12. 苏珊和罗尔的治疗

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.

Acknowledgments We have been married for over thirty years, have raised our children together, and have had countless discussions about our patients and CBT. This book comes out of our partnership. The book would not have been possible without our many client and patients who were willing to share their stories and problems, and in the process help us learn to apply CBT principles and become better therapists. We would like to thank the editors at New Harbinger for their enthusiasm and support for this project and for all of their helpful guidance. We would particularly like to thank Elizabeth Hollis Hansen and Vicraj Gill, who always had time for our numerous questions. Rona Bernstein provided detailed and constructive advice that greatly improved the final drafts. Nina would like to thank her many students at the University of Toronto, as well as all of the par- ticipants in the various workshops she has given over the years. This book would not exist without the many gifted students whose questions pushed her to think about how to explain CBT. We would also like to thank our many colleagues and friends who read parts or all of the manu- script. In particular, Dr. Joyce Isbitsky was never too busy to read and reread numerous versions of the same chapter, our research assistant Julie Hong was invaluable, and our friend Bernice Eisenstein was particularly helpful. David would like to thank Zindel Segal, Martin M. Antony, and Cynthia Crawford, who over many years of friendship were always willing to discuss challenging cases. David would also like to thank Dr. David Conn, Dr. Victoria Lee, and his many wonderful colleagues at Baycrest for their ongoing support and friendship. He would also like to thank the Geriatric Psychiatry Outreach Team, and in particular Joy Lipkin, Nira Rittenberg, and Peggy Solomon.