed a number of coping thoughts, including One step at a time; This is just a task, get it done; and Play ball. Raoul had been a successful football player in high school. We explored how he had coped as an athlete when he was feeling down or having trouble concentrating. He replied that he just focused on the task; it was not an option to stop playing. I wondered how he could apply this strategy to his current work. The phrase “play ball” reminded him to treat his current work as if it were a football game—no option but to play! When Raoul began procrastinating less, he started to feel somewhat better, but he was still depressed. At the end of session 4, I introduced the idea of behavioral activation. In session, we com- pleted the Daily Activities Schedule for the day before. Raoul agreed to try and complete a Daily Activities Schedule for the following week as homework. SESSIONS 5–8 Raoul completed the Daily Activities Schedule and we used Questions to Explore a Mood/Activity Relationship to understand his day and how his activities were affecting his mood. Raoul had not real- ized how much he had withdrawn from family and friends. Given the strong evidence for the impor- tance of social relations in boosting and maintaining a positive mood, I focused on having him increase his social activities with his wife, children, and friends. The next few sessions involved a combination of behavioral activation, problem solving, and coping thoughts. Within a couple of weeks, his mood had started to improve. It also became clear when we looked at his Daily Activities Schedule that Raoul did not have a good sleep routine. This was very different from when he was not depressed. Clients who have experi- enced sleep difficulties for many years may need to see a therapist who specializes in CBT for insomnia (Edinger & Carney, 2014). However, for many clients, adhering to basic sleep hygiene guidelines can be sufficient to significantly improve sleep. Below is the Good Sleep Guidelines list that I use; you can download it in handout form at http://www.newharbinger.com/38501.

1. Have regular bedtimes, both for going to sleep and for waking up.
2. Restrict napping to twenty minutes a day and only in the early afternoon.
3. Do not do strenuous exercise within two hours of bedtime.
4. Avoid exposure to bright lights and make sure the bedroom is dark; some people find computer use before bed disruptive to sleep.
5. Avoid heavy meals or drinking before bedtime.
6. Avoid caffeine or alcohol before bedtime. When Raoul looked at his Daily Activities Schedule, he noted that he came home from work, watched TV, and immediately fell asleep for at least an hour. He then went to bed between 1:00 and 2:00 a.m., and he was exhausted in the morning. On the weekend he woke up tired and lay in bed until 9:00 or 10:00 a.m., hoping to “make up” for his lack of sleep. We went over the Good Sleep Guidelines. Raoul decided he would try to establish a regular sleep schedule. Raoul wanted to try to go for a walk when he got home from work instead of watching TV and napping, and to try to go to bed at 11:00 p.m. The next session, Raoul reported that he had found it very hard to give up napping in front of the TV. He had liked the idea of taking a walk when he got home, but in reality he never did it. We problem solved other activities he could do, and he suggested that he help his wife with the cooking, call his children, and go through his emails. The next session Raoul reported that this plan worked better. When Raoul stopped napping, it became easier for him to get to bed at an earlier time, and his sleep started to improve with a more regular sleep schedule. SESSIONS 9–16 We continued to work on a combination of behavioral activation, problem solving, graded task assignments, and coping thoughts. Raoul started coming to therapy with increasingly more agenda items he wanted to address. Once Raoul was no longer procrastinating, he started bringing up issues related to social relations at work. We made a list of social activities he had stopped doing since his depression and slowly introduced the ones that felt the easiest. I always made sure that Raoul had a concrete plan that was doable. Raoul started having lunch with colleagues in the lunchroom, speaking up at meetings, talking to his boss about some of the projects he was involved with, and generally acting more like his “old self.” (You can see some of this work in chapter 9.) Usually Raoul expected that he would not enjoy these social activities and that they would not go well. However, he learned that the activities usually did go well and that once he did them, he felt better. We stressed the importance of acting according to his plan and not his depressed feelings. In the course of trying to connect with his colleagues and boss, Raoul often thought, They do not respect me, or They do not value my opinion. (See chapter 7 for how I identified Raoul’s thoughts.) Situations he raised included a time when he thought his boss had criticized him at a meeting (see chapter 5) and another time when he asked a colleague to go to lunch and his colleague was busy. In both those situations Raoul was able to look at possible alternative, more benign interpretations. I sug- gested to Raoul that he tended to catastrophize (see chapter 6 for a list of cognitive distortions), and he agreed. We often used catastrophizing as a shorthand way of checking if there was another more benign interpretation. By session 9, Raoul had started spontaneously applying some of the interventions we were using for work to his personal life. For example, a friend had told Raoul that he could not go bowling. Normally Raoul would have thought this meant his friend did not respect him, especially if his friend canceled on short notice. However, he was able to consider that there could be other interpretations. In session 14, Raoul told me that he had had his six-month review and everything seemed to be back on track. We talked about how much progress he had made since he started therapy. Raoul won- dered whether he could skip the next session as there was an office social event and he wanted to go. He usually looked forward to our sessions, but he seemed quite casual about planning our next meeting. I asked how he was feeling about coming to therapy. Raoul explained that I was a very nice lady, but he didn’t think he needed therapy anymore. Raoul’s experience is very common. As clients get better, therapy becomes less important to them, and the rest of their life becomes more important. I suggested that we have a session in two weeks to check that everything was going well, and if it was that we plan one more meeting after that to end therapy. SESSION 17 At our final meeting, we reviewed what Raoul had accomplished in therapy and looked at his origi- nal goals. Raoul was surprised to see how much he had improved, as he had forgotten how he was feeling when he first came. His sleep was more regular and he was no longer depressed. He and his wife were back to socializing and seeing friends and family. I stressed the importance of continuing to engage in enjoyable activities with his wife, family, and friends. We spent some time exploring what had been the most helpful for him. He thought that breaking large projects down into chunks had really helped, and he said he used it all the time and had even taught it to other colleagues. He also thought not catastrophizing was helpful. As I had said to Suzanne, I told Raoul that if he needed a booster session I was available and that I had enjoyed working with him. Homework: Practice CBT I hope you’ve found the homework throughout this book valuable. I know that for myself, in the course of writing this book, I have found many of the CBT interventions extremely helpful. I rediscovered positive psychology, and I have been trying to pause and savor the moment. Throughout the course of writing, I was particularly appreciative of the following CBT friends, without whom this book would never have been written. Agenda setting: You kept me organized. Reviewing at the end of a day of writing helped me remember that I actually had accomplished something! The four-factor model: Whenever I got stuck, you helped me pause and figure out my thoughts. I noticed my negative automatic thoughts, looked for the evidence, and usually was able to get back to the task. Coping thoughts: You kept me focused. Behavioral activation: I think my whole family wants to thank you. For a while I did nothing but write this book; you made me schedule daily walks and fun times. Problem solving: When I found myself staring at the computer and ruminating, I problem solved. My favorite solution was emailing the paragraph I was struggling over to one of my colleagues or a student and then asking my husband when he got home; all of them always had good advice. Graded task assignments: Without you this book would not have been completed. No matter how overwhelmed I got, you were there to help me break the task down into manageable chunks. I think you are the hero of the book. Apply What You Learned to Your Own Life Take a moment to think over everything that we have covered. How have you applied it to your own life? What changes have you made? What do you want to keep doing? I hope that you have had a chance to see firsthand how helpful CBT can be. Remember, the data is clear that if you apply CBT to your own life, you will become a better CBT therapist. Apply What You Learned to Your Therapy Practice Before we say good-bye, let’s end with a self-assessment. How have you changed your therapy prac- tice over the course of reading this book? What new skills and interventions have you tried with your clients? Are you setting agendas? Identifying your clients’ thoughts? What about looking for the evi- dence and creating balanced thoughts? Did you have a chance to try problem solving, behavioral acti- vation, or exposure therapy? What do you need to do to keep learning and improving your CBT skills? Can you set one or two professional goals and develop a learning plan?

Time to End Dear reader, we have come to the end of the book. At this point it is up to you whether you use what you learned. I surely hope you will. If you have made some changes in your therapy practice, or in your own life, take a moment to acknowledge the work you have done and give yourself a well-deserved pat on the back. Change is hard for both our clients and ourselves. By reading this book, it’s as if you have taken a course on CBT, complete with check-ins and reviews, agenda setting, action plans, homework, and practice, practice, practice. My hope is that you will have an easier time applying this structure to your therapy practice, and that both you and your clients will benefit from the work you have put in. It has been a pleasure to be your guide.