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CHAPTER以下的英文内容先直译，再根据信雅达原则进行调整，然后进一步调整为更符合中文习惯的表达方式。最后再根据文中内容进一步阐述知识点。所有的内容用markdown格式的代码形式呈现。 6 My Clients Have So Many Thoughts—Which Do I Focus On? In the previous chapter we covered identifying a trigger situation and how to understand your client’s reactions using the four-factor model. Did you have a chance to try the homework? Did you try asking your client about his or her feelings, physical reactions, or behaviors? Take a moment to reflect on what you learned from completing the homework. If you did not do the homework, can you identify the obstacles that got in the way? Before you read this chapter, take a moment to think about an upsetting experience that happened last week. Then identify your feelings, physical reactions, and behaviors. Don’t forget about structuring your sessions. Are you setting agendas and reviewing at the end? If you have not been using a structured session, try setting an agenda with just one client this coming week. Set the Agenda The next two chapters focus on how to help your clients identify their thoughts. In this chapter we will cover how to decide which thoughts are worth working on. We will call these thoughts hot thoughts. In the next chapter we will cover how to identify hot thoughts. Agenda Item #1: Identify hot thoughts. Agenda Item #2: Is this thought an unrealistic evaluation of self, others, or the future? Agenda Item #3: Does this thought explain your client’s feelings? Agenda Item #4: Does this thought contain a cognitive distortion?

Work the Agenda In CBT you are going to spend a lot of time and effort helping your clients identify and examine their thoughts. You want to be sure that time is well spent. We all have a continual stream of thoughts that go through our head every day, and not every thought is worth working on. You want to target thoughts that are central to your client’s distress and which, when targeted, will lead to meaningful change.

Agenda Item #1: Identify Hot Thoughts Thoughts that are worth working on explain the meaning of the situation and are strongly con- nected to intense feelings. We call these hot thoughts (Safran, Vallis, Segal, & Shaw, 1986) because they carry emotion, and when we work with them in therapy there is meaningful change. Here is an example. Jaylen’s father lives six hours away. He calls Jaylen once a week and always starts the conversation by sighing and saying, “I never see you. When will you come visit? I miss you.” Every week his father’s phone call triggers the same negative automatic thoughts: My father has called every week for the past two years. He is always critical. He does not appreciate what I do for him. Let’s look at Jaylen’s thoughts and identify which ones are hot thoughts. The thought My father has called every week for the past two years is a fact; it does not explain what his father’s phone call means to Jaylen or the reason for Jaylen’s emotional distress. It is not a hot thought. The thoughts He is always critical and He does not appreciate what I do for him are hot thoughts because they capture what his father’s words mean to him and explain Jaylen’s emotional reaction. When you are first learning CBT, it can be hard to know which thoughts are hot thoughts and worth focusing on. In this chapter we are going to look at three guidelines to help you identify a hot thought. Remember, a hot thought has to capture the meaning of the situation and is related to intense feelings. Below are the three guidelines.

1. Is this thought an unrealistic evaluation of self, others, or the future?
2. Does this thought explain your client’s feelings?
3. Does this thought contain a cognitive distortion? Agenda Item #2: Is This Thought an Unrealistic Evaluation of Self, Others, or the Future? It is your client’s unrealistic thoughts about self, others, or the future that capture the meaning of a situation and help you understand her distress. Sometimes it is easier to understand a concept if we start with an example. A client of mine, Regina, was recently fired from a job and was feeling very depressed and anxious. When I asked what she was thinking, she responded, “I can’t believe I was fired” and “I wish I hadn’t been fired.” These thoughts do not explain what being fired means to Regina, so they are not hot thoughts. I asked addi- tional questions and we identified the following thoughts:

Evaluation of self (thoughts that are a judgment about yourself) •I am too old to learn another skill. •Something is wrong with me. •I am stupid. Try to think of a negative evaluation that you have of yourself, or that one of your clients has of herself. Evaluation of others (thoughts that are a judgment about other people or an expectation about how other people will treat you) •My boss is unfair. •My father will be disappointed. •None of my colleagues cares about me. Try to think of a negative evaluation that you have of other people, or that one of your clients has of others. Evaluation of the future (thoughts that are a judgment of the future or an expectation of what the future will be like) •My friends and partner will no longer respect me (this is both about others and the future). •I will be poor and lose my house. •I will never get another job that is as good. Try to think of a negative evaluation that you have of the future, or that one of your clients has of the future. When you look at the thoughts that Regina identified about self, others, and the future, can you see how they explain what getting fired meant to Regina and why these thoughts would lead to her feeling depressed and anxious? Let’s look more closely at how to identify thoughts about self, as they can sometimes be hard to identify. Some thoughts are clearly about the self, for example, I made a serious mistake, or I am disorga- nized. However, sometimes negative thoughts about self are hidden in thoughts about others and in particular thoughts about how others treat you. Let’s take the thought My colleague never asks my opinion. You could believe this is the case because your colleague is unpleasant and bossy (thought about others), but you believe that you have good ideas (thought about self). In this case, the negative judgment is about your colleague and there are no negative judgments about yourself. However, you could believe that your colleague never asks your opinion because she thinks you do not have good ideas, and you think this as well. In this case, you have a negative judgment about your colleague, but you also have a negative judgment about yourself.

Here are some more examples of thoughts about others where there may be hidden negative beliefs about self: None of my new colleagues would want to be my friend, No one would want to help me, and No one will ever want to stay married to me. In all these situations, your client may believe that there is something about her that causes the other person’s negative behavior. For example, a client might think, None of my new colleagues would want to be my friend because I am too shy and boring. “I am too shy and boring” is a negative thought about self. A client could also think none of her new colleagues wants to be her friend because they are all close to retirement and are not interested in making new friends at work. In this case, there is no underlying negative evaluation of self. You can check whether there is an underlying negative evaluation of self by asking your client, “Is there something about you that would cause the other person to treat you this way?”

Your Turn! Identify Suzanne’s Thoughts about Self, Others, and the Future In their fourth session, Suzanne wanted to talk about how upset she was with her husband. She describes a recent fight. A few nights ago her husband was watching TV when she asked him if he had bathed Andrew, their four-year-old son. He responded by saying, “I’m exhausted, can you do it?” Suzanne blew up at him, yelled that he had promised to give their son a bath and that he was selfish, and then stomped out of the room. She is feeling depressed and hopeless. Her therapist wants to understand the thoughts that caused her to become so upset. Another way of thinking about it is, what did it mean to Suzanne that her husband did not give Andrew a bath and said, “Can you do it?” Look over the dialogue and list Suzanne’s thoughts. Then decide if the thought is a fact or an evaluation of self, others, or the future. You can find my answers in the appendix. Therapist: What were you thinking when you realized your husband did not give Andrew his bath and said, “I’m exhausted, can you do it?” Suzanne: I just keep thinking that he didn’t give Andrew his bath; no matter what I do, it won’t make a difference. Therapist: Any other thoughts? Suzanne: He doesn’t care about the kids or me. Besides, you can’t count on men. Therapist: Can you tell me more about those thoughts? Suzanne: I keep thinking that I’m a completely inadequate mother; I keep asking myself, Why do I have to do everything in the house? Therapist:A lot of thoughts, any others? Suzanne:No, that’s probably all; it’s enough!

Jim Forgets His Wallet, and (b) Richard’s Boyfriend Wants to End :the(a)Relationship Exercise 6.1 Practice identifying thoughts about self, others, or the future.

Agenda Item #3: Does This Thought Explain Your Client’s Feelings? The second guideline for evaluating whether your client has identified her hot thoughts is examin- ing whether her thoughts explain her feelings, and in particular her strong negative feelings. What do I mean by this? Given your client’s thoughts, the feelings have to make sense, and the intensity of the feeling has to make sense. Let’s look at an example. A client of mine, Angela, was concerned about her new babysitting arrangements. When her therapist asks about the situation, Angela explains that when she left her daughter with the new baby- sitter, her daughter cried and begged Angela not to leave. This is unusual behavior for her daughter, who loved her previous sitter and usually played happily when Angela left her with the sitter in the morning. Angela is feeling very guilty (8) and anxious (8–9). When asked about her thoughts, Angela responded, “My daughter is probably upset because it is a new sitter. She will just have to get used to her. It will take time.” These are very good coping thoughts; however, they don’t help us understand Angela’s feelings. If she really believed these thoughts, and she had no others, would she feel guilty at 8 and anxious at 8 to 9? Probably not. Given the strength of her anxiety and guilt, there are probably some other thoughts that Angela is not aware of. Had Angela’s feelings been “slightly sad,” these thoughts would have made sense. When your client’s thoughts don’t match her feelings, this is a sign that you need to keep exploring to identify the underlying thoughts. We will get to how you can help your clients identify their underly- ing thoughts in the next chapter. Different feelings have different types of accompanying thoughts. In CBT we call this content speci- ficity (Beck et al., 1979). Let’s look at the kind of thoughts that go with anxiety, depression, anger, guilt, and shame. Take a moment and think of the last time that you were anxious, and then focus on the feeling. What thoughts accompany this feeling of anxiety? Jot down your thoughts. Now do the same for depression, anger, guilt, and shame. See whether your own thoughts fit with the descriptions below. HOW TO UNDERSTAND ANXIETY Thoughts that accompany anxiety are about a future threat that you think will have awful conse- quences, is likely to occur, and you don’t think you can handle. Figure 6.1 shows how you can think of anxiety as an equation. Anxiety = Overestimate Danger or difficulty of situation + Overestimate Likelihood of situation occurring + Underestimate Your ability to cope

Figure 6.1. Understand anxiety.

If you think you can handle the threat, it becomes a challenge. Kendall et al. (2002), in their treat- ment program for anxious adolescents, describe anxiety as “expecting bad things to happen.” I find this a very helpful way to think about anxiety. If your client is feeling anxious, nervous, or worried, make sure you understand what “bad thing” your client is expecting to happen. For example, in the case of Angela leaving her child with the sitter, you could say, “I hear even though you are worried, you tell yourself it will be all right, but I wonder, what are you worried will happen?”

HOW TO UNDERSTAND DEPRESSION Depression is about loss and hopelessness. Usually when your clients are depressed, they have nega- tive thoughts about themselves, others, and the future. Below are the kinds of thoughts you would expect someone who is depressed to have. Thoughts about Self •I am inadequate. •I am ugly. •I am a bad friend. •I am a bad parent. •I am bad at sports (or work or school). •Nothing I do is any good. Thoughts about Others •No one likes me. •My kids don’t care about me. •My colleagues think my work is no good. •My partner thinks I am a burden.

Thoughts about the Future •Nothing will ever change. •I will never have any friends. •I will never get another job. Often depression is precipitated by a loss. It could be the loss of a relationship, the loss of health, the loss of a job, or another loss. Clients who are depressed believe that the future without what they have lost is bleak and hopeless. HOW TO UNDERSTAND ANGER Thoughts that accompany anger usually have to do with the belief that the client or someone he cares about has been treated unfairly. Angry thoughts are usually directed at other people. Generally, the person who is angry feels disempowered, disrespected, or put down and reacts with anger. Thoughts that include “should statements” are very common. With anger there is a belief that the rules of how the world should be have been broken to the client’s disadvantage. Anger is a complex feeling. Sometimes people have only angry feelings, especially if they believe that they have been unjustly wronged. However, anger is closely related to depression and hopelessness. If you believe you have been unjustly wronged and you believe that there is nothing you can do, you can easily become depressed. Some clients label all feelings as anger, and it can be very useful to help them recognize their other feelings.

HOW TO UNDERSTAND GUILT AND SHAME Guilt and shame often go together. When we feel guilty, we believe that we have done something wrong and broken an important moral rule. Guilt is often related to believing that we have hurt someone. When we feel guilty, we feel responsible, and we tell ourselves that we should have behaved differently. Shame is closely related, as it is also connected to believing that we have broken an impor- tant rule, but we believe that because we have broken that rule, we are somehow flawed or awful. When we are ashamed, we often hide what we are ashamed about and believe we would be rejected if people knew the “real me.” It is helpful to ask your client to specify what he did that is so terrible that he feels guilty or ashamed. Often, this is the first time that a client has articulated what it is he did. Once you have a clear idea what your client did, you can start to examine how terrible it really was. HOW INTENSE IS THE FEELING? We have talked about the types of thoughts that you would expect to accompany specific feelings. We also expect thoughts to match the intensity of the feeling. For example, a client rates her anger at a 2 out of 10, and her thought was, I can’t stand my boss; he humiliates me every chance he gets. Given her thoughts, would you expect her anger to be stronger than a 2? I would. What if a client rates her disap- pointment at an 8 and her thought is, I wish I had not sprained my ankle, but even if I can’t play I can still enjoy watching the basketball game. Do you think the thought and rating go together? I don’t. Either the rating is too strong, or the client has additional thoughts that you need to identify.

Your Turn! What Thoughts Go with These Feelings? Below are three situations. For each situation there are three possible thoughts the client might have. Choose the thought that is most likely to go with the feeling. You can find my answers in the appendix.

1. Cameron’s college hockey team was in the state semi-final. The score was tied. Cameron had the puck and was sure he would score, when another player knocked him over. Cameron is feeling furious. What might he be thinking? •Our team will never have another chance to play in the semi-finals. •That guy is an animal; he should be punished; it’s unfair. •If we lose, it is all my fault.
2. Annette just heard that she was the second-choice candidate for a job she had applied for. Annette is feeling disappointed. What might she be thinking? •I will never get a decent job; my life is over. •They should have hired me; what idiots! •I had hoped to get the job, but at least I was second choice.
3. Orly did not visit his best friend, Roy, when Roy was in the hospital for two weeks. Orly is feeling guilty. What might he be thinking? •I am a bad friend; I should have gone; I bet I hurt Roy’s feelings. •My friend is probably furious at me. •I bet Roy will not want to be my friend anymore.

Agenda Item #4: Does This Thought Contain a Cognitive Distortion? The term cognitive distortion is commonly used in the CBT literature and is familiar to many thera- pists. However, I don’t really like it. I think the term distorted suggests that the therapist is negatively judging the client’s thoughts. McKay, Davis, and Fanning (2011) have used the term patterns of limited thinking, which I prefer. In my own clinical practice, I often use the term thinking traps because there is an inherent assumption that you can avoid a trap. I also like the term thinking style. However, for the purpose of this discussion, I’ll stick to the common term cognitive distortions. Cognitive distortions are how your clients typically respond to situations that trigger them. You can think of cognitive distortions as a label for your clients’ negative thinking patterns. Initially, psy- chologists identified only a few specific distortions. Over time, the list of cognitive distortions has expanded to the point that many therapists and clients find them confusing and hard to use. It is important not to get lost in a long list. The purpose of identifying a client’s cognitive distortions is to have a label that a client feels captures his experience. Labeling a negative thinking pattern is another way of hitting the pause button on automatic negative reactions. When a client labels a thought as a cognitive distortion, he is also questioning the accuracy of his thoughts. Below is a list of the most common cognitive distortions. I also have included in italics a number of shorthand ways of describing the cognitive distortions, which were inspired by Kendall and his col- leagues (2002) and Stallard (2005). For each cognitive distortion, I have included an example from one of my clients. (Full disclosure—I snuck in one or two examples from my own life!) A Thinking Traps handout can be downloaded at http://www.newharbinger.com/38501.

Thinking Traps Filtering: Focusing on the negative details of the situation while other positive aspects are ignored. Negative glasses or walking with blinders: You only see negative things. Example: A student has consistently received A’s in a course. On a small quiz, the student receives a C+ and immediately assumes she’s doing poorly in the course. Overgeneralizing: You make a broad generalization, which is based on only one piece of usually nega- tive evidence. The repetitor: It happened once; it will always be that way. Example: Since I found out that my last boyfriend cheated on me, I can never trust another man again. All-or-Nothing Thinking or Black-and-White Thinking: You or others are either right or wrong, good or bad, perfect or a failure. There is no room for grays or middle ground in evaluating yourself or others. Examples: •The world is made up of winners and losers, and I sure don’t want to be one of those losers. •If it is not done perfectly, it is not worth doing at all. •My employee missed a small deadline—he’s completely useless! Mind Reading/Making Assumptions: You assume that you know what people are feeling and think- ing and why they are acting that way. Mind readers and fortune tellers: Knowing that things will go wrong. Examples: •My boss didn’t say anything about my last report; I know he thought it was terrible. •My partner gave me a funny look; I know she disapproved of what I said. Personalizing: You assume that what people are saying or doing is about you, even though there is no indication of that. Another aspect is that you often compare yourself to others, trying to determine how you measure up in a variety of attributes, such as intelligence, competence, or appearance. Example: In the meeting when Mary said that some people have not been pulling their weight on this project, I know that she was talking about me. Catastrophizing: You assume disaster will occur. Sometimes it is related to an initial difficulty. Catastrophic thoughts often start with “what if.” For example, your child borrowed the car to go to a party and comes home fifteen minutes late. You think, What if he had an accident? What if the car broke down? Blowing things up: Negative things become bigger than they really are.

Examples: •Since my son came home slightly drunk the other night, I’m sure he’s on his way to becom- ing an alcoholic like his uncle; it will ruin his life. •I lost my job; we will have to sell the house; I destroyed my whole family. Predicting the Future: In many ways, predicting the future is similar to catastrophizing, if the predic- tion is negative. However, individuals who engage in dysfunctional behavior, or who avoid completing necessary responsibilities, often falsely predict a positive or benign future. Example: I can handle my alcohol; seven beers a night is not too much for me. Magnifying and Minimizing: The degree or intensity of the problem is exaggerated so that anything difficult is deemed overwhelming, and anything positive is ignored or minimized. Positive doesn’t count: Throwing out the good things that happen. Example: A mother discovers that her son, who has schizophrenia, occasionally smokes marijuana. She says, “My child is a failure; nothing he does works out.” She ignores that he is also regularly taking his medication, is no longer paranoid, and has a part-time job. Shoulds: Individuals have a list of rules about how they and other people are expected to act, and they experience it as terrible if these rules are broken. They feel angry if other people break the rules, and guilty if they themselves break the rules. Examples: •I should always be available to my children and husband. •I should always try my hardest. •I should be perfect at everything I do. If a thought contains words that indicate extremes, such as “always,” “never,” “everyone,” or “no one,” it is most likely a cognitive distortion, as the real world is not so absolute. When people use these terms, they are usually focusing only on the negative aspects of a situation and ignoring other informa- tion. This is especially true if the thought is accompanied by a strong emotional reaction. Let’s look at some examples: I always fail at everything I do. No one will ever want to be my friend. Everyone hates me. I never do anything right. My partner never helps me. In the coming week, see if you can listen to your clients’ thoughts and identify when they use terms such as “always,” “never,” “everyone,” or “no one.”

Your Turn! Identify the Cognitive Distortion Below is a list of thoughts. See if you can identify the cognitive distortions. You will find my answers in the appendix.

1. If I don’t get this job, my life will be over. Cognitive distortion:
2. To be a good therapist, you have to give it your all and be there for your clients 100 percent of the time. Cognitive distortion:
3. I’m sure that no one will ever want to hire me after this last fiasco of a job interview. Cognitive distortion:
4. If I don’t help all of my clients, I am an inadequate therapist. Cognitive distortion:
5. I know that my last client canceled because she thinks I’m a bad therapist. Cognitive distortion:
6. A colleague told me he wondered if the group check-in should be a bit shorter next time. That was a terrible mistake I made in the first group. Cognitive distortion: Exercise 6.2: Julie Has a Terrible Week Practice listening for cognitive distortions as your client describes a problem. HELP YOUR CLIENTS IDENTIFY THEIR COGNITIVE DISTORTIONS After your client has identified her thoughts, it is helpful to explain cognitive distortions. I some- times give my client the Thinking Traps handout with the definitions of the cognitive distortions. I explain that these are common thinking styles that get people into trouble. I then ask my client to indicate whether she thinks any apply to her, and if so, to give me some examples from her own life. I make sure to tell her that identifying her cognitive distortions is an important first step. If my client is able to identify a cognitive distortion that she commonly uses, and if the exercise seems helpful to her, I then incorporate noticing cognitive distortions into her homework. I usually ask my clients to record three situations where they caught themselves in a cognitive distortion and to record their response on the What Are My Thinking Traps? worksheet that follows, which you can download at http://www.newharbinger.com/38501. What Are My Thinking Tr aps? Situation Thoughts Thinking Trap (filtering; overgeneralizing; all-or- nothing thinking; mind reading; personalizing; catastrophizing; predicting the future; magnifying and minimizing; shoulds)

IDENTIFY YOUR CLIENTS’ COGNITIVE DISTORTIONS BEFORE, DURING, AND AFTER A DYSFUNCTIONAL BEHAVIOR I often examine my client’s cognitive distortions before, during, and after a dysfunctional behavior in order to understand what is maintaining the behavior. For example, Shula is diabetic. Despite having difficulty controlling her blood sugar levels, she frequently eats sugary desserts. She tells her therapist, “I don’t know what is wrong with me; I have no willpower. I just end up having dessert.” Let’s see what we discover when we examine her thoughts before, during, and after eating a dessert. Shula Eats Dessert Before/During/ AfterShula’s ThoughtsCognitive Distortion Before Shula Eats Dessert• I will just have one small bite.Minimizing and predicting the future • I had a hard day; I deserve it.Magnifying • If I say no I will insult my host, who made the dessert.Mind reading and catastrophizing • As long as I have eaten a little sugar, I might as well have the whole dessert.All-or-nothing thinking • It is too hard to keep to my eating plan.Magnifying • It doesn’t matter if I eat some dessert.Minimizing • I am a loser.Black-and-white thinking • I will never get my diabetes under control.Predicting the future While Shula Eats Dessert After Shula Eats Dessert

Once we examined Shula’s thoughts before, during, and after she ate dessert, it made sense that she was having so much trouble keeping to a healthy eating plan. Shula had been aware of her self-critical thoughts after she ate the dessert, but she had not been aware of her thoughts before and during, and the role they played in maintaining her dessert eating. I have had clients who tell me they “end up” drinking until they black out, having unprotected sex, or not studying for exams. The reality is people don’t “end up” doing these things. Even if it is fleeting, there is almost always a thought before the behavior that enables or justifies the dysfunctional behavior. Helping your client identify her cognitive distortions before, during, and after dysfunctional behavior is an important step in helping her feel more in control and starting a change process.

Exercise 6.3: Raymond Drinks Too Much Practice identifying cognitive distortions that occur before, during, and after your client’s prob- lematic behavior. Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to a Clinical Example Complete the following exercises.

Exercise 6.1: (a) Jim Forgets His Wallet, and (b) Richard’s Boyfriend Wants to End the Relationship Exercise 6.2: Julie Has a Terrible Week Exercise 6.3: Raymond Drinks Too Much Apply What You Learned to Your Own Life Look over the Thinking Traps handout for this homework assignment.

Homework Assignment #1 Identify Your Own Cognitive Distortions Choose one or two thinking traps that resonate with you and think of a recent example from your own life for each one. This coming week, see whether you can catch any thinking traps you are currently doing and try to complete the What Are My Thinking Traps? worksheet. What Are My Thinking Tr aps? Situation Thoughts Thinking Trap (filtering; overgeneralizing; all-or- nothing thinking; mind reading; personalizing; catastrophizing; predicting the future; magnifying and minimizing; shoulds)

Homework Assignment #2 Identify Your Own Cognitive Distortions Before You Either Avoid or Act Impulsively The guided audio file available for this exercise also gives an example from my own life of my forever failing attempts to drink less coffee. Think of a situation where you would like to change your behavior and where you are either avoid- ing or acting impulsively. For example, most of us would like to exercise more, eat less junk food, or be more organized. Choose one of these issues or a similar one. Next, think of a specific situation where you had planned to exercise but didn’t, or you ate the whole pack of potato chips when you had decided no more junk food, or instead of neatly filing your bills or reports you just left them in a pile on your desk. Once you have chosen a specific situation, think back and try to identify what your thoughts were that enabled you to not exercise, to eat the junk food, or to stick the paper onto the already messy pile of papers. Once you have identified your thought, try to identify the cognitive distortion. Apply What You Learned to Your Therapy Practice Now that you’ve had a chance to practice with your own thoughts, let’s turn to your clients’ thoughts.

Homework Assignment #3 Try Identifying Your Client’s Thoughts about Self, Others, or the Future During your next few therapy sessions, when a client spontaneously mentions a thought, ask yourself if the thought is about self, others, or the future. Try to complete the worksheet below for three thoughts that a client spontaneously mentions. Are My Client’s Thoughts about Self, Others, or the Future? Client Thought Self, Others, or Future?

Homework Assignment #4 Help Your Clients Identify Their Thinking Traps Choose a client who often discloses his or her thoughts and who you think would find the idea of thinking traps helpful. Give him or her the Thinking Traps handout, which is available at http://www. newharbinger.com/38501, and ask if any of the thinking traps apply. If this part of the exercise goes well, ask your client to identify and write down three thoughts that are thinking traps this coming week. You can use the What Are My Thinking Traps? worksheet. Let’s Review Answer the questions under the agenda items. Agenda Item #1: Identify hot thoughts. • What are two characteristics of hot thoughts? Agenda Item #2: Is this thought an unrealistic evaluation of self, others, or the future? • Why is it important to identify thoughts about self, others, or the future? Agenda Item #3: Does this thought explain your client’s feelings? • What type of thoughts would you expect to go with depression, anxiety, anger, and guilt? Agenda Item #4: Does this thought contain a cognitive distortion? • Explain three cognitive distortions. What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

CHAPTER 7 Identify Your Clients’ Thoughts Did you have a chance to do the homework from the last chapter? Here is one of my catastrophizing cognitive distortions that I caught. I am in the car, driving to a meeting with colleagues I don’t know very well. I pick up coffee, and within five minutes I manage to spill a good part of it on my new white shirt. Can you guess my thoughts? I will look like a complete idiot; everyone will think I am totally incom- petent. However, the truth is I simply pulled my jacket over my shirt—and it wasn’t great, but it certainly wasn’t a catastrophe. Were you able to catch any of your own cognitive distortions? Were you able to identify your clients’ thoughts about self, others, or the future? If you did the homework, take a moment to reflect on what you learned. If you did not do the homework, think about an upsetting experience that happened last week. Identify your thoughts and then ask yourself, Do my thoughts contain unrealistic judgments about self, others, or the future? Are they a cognitive distortion? Set the Agenda In the last chapter we focused on how to decide which thoughts are worth working on. Now that we know what to look for, it’s time to get our hands dirty and learn how to look. Agenda Item #1: Identify automatic thoughts. Agenda Item #2: Helpful questions. Agenda Item #3: Your clients’ images. Agenda Item #4: Additional strategies to identify thoughts. Agenda Item #5: How do you know which questions to use? Agenda Item #6: Link thoughts to feelings, physical reactions, and behavior.

Work the Agenda Remember that the purpose of identifying your client’s thoughts is to understand what a situation means to your client, or how he interpreted the situation. We want to help our clients identify their hot thoughts. To recap, a hot thought explains your client’s feelings and behavior and is an unrealistically negative evaluation of self, others, or the future. Clients can have a variety of reactions when they start to identify their negative thoughts. Many clients feel more in control when they understand what is maintaining their difficulties and can iden- tify the relationship between their thoughts, feelings, physical reactions, and behaviors. Other clients become more distressed when they realize how negative their thoughts really are. It is important to explain that even though it can be hard to look at negative thoughts, it is a first step to feeling better. Agenda Item #1: Identify Automatic Thoughts It sounds simple, but if you want to know what your client is thinking, just ask. The following “Just Ask” questions are often all that you need. “Just Ask” Questions General Probing Questions • What were you thinking? • What were you saying to yourself at the time? • What was running through your mind? Prompting Questions • Any other thoughts? • Anything else? Reflective Statements • So you were thinking…(repeat last thought) Often just repeating the last thought or statement will encourage the client to elaborate on more thoughts. You can then choose to add a prompting question. Clarifying Questions • Can you tell me more about that thought? When you ask your client, “What were you thinking?” use a gentle, curious tone that encourages self-reflection. It is often helpful to refer to the situation you are exploring. For example, Suzanne’s therapist asked, “When you received the invitation to the barbecue, what were your thoughts?” Don’t forget to go slowly and give your client time. It can take a couple of questions before your client can identify his thoughts. Let’s look at the example we started working on with Suzanne in chapter 5. If you remember, the principal of her new school invited her to a barbecue with the other new teachers. You know about the situation (invitation to the barbecue), you already know her feelings (nervous, worried, and embar- rassed), you know her physical reaction (clenched stomach and tense shoulders), and you know her behavior (put the invitation aside and did not respond). You now want to identify Suzanne’s thoughts, and in particular you want to help her identify her hot thoughts. Let’s see what happens if her therapist uses the “Just Ask” questions. Therapist: Suzanne, you have done a good job identifying your feelings, physical reactions, and behav- ior. Let’s see if we can also identify your thoughts. When you were invited to the party, what thoughts went through your mind? Notice her therapist starts by positively reinforcing Suzanne for identifying her feelings, physical reactions, and behavior. She then refers to the situation before asking a general probing question. Suzanne: (pausing) I don’t know, just that I don’t want to go; the other new teachers will all be there. The thought I don’t want to go is the behavior Suzanne wants to do. It is a fact. The thought All the other new teachers will be there is also a fact. These thoughts do not contain unrealistic judgments about self, others, or the future; they do not explain her feelings; and they do not contain a cognitive distor- tion. Suzanne has not yet identified a hot thought. Therapist: Any other thoughts? The therapist uses a prompting question. Suzanne: Well, just that I won’t fit in. Suzanne is starting to identify her hot thoughts. I won’t fit in is a thought about self. Her therapist wants to keep exploring. Therapist: Are there other thoughts that go with I won’t fit in? The therapist uses another prompting question. Suzanne: I feel that I will just stand there looking awkward, and no one will talk to me. I will be so anxious, and I will probably get all sweaty. This is an example of a client using “I feel,” when what Suzanne really means is “I think.” When this happens, simply repeat the sentence saying, “You were thinking,…” Therapist:You were thinking, I will just stand there looking awkward, no one will talk to me, and I will probably get all sweaty. Suzanne:That’s right, it’s not just that they won’t talk to me, it’s that no one will want to talk to me. At this point Suzanne has identified a thought about herself: I won’t fit in; thoughts about herself and the future: I will stand there looking awkward, and I will probably get all sweaty; and a thought about others and the future: no one will want to talk to me. Her therapist then asked Suzanne if she would like to write down her thoughts on the Understand Your Reaction worksheet. Sometimes clients like to write, and sometimes they like me to write. I don’t think it matters. If I am writing, I repeat my client’s thoughts out loud as I write. I find that this encour- ages my client to start thinking about his thoughts, rather than just experiencing them. Let’s see what Suzanne’s worksheet looks like.

Understand Your Reaction SituationFeelings (Rate 1–10)Physical Reactions (Rate 1–10)BehaviorsThoughts What? Who? Where? When?What did I feel?How did my body react?What did I do?What did I think? Principal invited me to barbecue with the three other new teachersNervous (7)Clenched stomach (4)Has not responded• I don’t want to go. Worried (8) Tense shoulders Embarrassed (6) (5) • The other new teachers will be there. • I won’t fit in. • I will just stand there looking awkward. • No one will want to talk to me. • I will probably get all sweaty. Agenda Item #2: Helpful Questions Sometimes when you ask your clients what they are thinking, they respond with thoughts that are not hot thoughts. For example, Raoul felt very awkward going to the lunchroom. When his therapist asked what he was thinking, he responded, “I don’t know, I just feel awkward.” His therapist needs to ask additional questions to help Raoul identify his thoughts. WHAT DOES THE SITUATION MEAN TO YOUR CLIENT? One way to discover what a situation means to your client is to ask him directly. You can use any of the following questions: •What does this situation mean to you? •What does this situation mean about you, other people, or the future? •What is it about this situation that is so distressing for you? • How is this situation a problem for you? Initially, I felt very awkward using these questions. My clients had just told me about an emotion- ally difficult situation, and I was asking what it meant to them or why it was a problem. However, I have consistently found these questions to be very helpful. Like all questions, it is important that you use a gentle, curious tone that conveys your desire to understand your client’s experiences. Let’s go back to Suzanne. Her therapist decided to keep exploring, using the additional questions identified above, in order to be sure she fully understood why Suzanne found the invitation to the bar- becue so distressing. Therapist:I want to be sure I understand what it is about the invitation to the barbecue that is so distressing for you. Suzanne:It’s not the invitation, it’s going there with all the other new teachers. Therapist:What is it about being there with all the other new teachers that is so distressing for you? Her therapist uses one of the questions to keep probing what the situation means to Suzanne. Suzanne:It’s hard to figure out. I guess that I won’t fit in; (pausing) I think my biggest fear is that they won’t want to be my friend. Therapist:Sounds like the big fear is “they won’t want to be my friend”? Suzanne:That’s right, that no one will want to be my friend, and I will be there all alone. In the example above, the question “What is it about this situation that is so distressing for you?” helped Suzanne figure out her underlying thought. Let’s look at another example and see how you can use these questions.

Your Turn! What Does This Situation Mean to Suzanne? In her fifth session, Suzanne wanted to focus on her feelings at recess. She was increasingly anxious and uncomfortable during recess duty and had been trying unsuccessfully to avoid it completely. Her thera- pist asked if Suzanne could give an example of what happens. Suzanne explained that she stands alone in the schoolyard, does not talk to anyone, and tries to look as if she is supervising the children. She feels very lonely and wishes the other teachers would talk to her. Suzanne adds that this exact situation happened yesterday. Her therapist believes this is a good situation to work with. She knows Suzanne’s feelings (anxious) and her behavior (she stands alone). She wants to understand Suzanne’s thoughts. Therapist:When you are standing in the schoolyard at recess, what are you thinking? Suzanne:(looking sad) None of the other teachers are talking to me. Suzanne’s thought is a fact. It does not indicate what the situation means to Suzanne. Look at the three possible responses below and pick the one that will help Suzanne identify what the situation means to her.

1. Help me understand what it is about the other teachers not talking to you that is a problem for you.
2. Have you tried talking to them?
3. What do you feel when the other teachers don’t talk to you? Response #1 is the best answer to help Suzanne identify what the situation means to her and to help Suzanne identify her hot thoughts. Response #2 starts problem solving, and response #3 takes therapy into a different direction. Therapist: Help me understand what it is about the other teachers not talking to you that is a problem for you. Suzanne: The main problem is that I stand alone, while all the other teachers stand with a friend and talk to each other. Look at the three possible responses below. Choose the response that will help Suzanne explore what the situation means to her.
4. When the other teachers don’t talk to you, how do you feel?
5. What does it mean to you that you are standing alone, and the other teachers are standing with a friend and talking to each other?
6. When you say the other teachers don’t talk to you, how many other teachers are outside at recess? Response #2 is the best response to explore what the situation means to Suzanne. Response #1 would be a good response if you wanted to identify her feelings, and response #3 would be a good response if you wanted to understand the situation. Therapist: What does it mean to you that you are standing alone, and the other teachers are standing with a friend and talking to each other? Suzanne: It means that the other teachers don’t want to talk to me, because none of them approaches me. At this point, Suzanne has identified a hot thought that explains her distress at recess. Her hot thought The other teachers don’t want to talk to me is a thought about others. Her therapist could con- tinue using the “Just Ask” questions and the questions about the meaning of the situation to explore whether there were other hot thoughts.

WHEN THE SITUATION INVOLVES ANOTHER PERSON Many difficult situations involve other people besides your client. It can be helpful to ask what your client thinks the other person’s behavior means about how he or she thinks or feels about your client. For example, in Suzanne’s situation, her therapist asked, “What do you think the other teachers not talking to you means about how they feel toward you?” Suzanne responded that she thought it meant that they did not want to get to know her and liked to stay in their own little cliques. A good follow-up question is whether there is anything about your client that causes the other person to behave in this manner. For example, Suzanne’s therapist asked if there was anything about her that would cause the other teachers not to include her. Suzanne responded that she was shy and awkward and would not fit in. Go to College Exercise 7.1: (a) Yonas Asks a Question, and (b) Diana Wants to Practice identifying what situations mean to your clients. FOCUS ON FEELINGS Another approach to exploring your client’s thoughts is to ask what thoughts go with specific feel- ings. I often use this approach when my client is very aware of his feelings but is having trouble identify- ing his thoughts. There are a number of ways I ask what thoughts go with my client’s feelings. I have used these ques- tions to explore a great variety of feelings, including sad, hurt, annoyed, disappointed, angry, and anxious. I often ask my client to take a moment, go back to the situation in his mind, and focus on the feeling. I then ask one of the following questions: •What thoughts go with this feeling? •Help me understand, when you have this feeling, what thoughts go through your mind? •Just before you started to have this feeling, what went through your mind, or what were your thoughts? Let’s look at an example of how you could use these questions. Jasmine just found out that her grandfather, who lives out of town, was not feeling well. She has been feeling overwhelming guilt that she had not visited him in a few months. Therapist:When you found out that your grandfather was not feeling well, what were your thoughts? Jasmine:I just felt so guilty. Therapist:Any other thoughts?

The therapist starts by using one of the “Just Ask” questions. When Jasmine was unable to identify a hot thought but kept repeating her feelings, the therapist decided to try and identify the thoughts that went with Jasmine’s feelings. Jasmine:No, just this really strong, overwhelming feeling of guilt. Therapist:Can you go back in your mind to when your mother told you that your grandfather was not well? Jasmine:Sure, I can remember it really clearly. Therapist:Can you focus on your feeling of guilt? Really let yourself feel the guilty feeling. (pausing) I am wondering what thoughts go with this guilty feeling. Jasmine:I just think that a good granddaughter would visit more regularly; now he is sick and old. Video 7.1: Identify Thoughts

LIST WORRIES Often when clients are in emotional distress, they worry. Worry is a big component of anxiety, but clients who feel depressed, guilty, ashamed, and angry also often worry. Worry is about expecting bad things to happen. When my client is anxious or worried, I start by making a list of all the “bad things” he is worried will happen. The more concrete the list, the more useful it is. Remember, I am looking for what my client is expecting to happen, not what he is expecting to feel. For example, “I am worried I will be anxious when giving a presentation,” or “I am worried that my presentation will not go well” are less concrete worries than “I am worried I will forget my talk.” Below are some good questions to explore what specifically your client is worried or anxious will happen: •What are you anxious or worried is going to happen? •Is there anything you are specifically worried about happening? •What is the worst that could happen? Or what is your worst-case scenario? •What do you imagine happening? Suzanne’s therapist realized that she did not fully understand what Suzanne was worried would happen at the barbecue. The therapist said, “I can tell that you are pretty anxious about the barbecue. I thought it would be helpful if we could make a list of what you are worried will happen, including your worst-case scenario.” Together they made the following list: When I get there, everyone will be talking to each other, and no one will say hi to me. If I approach one of the new teachers, she will turn her back on me. I will stand there alone, with no one to talk to. If I go up to one of the other teachers and say hi, I will have nothing to say. Clear image of standing next to the barbecue, looking very awkward, holding a glass in my hand. I see myself standing there all alone as everyone else is talking together. Making a specific list of worries can be a very helpful tool to manage anxiety. Often, when clients see their worries written out, they realize that some are unrealistic. I want you to try a quick exercise. Think of an upcoming event that you are somewhat anxious or worried about. Now, write down every bad thing you are worried might happen, and look at the list. Try to make your worry list as specific and concrete as possible. Do your worries seem more manage- able? Maybe some of your worries are reasonable, in which case you can start to problem solve. Making a list takes anxiety from a big ball of bad feelings to specific worries you can start to address. It is one more way to hit the pause button on your automatic negative path.

Exercise 7.2: Isabella Lists Her Worries Practice helping your clients list their worries. Agenda Item #3: Your Clients’ Images Some of the most exciting work in CBT involves working with clients’ images (Hackmann, Bennett- Levy, & Holmes, 2011). Imagery can be a very useful tool to help clients identify their hot thoughts. USE IMAGERY TO RECREATE THE SITUATION Sometimes when you ask your client, “What were you thinking?” he will respond with, “I don’t know.” I usually follow up with one of the “Just Ask” questions. I might say, “Was anything going through your mind?” Often that is enough to prompt my client to start talking about his thoughts, but sometimes my client still says, “I don’t know,” or tells me a thought that is not a hot thought. In that case, one way to help your client identify his thoughts is to ask him to take a moment and imagine himself back in the situation. When a client imagines being back in the situation, some of the feelings he had at the time come back and he has better access to his thoughts. When you recreate a situation using imagery, you can use all of the five senses; however, asking clients to imagine seeing the situation and hearing anything that was said or any other sounds in the environment is often the most effective way to recreate the situation (Richardson, 1999). Here is an example of how recreating the situation in imagery helped Charles identify his thoughts. Charles is newly married and has a two-month-old baby. He has had trouble with alcohol in the past and is trying to drink moderately. He comes to therapy saying he “blew it.” He tells his therapist that a few nights ago he went out with his buddies to a bar for a drink. When he got home he was very depressed and had three glasses of scotch.

Charles: I was so depressed when I got home, I just thought if I had a drink I would feel better. There is no one right way to respond. Before she addressed the drinking, Charles’s therapist wanted to understand what had happened at the bar that he became so depressed. Therapist:When you were out with your buddies, do you remember what you were feeling? Charles:Just normal, sort of down. Therapist:And your thoughts? Charles:Nothing, just hanging out with the guys. CBT theory tells us that if a client becomes distressed, there was a thought that fueled the distress. Charles’s therapist wanted to discover what Charles was thinking that led to his feeling so depressed. Therapist:I am wondering if we could go back to the situation in the bar and try and figure out what was going on with you, in particular your thoughts and feelings. Before you started feeling down, can you remember any particular incident? Charles:My buddies were all talking about the baseball game, and I hadn’t gone with them as I had to stay home with my kid that night. They were drinking and talking about all these plans that I knew I couldn’t do, ’cause I now spend weekends with my wife and son. Therapist:Can you go back to the night in your mind? Take a moment to see the bar, look around. (pauses) See your buddies’ faces. Can you hear them talking about the game they went to? Now hear them talking about the other plans. Take a moment to really go back to the bar in your mind. See if you can remember what is going through your mind as your buddies were talking. The therapist uses both visual and auditory imagery. Charles: I guess I started thinking what a great time they were having, and that now all I do is change diapers and work. Feels like my life is at a dead end. My wife never wants sex anymore; she just complains about how tired she is. Once Charles can identify his thoughts, his depression and drinking make a lot more sense. EXPLORE IMAGES Strong negative feelings are often accompanied by intense affect-provoking images. For example, clients who are scared of spiders tend to have images of huge horrible spiders (Pratt, Cooper, & Hackmann, 2004), and clients who are socially anxious tend to have negative images of themselves in social situations. A socially anxious client may have an image of himself stuttering, sweating, or behav- ing in an extremely awkward manner (Hirsch, Clark, Mathews, & Williams, 2003). Images can also be about the past. It has long been known that clients with post-traumatic stress disorder (PTSD) fre- quently have intrusive images in the form of flashbacks of the traumatic event. What researchers and clinicians are discovering is that clients with a variety of problems can have intrusive images that contribute to their distress. For example, often clients who are depressed have intrusive images of nega- tive events that occurred in the past (Wheatley & Hackmann, 2011). Some clients can easily identify their images; however, many clients become aware of their images only when specifically asked whether images accompany their emotional reaction (Brewin, Christodoulides, & Hutchinson, 1996). In my article “Incorporating Imagery into Thought Records” (Josefowitz, 2017), I describe different types of questions that can help clients identify their images. You can find a Questions to Identify Your Client’s Images handout at http://www.newharbinger.com/38501. Start with a general question. Do you have any images or memories connected with this situation? When you think of this situation, does it bring up any images or memories? Explore worries. Many clients who are anxious have very clear images of their feared event occurring. If your client has a worst-case scenario, be sure to ask whether he actually sees the worst case happen- ing in his mind.

Ask about images that accompany your client’s feelings. Do you have any images or memories that accompany your feelings? When you have this feeling, do you ever see pictures or images in your mind of yourself or other people? Ask about images that accompany your client’s verbal thoughts. Clients often have thoughts about themselves (I don’t fit in); thoughts about others (my father is always critical of me); and thoughts about the future (my boss will refuse to pay me overtime). You can ask, “When you have this thought, do you see or imagine this happening? Do you get a picture in your mind of yourself or the other person? What do you see yourself or the other person doing or saying?” Some clients’ images are very detailed and elaborate. Many clients tell themselves long, complex stories; others have very brief, fleeting images. Try to notice your own images. Suzanne had a very clear image of herself standing in the principal’s backyard, looking very awkward. She is holding a drink in her hand and is slightly sweaty. She is all alone and everyone else is happily talking together. Her therapist asked if there were any sounds in her image or if she heard any- thing. Suzanne said she could hear the other teachers talking and laughing, and she was outside the group with nothing to say. Images hold encapsulated meanings. Once you have identified your client’s images, you can ask what these images mean about himself, other people, or the future. Often images hold the same meaning as—and reinforce—the hot thought (Josefowitz, 2017). In Suzanne’s case, her images rein- forced her hot thoughts that no one would want to talk to her and that she would not fit in.

Exercise 7.3: Aabir Explores His Images Practice helping your clients identify their images. Video 7.2: Use Imagery to Explore Thoughts Agenda Item #4: Additional Strategies to Identify Thoughts Clients’ hopes, questions, and mood shifts can also provide glimpses into their thoughts. WHEN THOUGHTS ARE HOPES OR QUESTIONS Thoughts that are hopes or questions pose unique challenges because they do not clearly explain the meaning of the situation. This means that you need to continue to explore these thoughts in order to identify a hot thought. Let me give you some examples. Karl is very depressed. When his therapist asks about his thoughts, he sighs sadly and says he really hopes one day he will have children. This hope is not a thought that captures what his depression is about. If Karl were truly hopeful, he would not be feeling depressed. When clients are depressed or anxious, they sometimes express as hopes the very things they feel hopeless or worried about. Karl’s therapist follows up and asked, “I hear you hope that you will have children; are you worried that will not happen?” Karl became teary and responded, “Yes I think that for me having children is pretty hope- less, and it is the most important thing to me.” Karl’s thought, It is hopeless that I will have children, starts to explain his sadness. Karen is also depressed. When her therapist asks about her thoughts, she becomes teary and says she keeps thinking, Will my husband leave me? The problem is you can’t look for evidence for a ques- tion—you need a statement to look for evidence. You can turn the question into a statement by either rephrasing it or exploring how your client would answer the question. For example, Karen’s therapist rephrased her question by asking Karen, “Are you thinking, My husband will leave me?”

Let’s see how Raoul’s therapist helped him further explore a thought that was in the form of a ques- tion. About a week ago, Raoul’s boss asked him to work on a new project with some of his junior col- leagues. He had been procrastinating over contacting them. Raoul was able to identify his feelings and told his therapist he was embarrassed (8) and anxious (8). His therapist then asked him what he was thinking. Raoul:I keep wondering, Why didn’t I get the promotion? Therapist:When you think, Why didn’t I get the promotion, how do you answer the question in your head? Raoul:I guess I think I just wasn’t competent enough. Therapist:So one answer you give yourself is, I just wasn’t competent enough. Do you give yourself any other answers? Raoul:Well, I also think my colleagues and boss don’t respect me, and don’t respect my work. When Raoul’s therapist starts to explore how he answers the question, he starts to identify thoughts about himself, I wasn’t competent enough, and thoughts about others, My colleagues and boss don’t respect me and don’t respect my work.

Exercise 7.4: Carol Wants to Apply for a Job Practice exploring thoughts that are facts, hopes, or questions. USE SHIFTS IN YOUR CLIENT’S MOOD When clients talk about a difficult situation, they often become emotional. A shift in your client’s mood usually goes with an important thought about self, others, or the future. For example, if a client looks sad, blushes, or becomes agitated, it is an opportunity to “catch” important thoughts. I usually say, “I noticed you looked sad [or I noticed you looked upset]; what were you thinking?” Let’s look at an example that Suzanne brought up in the sixth session. Suzanne came into the session saying she wanted to talk about her relationship with her husband. She started in a very calm manner, saying that last night, she said she was tired and wanted to go to bed early. Her husband became annoyed and angry and told her that she was always tired and never wanted to do anything fun anymore. Suzanne started to become teary as she described her husband’s response. Her therapist wanted to identify what thoughts went with her change in mood. Therapist:You looked teary as you remembered what your husband said. Suzanne:Yes, it was pretty awful to hear him say that I never want to go out anymore. Therapist:I am wondering what was going through your mind just now, as you got teary. Suzanne:(looking very sad and more teary) I thought that if I don’t start being more fun, that he will leave me, and I will be all alone.

YOUR TURN! Notice Raoul’s Change in Mood Up to now Raoul has mainly focused on work issues. In session 7 he comes in and tells his therapist that his youngest niece may have a serious illness. He explains in a calm voice, “When I think of the pos- sibility of my niece being sick, I know the whole family will just have to find a way to cope, as hard as it will be.” He then goes on: Raoul: We will know for sure whether my niece has the illness on Monday, when we get the results of the lab tests. (His voice cracks, he takes a deep breath, and looks very upset.) How could his therapist use the shift in Raoul’s mood to help him identify his thoughts about the lab results? Look at the three possible responses below and pick the one that will help Raoul identify his thoughts:

1. What a hard situation. I hope that you are taking care of yourself.
2. You just looked so upset, I am wondering what was going through your mind when you thought of getting the lab results?
3. I can see how upset you are, but I also hear how important it is to you to cope. How are you coping? Response #2 is the most likely to lead Raoul to identify the thoughts that accompany his change in mood. In response #1, the therapist tries to be supportive but does not ask about Raoul’s thoughts and is giving advice that Raoul did not ask for. In response #3, the therapist tries to be empathic and then moves to problem solving without having a good definition of the problem. Agenda Item #5: How Do You Know Which Questions to Use? It can be hard to know which question to use, and there is no right answer. Here is a summary of the questions I use, in the general order in which I use them. You may initially find it helpful to keep this list by your side during therapy. (You can download a Questions to Identify Your Client’s Thoughts handout at http://www.newharbinger.com/38501.) The more you use these questions, the more they will start to feel natural. •What were you thinking? Any other thoughts? •When a client’s mood shifts, ask about thoughts. •What does the situation mean to you? OR What does the situation mean about yourself, others, or your future? •How is this situation a problem for you? •What are some of the thoughts that go with your feelings? •Let’s make a list of your worries. Do you have a worst-case scenario? •Do you have any images? •If the thought is a question: How do you answer this question in your mind? •If the thought is a hope: What are you worried about? Let’s use some of these questions to help Michael, a twenty-eight-year-old client of mine, to identify his thoughts. Michael’s main agenda was addressing his anxiety about his relationship with a new girl- friend. He didn’t understand why he was so anxious. We began with identifying situations where he felt anxious. Michael told me that his girlfriend was rarely verbally affectionate toward him; she almost never said she missed him or that she was happy to see him. He described a text message he just received where she said, “See you tonight for dinner.” As he talked about her behavior, he became almost teary. Below is how I explored his thoughts; however, there are many other possible helpful responses. As you read through the dialogue, consider what you would have said.

Therapist:When you received the text, what were your thoughts at the time? Michael:I don’t know, it just doesn’t feel good to get a text like that (eyes well up with tears). I started with using one of the “Just Ask” questions. However, Michael responded with a thought that was not a hot thought, so I wanted to try another approach. Therapist: I can see you’re becoming almost teary. What thoughts are going through your mind? I noticed the shift in his mood and thought it probably signaled an important thought. Michael: I know she had a relationship with another man for two years before me. I keep wondering, Did she treat him the same way? Michael’s first thought is a fact: She had a relationship for two years before me. His second thought is a question: Did she treat him the same way? I chose to explore how he answered the question, as there seemed to be more emotion attached to that thought. Therapist:And how do you answer the question, “Did she treat her past boyfriend in the same way”? Michael:I think she treated him differently, or the relationship wouldn’t have lasted. I wanted to explore what it meant to Michael that he thought his girlfriend had treated her previous boy- friend differently. Therapist:If she did treat her previous boyfriend differently, what would it mean to you? Michael:That she doesn’t care about me as much as her previous boyfriend, maybe that she doesn’t really care about me at all. At this point, Michael started to talk with more emotion about his fears that his girlfriend was not com- mitted to the relationship and that he was not very important to her. Agenda Item #6: Link Thoughts to Feelings, Physical Reactions, and Behavior At this point in therapy, you have identified a specific situation that is problematic for your client, and you’ve explored your client’s reaction using the four-factor model. Identifying the relationships among the four factors provides your client with a structure for understanding what is maintaining his problems, and provides you with a way of organizing your client’s treatment. Here’s where the written worksheet Understand Your Reaction comes in handy: you and your client have a document you can look at when developing a model to understand the factors that are maintaining his problem. I start with asking my client to look over the Understand Your Reaction worksheet and ask if he sees a connection among the four factors. Often a client will spontaneously comment that his reaction makes more sense, or that given his thoughts, it makes sense how he is feeling or behaving. If a client does not see the link between his thoughts and his feelings, physical reactions, and behaviors, I point it out to him. For example, I might say, “When I look at your thoughts, it makes sense to me that you would be [a feeling, for example depressed], or do [a behavior, for example procrastinate]. Does this make sense to you?” If my client agrees with me, I ask him to explain the link among the four factors in his own words.

Let’s look at the Understand Your Reaction worksheet that Suzanne completed to see how we can help her understand her difficulties. Understand Your Reaction Situation Feelings (Rate 1–10) Physical Reactions BehaviorsThoughts (Rate 1–10) What? Who? What did I feel? Where? When?How did my body react?What did I do?What did I think? Principal invited me to barbecue with the three other new teachersClenched stomach (4)Has not responded• I don’t want to go. Nervous (7) Worried (8) Embarrassed (6) Tense shoulders (5) • The other new teachers will be there. • I won’t fit in. • I will just stand there looking awkward. • No one will want to talk to me. • I will probably get all sweaty. Therapist:Let’s look at what you wrote down. (Suzanne and her therapist look at the worksheet.) When you look at it, do you notice any connection among the four factors? Suzanne:Sort of…I wasn’t aware that I had all of those thoughts. Suzanne’s therapist wants to positively reinforce Suzanne for identifying her thoughts. Rather than telling her, she wants Suzanne to make the link between her thoughts and how she was feeling and behaving. Therapist:You did a really good job of identifying your thoughts. Do you see a connection between your thoughts and your feelings, physical reactions, and behaviors? Suzanne:I do. It makes sense to me that if all these thoughts were going through my head, I would feel anxious. Therapist:I think you are right, and you said it very well. The thoughts really explain your feelings. Notice how Suzanne’s therapist reinforces Suzanne’s understanding of the relationship between her thoughts and her feelings; she tells Suzanne that she articulated the relationship well, and repeats the connection. At this point Suzanne’s therapist would introduce the idea of examining her thoughts, to see if there is any evidence for her beliefs. In the next chapter, we are going to cover how to look for evidence for your clients’ thoughts. DO I ALWAYS EXPLORE ALL FOUR FACTORS? For most clients I use the Understand Your Reaction worksheet. However, you can start with just focusing on one aspect of a client’s problem. For example, remember my client Elsbeth, in chapter 5, who was angry at her son for not doing his homework and chores? We started with just monitoring situ- ations where she was angry. With other clients, if behavior is not part of the presenting problem, I start with exploring feelings, physical reactions, and thoughts. Once my client understands the feeling– thought connection, we add exploring his behaviors. EVALUATING YOUR CLIENT’S WORKSHEET Below are five criteria I use to evaluate whether I need to spend more time exploring any aspect of a client’s Understand Your Reaction worksheet. If a client did not find completing the worksheet helpful, I check that it was done well; if it was not done well, I keep working with my client. You can download Understand Your Reaction Checklist at http://www.newharbinger.com/38501.

1. Is the situation a factual description of what occurred or does it include feelings, physical reac- tions, behaviors, or thoughts?
2. Is the feeling really a feeling or is it a thought or behavior?
3. Did the client rate his or her feelings and physical reactions?
4. Is the behavior a factual description or does it include feelings, physical reactions, or thoughts?
5. Are the thoughts hot thoughts? a. Are the thoughts about self, others, or the future? b. Are the thoughts related to the client’s feelings?

Exercise 7.5: Sophia Completes the Understand Your Reaction Worksheet Practice evaluating the Understand Your Reaction worksheet. Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to a Clinical Example Complete the following exercises.

Exercise 7.1: (a) Yonas Asks a Question, and (b) Diana Wants to Go to College Exercise 7.2: Isabella Lists Her Worries Exercise 7.3: Aabir Explores His Images Exercise 7.4: Carol Wants to Apply for a Job Exercise 7.5: Sophia Completes the Understand Your Reaction Worksheet Apply What You Learned to Your Own Life Before you try completing the whole Understand Your Reaction worksheet, it is helpful to practice identifying just your thoughts and feelings. Homework Assignment #1 Identify Your Own Feelings and Thoughts This coming week, choose two situations when you had at least a moderately strong negative reaction. Describe the situation, identify and rate your feelings, then identify your thoughts using Questions to Identify Your Client’s Thoughts. Record your responses on the What Are My Feelings and Thoughts? worksheet, which you can download at http://www.newharbinger.com/38501.

What Are My Feelings and Thoughts? SituationFeelings (Rate 1–10)Thoughts What? Who? Where? When?What did I feel?What did I think? Homework Assignment #2 Complete the Understand Your Reaction Worksheet Once you have practiced the What Are My Feelings and Thoughts? worksheet, you are ready to try completing the entire Understand Your Reaction worksheet. There is a copy below, and you can also download it at http://www.newharbinger.com/38501. Once you have identified your thoughts, ask your- self if they are about self, others, or the future.Feelings (Rate 1–10)What did I feel? SituationWhat? Who? Where? When? How did my body react? What did I do? Physical Reactions Behaviors (Rate 1–10) Understand Your Reaction What did I think? Thoughts

Apply What You Learned to Your Therapy Practice It’s time to try the same exercise that you just did, but this time with a client. Homework Assignment #3 Identify Your Client’s Feelings and Thoughts Choose a client who is easy to work with and follow these steps:

1. Identify a situation that is problematic.
2. Introduce the What Are My Feelings and Thoughts? worksheet, which you completed in Homework Assignment #1, and explain that you want to use it to help identify your client’s feelings and thoughts.
3. Identify and rate your client’s feelings.
4. Use Questions to Identify Your Client’s Thoughts.
5. Help your client link his or her thoughts to his or her feelings. Homework Assignment #4 Complete the Understand Your Reaction Worksheet with a Client If the last exercise went well, try the Understand Your Reaction worksheet with a client. The first time you try this you may feel awkward and worry about your client’s reaction. This is a normal response to trying something new. However, try to put your worries aside and focus on the task.

Let’s Review Answer the questions under the agenda items. Agenda Item #1: Identify automatic thoughts. • What is the most straightforward way to identify negative automatic thoughts? Agenda Item #2: Helpful questions. • How can you ask what a situation means to your client? Agenda Item #3: Your clients’ images. • What are two good questions you could use to ask about your client’s images? Agenda Item #4: Additional strategies to identifying thoughts. • If a thought is a question or a hope, how can you explore it further? Agenda Item #5: How do you know which questions to use? • What are some of the questions you could use to help your clients identify their thoughts? Agenda Item #6: Link thoughts to feelings, physical reactions, and behavior. • Why is it helpful to look at the relationship among the four factors? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

PART 3 Cognitive and Behavioral Interventions

CHAPTER 8 Look for Evidence and Create Balanced Thoughts In chapter 7 we covered how to help your clients identify their thoughts. Did you have a chance to notice your own thoughts? Did you ask your clients about their thoughts and feelings? What did you discover? If you did not do the homework, think about an upsetting experience that happened last week. Try to identify your feelings and thoughts. What did the situation mean to you? What was your worst-case scenario? Did you have any images? Set the Agenda In this chapter we are going to build on the Understand Your Reaction worksheet and learn how to work with thought records. You will ask your clients to examine the evidence for their negative thoughts and develop a balanced thought that takes into consideration all of the evidence. The whole process is called cognitive restructuring. Agenda Item #1: What are thought records? Agenda Item #2: Explain looking for evidence. Agenda Item #3: Find evidence that supports negative thoughts. Agenda Item #4: Find evidence against negative thoughts. Agenda Item #5: Develop balanced thoughts. Work the Agenda In chapter 5 we talked about how your client has a well-worn automatic negative path that she zooms down, ending up in a big black jumbled ball of feelings, physical reactions, behaviors, and thoughts. One way to hit the pause button on your client’s automatic negative reaction is to use the four-factor model to help your client understand her reaction. Once your client has identified her feelings, physical reactions, behaviors, and thoughts, she is ready to actively change her negative path. One way to help your client change her negative path is to ask her to step back and examine the evidence for her thoughts. Negative thoughts are like thinking habits; we assume they are true and don’t stop to ques- tion whether they make sense. However, habits can be changed. Looking for evidence starts a process of developing new and more positive thought habits that are based on reality.

Agenda Item #1: What Are Thought Records? A thought record is essentially a structure for helping your client look for the evidence for her hot thoughts. In its simplest form, a thought record is a worksheet where a client identifies a problematic situation and then records her feelings and thoughts about the situation. The client then choses one thought to focus on. For a thought record to be effective, the thought the client chooses needs to be a hot thought. Once your client has identified the hot thought she wants to explore, she then looks for the evidence for and against her thought. After the client has examined the evidence, she develops a new more balanced or alternative thought. Many thought records also include space to record physical reactions and behavior. The Understand Your Reaction worksheet can be used as the first five columns of a thought record. Thought records also frequently involve having clients rate how much they believe their new balanced thought and rerate their feelings after completing the thought record; however, this is not essential. Below are the steps to complete a thought record. The steps in italics are common but not essential to the process.

1. Identify a problematic situation.
2. Identify and rate feelings.
3. Identify physical reactions.
4. Identify behaviors.
5. Identify thoughts.
6. Choose a hot thought (a thought that is related to a negative feeling and a negative evaluation of self, other, or the future).
7. Look for evidence for and against the hot thought.
8. Create a balanced or alternative thought based on all of the evidence.
9. Rate the extent to which you believe the new balanced thought.
10. Rate your feelings now that you have examined the evidence. I use the Examine the Reality of Your Thoughts worksheet, which follows, to help clients complete the rest of the thought record process. Examine the Reality of Your Thoughts Thought I want to examine: Evidence for My Thought Evidence Against My Thought Conclusion or thoughts that consider all the evidence: The theory behind thought records is that clients assume their negative thoughts are true. Asking clients to examine the evidence for their thoughts stops their automatic reaction and starts a process of self-reflection. When clients examine the evidence for their thoughts and create their own balanced thought, they develop new ways of thinking and less extreme attitudes toward the world and them- selves. New ways of thinking open up the possibility of behavioral change. Evidence clearly shows that this process of cognitive restructuring is related to alleviating depression and anxiety (Beck & Dozois, 2011). A written thought record is not essential. Looking for the evidence for a thought can be done as part of a therapy conversation. However, I would encourage you to use the Understand Your Reaction and Examine the Reality of Your Thoughts worksheets as written tools. A written thought record pro- vides a structure and makes the process of identifying thoughts and looking for evidence very concrete. Some therapists like to use a seven-column thought record with space for identifying the four factors, looking for evidence, and developing a balanced thought. Dennis Greenberger and Christine Padesky use this type of thought record in their book Mind Over Mood (2016). Personally, however, I like to break the thought record down into two stages, first using the Understand Your Reaction worksheet and then the Examine the Reality of Your Thoughts worksheet. You can download both at http://www .newharbinger.com/38501. Although looking for evidence is a powerful intervention, looking for evidence once will not shift a longstanding negative thought. Your clients will need to complete many thought records, over a period of time, to change their negative thoughts. However, while a client’s thoughts vary somewhat from situation to situation, most clients have recurring negative thinking patterns. If you identify a cli- ent’s thoughts in one situation, most likely these thoughts will recur in other situations. This means that the thought record you complete for one situation will often be relevant to other situations. CHOOSE A HOT THOUGHT If your client has one central negative hot thought that is closely related to her emotional distress, that is the thought you will focus on. However, your client may have more than one hot thought, for example, I am an inadequate mother and My partner does not love me. In this case, your client needs to choose which thought to work with, as you can only examine the evidence for one thought at a time. If a client has more than one hot thought, I ask, “Which thought do you think is the most central, or the most important for us to examine?” Another question I have found helpful is, “Which thought do you think is most closely related to your strongest negative emotion?” Clients usually know which thought they need to focus on. Most of our negative thoughts are repetitive. If your client chooses to examine I am an inadequate mother, she will have another chance to examine My partner does not love me. WHAT IS SOCRATIC QUESTIONING? All CBT books talk about the importance of Socratic questioning. The term comes from the Greek philosopher, Socrates. Socratic questioning is the idea that skillful questioning can help your clients examine the assumptions behind their thoughts, consider aspects of the situation they had ignored, or understand their situation from a different perspective. Your role is to ask questions that help your client understand her problems in a new light. The basic idea is that it is more effective to ask questions that help clients reach their own conclu- sions than to tell a client what to think. If I could post one sticky note on all my readers’ heads, it would say: Conclusions you reach yourself are more convincing than conclusions someone tells you.

Agenda Item #2: Explain Looking for Evidence Once your client has identified a hot thought, you need to explain the idea of looking for evidence. Essentially, you are going to teach your client to examine her thoughts for their validity rather than treating thoughts as facts. Your client needs to learn to take a step back and put some distance between herself and her thoughts. My clients almost always immediately grasp the idea of looking for evidence, though sometimes they assure me that they know their negative thoughts are accurate. Here is how I usually explain looking for evidence (you can find a copy at http://www.newharbinger.com/38501): You did a really good job of identifying your thoughts and catching the negative thoughts that cause you to feel bad. I am wondering if you would be willing to examine your thoughts. I would like to look at the evidence that supports your negative thoughts, and also at evidence that doesn’t support your negative thoughts. Negative thoughts are like thought habits. By that I mean they are ways of thinking that you are used to, but you have not examined whether they are accurate. When we look for evidence, I want us to focus on facts. That way, we can evalu- ate the accuracy of your thoughts. Would that be okay with you? We need to pick one thought that we want to examine. I want to look over the thoughts you identified that go with your negative feelings and see if we can pick one that feels the most central to you, or is the most related to your strongest negative emotional reaction.

YOUR TURN! Practice in Your Imagination: Explain Looking for Evidence I want to ask you to imagine explaining looking for the evidence for a hot thought. Before you start, rate from 1 to 10 how comfortable you feel explaining looking for evidence for and against a hot thought. At the end of the exercise, rate your level of comfort again to see if it changed. Now, let’s try this exercise. Choose a client who you think would benefit from looking for evidence for his or her thoughts. Try to get a picture of him or her in your mind. Imagine yourself in your office with your client. See your office; notice the sounds and smells in the room. Imagine that your client has identified a negative thought and you want to explain how to examine the evidence for his thought. Read over how I suggest explaining the process of looking for evidence while imagining yourself saying the words. You can also use your own phrases. Really hear and feel yourself explaining how to examine the evidence. Now, imagine explaining looking for evidence two more times with the same client. Each time, imagine that your client responds positively.

Agenda Item #3: Find Evidence That Supports Negative Thoughts If you are going to help your client reevaluate her negative thoughts, you need to understand the evidence she uses to support them. Many clients find that writing down the evidence, or saying the evidence out loud, makes it more manageable. It becomes a fact that you can talk about, rather than something that sits in your head. Sometimes when a client starts to look for facts that support her nega- tive thoughts, she realizes that there aren’t any, or not as many as she thought. Sometimes a client discovers that her negative thoughts are fairly accurate. This can also be helpful, as it highlights the need to problem solve and cope with a real problem.

SUZANNE EXAMINES THE EVIDENCE Let’s look at how we could help Suzanne with her anxiety about the invitation to the principal’s barbecue. She identified her hot thought as No one will want to talk to me. Suzanne’s therapist explained the process of looking at the evidence, and Suzanne was willing to try. Therapist:I want to start with looking for the evidence that supports your thought, No one will want to talk to me. What makes you think that it might be true? Suzanne:Well, I know that I will feel anxious when I go to the barbecue. Suzanne’s thought, I will feel anxious when I go to the barbecue, is not a fact. It is a prediction about how she will feel. Suzanne’s therapist wants to explore whether there are any facts that support her hot thought. Therapist:I hear you will feel anxious, but I wonder if there are any facts that support your belief that no one will want to talk to you. Suzanne:What do you mean? Therapist:If I wanted to prove that no one would want to talk to you, I would have to back up my opinion with facts. For example, if you were in a court of law, the judge would look only at the facts. Does that make sense to you? The therapist wants to be sure that Suzanne understands the idea of facts. Sometimes using the analogy of a court of law can be helpful. Suzanne:What about the fact that I hardly know any of the other teachers, does that count? Therapist:Of course, that is a fact. I wonder…how is it related to no one wanting to talk to you? Suzanne:Well, none of them have made an effort to talk to me. I usually stand alone at recess and I eat lunch by myself also. Therapist: Okay, so let’s write down what you just said, to be sure we don’t forget. How would you put that in your own words? (Either Suzanne or her therapist writes.) Other evidence that makes you think, No one will want to talk to me? Notice that Suzanne’s therapist is gathering data; she is not refuting or problem solving. Suzanne: I think it’s mainly at lunch and recess. Maybe also when I arrive in the morning, no one says hi to me, or smiles. USE THE PAST TO UNDERSTAND THE PRESENT It can be helpful to ask your client if she had any experiences in her childhood or past that support, or that are related to, her negative thoughts. Making the link between her history and her current thinking can help your client start to see that what was true in her past is not necessarily true in her current life. Take a moment to think about how you could ask Suzanne about the relationship between any past events and her hot thought. Therapist:Suzanne, is there anything in your past that would cause you to think, No one will want to be my friend? Suzanne:Actually, when I was in high school, in my last year, there was a group of really awful girls who made my life miserable. They wanted to use my house for a drinking party when my parents were away for the weekend, and I said no. They spread awful rumors about me, and I lost almost all my friends. It was a horrible, lonely time in my life. I felt then that no one wanted to be my friend. When a client discloses painful memories from her past, you need to decide if you want to focus on the memory or continue with the thought record. Generally, if it is the first time a client discloses a traumatic memory, I ask my client if she would like to focus on the memory. Suzanne disclosed a painful memory from high school that was upsetting, but not traumatic. Her therapist thought it was more important to continue with the thought record than to explore the high school memory. Therapist:It must have been very upsetting to have this happen. Is that when the thought No one wants to be my friend started? Suzanne:It was pretty awful. Yeah, that’s when I became more self-conscious and started worrying about people liking me. Before that, I just had a bunch of friends whom I hung out with. Therapist:It sounds like it really changed your outlook. In another session, it might be important for us to talk about what happened in high school. For now, could we just put it down in the “Evidence for” column? Let’s see how Suzanne filled in the “Evidence for My Thought” column of her Examine the Reality of Your Thoughts worksheet. Thought I want to examine: No one will want to be my friend. Evidence for My Thought Evidence Against My Thought • No one has made an effort to talk to me. • I am alone at recess and lunch. • Other teachers do not say hi when I get to school in the morning. • In high school, some girls started rumors and I lost almost all my friends.

Agenda Item #4: Find Evidence Against Negative Thoughts Clients tend to focus on information that confirms their negative thoughts. Your job is to help your client focus on information she usually ignores and that challenges her negative thoughts. You can think of your client as living in a room filled with information, but only the information that supports her negative thoughts is lit; the rest of the room is in the dark. Your job is to use questions so that the whole room is in the light. Once the whole room is lit and your client sees all of the evidence, she can decide if her previous belief still makes sense. Figure 8.1 shows how a therapist used a drawing of lighting up a room to help her client Paula, who is a doctor, understand that she was only looking at information that confirmed her hot thought. In one of Paula’s therapy sessions she was very distressed and told her therapist she thought that she was not a good doctor. Her evidence for her belief was that this past week she had misdiagnosed a patient and another patient had been very angry because she had kept him waiting half an hour. Paula and her therapist looked at the evidence against her belief. Paula noted that she had been a successful doctor for twenty years, almost all her patients are happy, and she rarely keeps patients waiting; she also gave examples of many complicated diagnoses she made over the years. Her therapist drew figure 8.2 to help Paula understand that she only sees information that confirms her belief that she is a bad doctor, and that all of the information that suggests she is a good doctor is ignored or kept in the dark. Her therapist told Paula they had to shine a light on all of the information. Successful doctor for 20 years Patients rarely wait Most of my patients are happy Many complicated diagnoses One patient waited Misdiagnosed one patient Figure 8.1. Paula’s therapist shines some light on ignored information.

There are three types of questions you can use to examine the evidence against a hot thought:

1. Is there evidence that contradicts my negative thoughts?
2. How probable is my negative prediction?
3. Is there another perspective?

EVIDENCE THAT CONTRADICTS YOUR CLIENT’S NEGATIVE THOUGHTS I generally start by directly asking my client if she has any experiences that suggest that her hot thought is not true, or not true all of the time. When Suzanne’s therapist asked, “Have you had any experiences that suggest that people may want to be your friend?” Suzanne responded quietly, “I had some friends in my previous school.” Evidence needs to be concrete and detailed. Examining the evidence for and against a negative auto- matic thought is similar to weighing evidence on a scale. On one side is the evidence for the negative thought and on the other side is the evidence against the negative thought. The evidence for the nega- tive thought is usually very heavy and full of details. The evidence against the negative thought is often more abstract and lacking in details. It can feel light compared to the heavy evidence for the thought. The more your client can provide detailed examples of evidence against the negative thought, the more she will be emotionally engaged, and the more the evidence against the negative thought will weigh compared with the evidence for it. Suzanne’s evidence against her hot thought is that she had “some friends.” This is not very strong or emotionally compelling evidence. To make the evidence more compelling, her therapist started by asking for specific examples, and then asked for details about the examples. Below are some of the ques- tions her therapist asked. •Can you give me examples of some of your friends? •When you say you had “some friends,” can you tell me about them? •What kinds of things did you do with your friends, both at school and outside of school? •How did you know that they wanted to be your friend? Her therapist discovers that Suzanne was friendly with many of the teachers at her previous school, but she had two good friends, Rita and Faiza. They generally ate lunch together and worked on the school play together. They often saw each other on weekends, and sometimes they would get together with their children and spouses. Suzanne thought they were funny, nice, warm people whom she had a good time with. Since she moved to her new school, she has seen less of them. They have often called to see if she wanted to do something on the weekend, but she’s been too tired. Faiza dropped by the other day with a cake she had made to cheer Suzanne up. What was the effect of making the evidence more concrete and detailed? Did it become more emotionally compelling? When her therapist explores the details of her friendship with Rita and Faiza, Suzanne’s mood lifts. When her mood lifts, she is also more likely to remember other situations that challenge her negative automatic thoughts. Figure 8.3 captures the idea of making the evidence heavier: when Suzanne’s evidence against her hot thought No one will want to be my friend becomes more detailed and concrete, it becomes more compelling. No one has made an effort to talk to me. I am alone at recess and lunch. Other teachers do not say hi in the morning. High school rumors, lost friends. I have some friends.

EVIDENCE AGAINST EVIDENCE FOR No one has made an effort to talk to me. I am alone at recess and lunch. Other teachers do not say hi in the morning. High school rumors, lost friends. EVIDENCE FOR Friends with Rita and Faiza. Had lunch together. Worked on school play together. Hung out on weekends together. I have some friends. EVIDENCE AGAINST Figure 8.3. Weighing Suzanne’s evidence.

Exercise 8.1: Suzanne Is Upset with Her Husband Practice making evidence concrete and detailed.

ADDITIONAL QUESTIONS TO CHALLENGE YOUR CLIENT’S HOT THOUGHT Clients may need additional help to think of evidence against their hot thoughts. The following questions are inspired by a number of wonderful CBT therapists, including Judy Beck (2011), Dennis Greenberger and Christine Padesky (2016), and Jackie Persons and colleagues (2001). You can down- load a Questions to Identify Evidence Against Negative Thoughts handout at http://www.newharbin ger.com/38501. •What would you say to someone who thought this way? •What do you think a friend or someone who cared for you would say if he or she knew you had this thought? •If you were in a better mood, what would you think? •Five years from now, looking back, what might you think? •Is there any information that contradicts your interpretation? Even small pieces of information? •Is there any positive information that you are ignoring? Let’s see how Suzanne’s therapist uses some of these questions. Therapist:It sounds as if Faiza and Rita are really good friends. What do you think they would say if they knew you were thinking, No one will want to be my friend? Suzanne:They would say it was ridiculous. That of course people would want to be my friend. Her therapist wants to expand this evidence. Therapist: And if they really wanted to convince you, what might be some evidence they would tell you? Suzanne:Well, they would probably remind me of all the friends I had at my previous school; they would also remind me that they like me. Therapist:So they would remind you of your friends from your previous school and that they like you. And how is the fact that Rita and Faiza like you evidence against No one will want to be my friend? The therapist starts with a summary statement and then relates the evidence to the hot thought. Suzanne:(tentatively) Well I guess, if they like me, other people might like me? Therapist:(smiling) Do you think that might be true? Suzanne:(smiling) Yeah, I guess so.

Given that Suzanne’s mood has lifted a bit, she is more likely to remember other positive information. Therapist:I am wondering if there is any positive information that you are ignoring. Suzanne:(smiling) When I think of it, there is actually quite a bit. In college I had lots of good friends whom I still see, at least I saw them until I got depressed. I also have a bunch of friends from my neighborhood that I see on weekends, at the park. How could you expand the evidence that Suzanne just discussed? Remember, ask for an example and then ask for details. Suzanne’s evidence is starting to look very different! Thought I want to examine: No one will want to be my friend. Evidence for My ThoughtEvidence Against My Thought • No one has made an effort to talk to me.• I had some friends in my previous school. • I am alone at recess and lunch.• Rita and Faiza are good friends; ate lunch together; worked on the school play; hung out on weekends; went out as couples; still call to see if I want to do something; Faiza brought a cake. • Other teachers do not say hi when I get to school in the morning. • In high school, some girls started rumors and I lost almost all my friends. • Friends from college whom I still see • Friends from neighborhood Video 8.1: Looking for Evidence HOW PROBABLE ARE MY PREDICTIONS? Clients’ thoughts are often about the future and include negative predictions. Some examples might be No one will like me, I will fail the test, I will not get the job, or No one will like my Facebook post. When thoughts are about the future, you want to look for evidence about how likely it is that the nega- tive event will occur. Below are the steps I usually use.

1. Identify what your client fears will happen, and make the list as concrete as possible.
2. Rate the probability that each feared event will occur.
3. Examine the evidence for the probability that each feared event will occur.
4. Rerate the probability that each feared event will occur.

I often use the following worksheet, How Probable Are My Predictions?, which you can download a full-scale version of at http://www.newharbinger.com/38501. How Probable Are My Predictions? What I Fear Will Happen Probability Evidence That That Feared Supports the Event Will Probability Occur Evidence Against the Probability (0–100%) Rerate the Probability That Feared Event Will Occur Here is Suzanne’s list of what she feared would happen at the barbecue: •When I get there, everyone will be talking to each other, and no one will say hi to me. •If I approach one of the new teachers, she will turn her back on me. •I will stand there alone, with no one to talk to. •If I go up to one of the other teachers, I will have nothing to say. •Clear image of standing next to the barbecue grill, looking very awkward, holding a glass in my hand, and being all alone as everyone else talks together. Rate the probability of each event occurring. Suzanne’s therapist asked her to rate from 0 to 100 percent how likely it was that each of these events would occur. Suzanne thought that the first three events, as well as her image, were very unlikely and rated them at 20 percent. Her therapist asked Suzanne to explain what made them unlikely. Suzanne laughed and said that it was a small group, and the principal would make sure everyone was talking to someone. She rated “having nothing to say” as probable, at 80 percent. Examine the evidence. Suzanne and her therapist looked at the evidence for “If I go up to one of the other teachers, I will have nothing to say.” Suzanne explained that when she was anxious, she some- times had difficulty finding something to talk about. This had happened at her husband’s holiday party.

When Suzanne and her therapist examined the evidence against her prediction, she was able to think of many examples when she had been able to find something to say at social events, even if it had been difficult. Even at her husband’s holiday party she had found something to talk about with her husband’s colleagues. Rerate the probability. After looking at the evidence, Suzanne rated the probability of having nothing to say at about 50 percent. Before and after probability ratings allow your client to see that there has been a decrease, even if the probability is not a 0. You can see how Suzanne and her therapist completed the How Probable Are My Predictions? worksheet at http://www.newharbinger.com/38501. Real and false alarms. Friedberg, Friedberg, and Friedberg (2001) have a wonderful exercise that helps clients look at whether their negative predictions actually occur. The therapist asks the client to list all of her worries for the coming week. The next week they check which worries actually happened. Most of the time, the majority of worries are “false alarms.” Tolerance of uncertainty. Unless your client’s negative predictions are totally bizarre, no one can guarantee that they will not occur. Clients need to learn to tolerate uncertainty (Dugas & Robichaud, 2007). This can be hard, but a first step is talking honestly with your clients about accepting that life is uncertain, and that while not impossible, the probability of the feared events occurring is small. Video 8.2: How Probable Are My Predictions? IS THERE ANOTHER PERSPECTIVE? Sometimes a client’s negative thought is based on an overly negative interpretation of an event; you want to help your client find a more benign interpretation. Let’s look at an example. Raoul was upset because a colleague walked past him in the hall without saying hello. Raoul thought this meant that his colleague was avoiding him. Another possible interpretation is that his colleague was in a hurry or preoccupied. Sometimes simply asking your client whether she can think of a different perspective is enough to start her thinking in a different way. However, sometimes you need to be more active. The following two approaches can help clients reach a more benign interpretation: (1) taking a close look at the facts of the situation and (2) exploring whether your client is blaming herself for something she has little or no control over. Take a close look at the facts. Clients tend to focus on narrow information that reinforces their thoughts; your job is to help your clients broaden their perspective and look at all of the facts of a situ- ation to see whether there is a more balanced interpretation. Do you remember in the last chapter Raoul was extremely upset that he had been assigned to work with junior colleagues on a report? He was sure this meant that his boss did not respect him. Below are questions you can use to help your client examine her interpretation of a situation. You can download a Questions to Gather More Information about the Situation handout at http://www.newharbinger .com/38501. •How did this situation come about? •Who are the other people you will be working/interacting with? •Is there any information that contradicts your interpretation? Even small pieces of information? •Is there any positive information that you are ignoring? •Have you ever behaved in a similar way? What was your motivation?

Let’s see what happens when Raoul’s therapist uses these questions to explore Raoul’s interpreta- tion of the situation. Questions to Gather More Information about the Situation QuestionsRaoul’s Response How did this situation come about?My boss approached me and said he would like me to work on this report, as he thought I had the needed expertise and had done this kind of work before. Who are the other people you will be working/ interacting with?Two junior colleagues, who have been hired in the past two years. Is there any information that contradicts your Often senior people are asked to work with more interpretation? Even small pieces of information? junior people on reports. It is pretty common in the firm. Is there any positive information that you are ignoring?One of the junior people told me she was really glad to have me on the team, that she had heard great things about me. Have you ever behaved in a similar way? What was your motivation?In the past, I assigned a senior person to work on a project, to be sure that there was someone with the needed expertise on the project. Raoul’s therapist asked him whether this additional information had any implications for his thought that being assigned to the project meant that his boss did not respect him. Raoul replied that it might mean they wanted a senior person on this project. I am looking for a crack in my client’s beliefs. Just like water seeping through a stone, if you can get a small crack, it can spread.

Your Turn! Help Suzanne Take a Close Look at the Facts Suzanne was very distressed that none of the teachers talked to her at recess. This was a key piece of evidence in her belief that no one would want to be her friend. Her therapist thought it would be worth- while to see if there was a more benign interpretation. Therapist: One of the pieces of evidence you use to support your belief that none of the teachers would want to be your friend is that no one talks to you at recess. Look at the three possible responses below and pick the one that will help Suzanne start to gather facts about the situation.

1. It seems strange to me that they don’t talk to you; they sound like horrible people.
2. How could you join one of the groups of teachers?
3. Can you describe to me what happens at recess, what the other teachers do, and what you do? Response #3 is the best question to help collect information on what occurs at recess. Depending on the answer, the therapist can follow up in different ways. Response #1 supports Suzanne’s interpreta- tion of the situation. Response #2 starts a problem-solving process before the problem is clarified. Therapist: Can you describe to me what happens at recess and what the other teachers do? Suzanne: We each have an area we are responsible for. Actually, when I think of it, only the two teachers who are assigned to the jungle gym stand together. The rest of us stand alone in the school yard. Some of the other teachers might approach each other and say a few words. I just stand in the back of the school yard next to the swings. Look at the three possible responses below and pick the one that will help Suzanne start to gain a different perspective.
4. I hear that everyone is assigned to an area and that most of the teachers are standing alone; do I have it right?
5. How much of a discipline problem are the children? What kinds of things do you find help with maintaining order?
6. It seems to me that everyone is alone, and it doesn’t mean they don’t want to talk to you. Response #1 is the best response. It is a summary of what Suzanne has told her therapist and is most likely to encourage her to consider a different perspective on what standing alone at recess means. In response #2, the therapist is gathering data about the situation, but the data is not relevant to Suzanne’s thought, No one wants to be my friend. In response #3, the therapist is telling Suzanne what to think.

Video 8.3: Take a Close Look at the Facts Is your client blaming herself for something she has little or no control over? Many clients feel responsible for situations they have no control over or believe that the situation is a reflection of them- selves, when it is at least partially due to external factors. Two of the questions I find most helpful are:

1. Are there other factors that could contribute to this situation?
2. Am I blaming myself for something I have little or no control over? Let’s look at some examples of clients’ thoughts and see if there are other ways of looking at the situation. You can download a Other Ways of Understanding the Situation worksheet at http://www .newharbinger.com/38501. Other Ways of Understanding the Situation SituationClient’s ThoughtAre there other factors that could contribute to this situation? List all of the factors.What can I control? Am I blaming myself for something I have little or no control over? Client’s 16-year- old son is using marijuanaI am a bad mother.Many factors contribute to a child using marijuana, including availability, peer group, and laws.I can control telling my child not to use marijuana, but there are many other factors that contribute to marijuana use. Yes, I am blaming myself for something I do not have complete control over. Only 15 people came to my talk at the confer- ence; many people had over 25 at their talks. My work is not interesting or important. My talk was at the end of the day; it was a beautiful day outside; there were other similar talks at the same time. I can control how much work I put into my talk. I cannot control when my talk is scheduled or the weather. Yes, the other factors would also impact how many people came.

HELP YOUR CLIENTS REACH THEIR OWN CONCLUSIONS Sometimes you remember information that challenges your client’s negative thought, but your client does not think of the information. Should you just tell your client? Let’s go back to the basic principles of Socratic questioning. You want to ask questions that draw your client’s attention to infor- mation she is not thinking about. Once your client has the information, you want her to draw her own conclusion. For example, Raoul tells you that he has stopped contributing to meetings because he believes that “no one is interested in my comments.” You remember that a few weeks ago Raoul described making a comment in a project meeting, to which one of his colleagues responded, “That is the best solution anyone has suggested so far.” You could remind Raoul of his colleague’s comment and then tell Raoul that clearly people are interested in what he has to say. However, it is more effective if Raoul can reach his own conclusions. It is better to ask Raoul if he remembers what his colleague said, and then once Raoul has told you, ask him what his colleague’s statement might mean about his thought, No one is interested in my comments.

YOUR TURN! Help Cynthia Reach Her Own Conclusions Cynthia was in therapy because she was having trouble with low self-esteem that was affecting many different areas of her life. She tells her therapist, “I was so embarrassed. I was at a party and a guy I know from work kept hitting on me. He kept telling me he wanted to go out with me and that I was beautiful. I just kept ignoring him. Men are only interested in me for sex.” Cynthia’s hot thought is Men are only interested in me for sex. Cynthia’s therapist tells her, “You are a wonderful woman; you deserve to find a great man. You have told me that lots of your male colleagues like and respect you.” Instead of telling Cynthia what to think, what questions could the therapist ask that would help Cynthia reach her own conclusions? From previous sessions her therapist knows that Cynthia is dating John, who frequently tells her that he cares about her. John always checks that she also wants sex before they have sexual relations. Cynthia has also talked about male colleagues who made comments indicating they respect Cynthia, especially Mike and Chris, whom she works closely with. Your job is to think of questions that you could ask to help Cynthia reach her own conclusion about whether men are only interested in her for sex. You can find my suggestions in the appendix.

Exercise 8.2: A Therapist Is Having a Bad Day Practice developing questions to help your clients reach their own conclusions.

Exercise 8.3: Suzanne Is Asked to Be a Maid of Honor Practice using a therapy dialogue to help clients reach their own conclusions.

CONSOLIDATE THE EVIDENCE AGAINST THE HOT THOUGHT Most likely your client is used to thinking about the information that supports her negative thoughts and tends to minimize the information against her negative thoughts. If you want your client to emo- tionally connect to the information against her negative thought, it is important to review the informa- tion. Reviewing focuses your client’s attention on this information and starts to create new thought habits. Usually I simply say, “Let’s review the information we have gathered.” If you have not written down the evidence, this is a good time to do so. You can say, “You collected some very important evidence about your thoughts. I think it would be helpful if we wrote it down, to be sure that we don’t forget it.” I encourage my clients to do the writing, as I think it helps with the review process. (If I am doing the writing, I repeat out loud what I am writing.) This also provides the client with a piece of paper she can take home and review as part of homework. You can also use imagery to help evidence against a hot thought come alive (Josefowitz, 2016) by asking your client to form an image in her mind of the memories and situations that constitute the evidence against the hot thought. For Suzanne, an important piece of evidence against her hot thought was eating lunch almost every day with Rita and Faiza at her previous school. Her therapist asked Suzanne to form an image in her mind of eating lunch with her friends. She asked Suzanne to remem- ber the lunchroom, the fun of being together, and how much they liked each other. Her therapist then went over the rest of the evidence, asking Suzanne to form an image for each example. When they had finished, the evidence felt much more real and emotionally engaging. Agenda Item #5: Develop Balanced Thoughts The final step in completing a thought record is evaluating the original hot thought and creating a new more balanced thought that takes all of the evidence into account. This is when you fill in the “Conclusion” section of the Examine the Reality of Your Thoughts worksheet. The basic question is, “Given all of the evidence, is your hot thought accurate, or does it need to be modified?” Here are some questions I regularly use. You can find Questions for a Balanced Thought at http://www.newharbinger .com/38501. •When you look at all of the evidence, what does this say about your original hot thought? •When you look at all of the evidence, what would be a more accurate thought? •What might be a thought that captures all of the evidence? •Let’s take a moment and look at all of the evidence. What did you learn? •You initially interpreted the situation in a specific way. When you look at the evidence, is there another interpretation that either makes more sense or might be equally true? •What would you tell someone who thought the way you did, and had all of this evidence? Let’s look at how Suzanne initially completed the Understand Your Reaction worksheet and the Examine the Reality of Your Thoughts worksheet. Then, let’s look at the evidence that Suzanne and her therapist collected.

SituationFeelingPhysical ReactionBehaviorThoughts Principal invited me to barbecue with the three other new teachersNervous (7)Clenched stomach (4)Did not respondI don’t want to go; the other new teachers will be there; I won’t fit in; I will just stand there looking awkward; no one will want to talk to me; I will probably get all sweaty. Worried (8) Embarrassed (6) Tense shoulders (5) Image: Standing alone in backyard as other teachers talk HOT THOUGHT: No one will want to be my friend. Thought I want to examine: No one will want to be my friend. Evidence for My ThoughtEvidence Against My Thought • No one has made an effort to talk to me.• I had some friends in my previous school. • I am alone at recess and lunch.• Rita and Faiza are good friends; ate lunch together, worked on the school play; hung out on weekends; went out as couples; still call to see if I want to do something; Faiza brought a cake • Other teachers do not say hi when I get to school in the morning. • In high school, some girls started rumors and I lost almost all my friends. • Friends from college whom I still see • Friends from the neighborhood Try to think of a balanced thought that captures all of the evidence. Write it down so you can compare it to the one Suzanne came up with. Therapist:It seems to me that when you think, No one will want to be my friend, you are only consider- ing the evidence that supports your thought. What happens when you consider all of the evidence? Suzanne:I guess that it doesn’t seem to be so true. Therapist:In what way is it not so true? Suzanne:Well, I do have friends who like me and want to be my friend. I think one of the problems is that I have been avoiding my friends from my old school. Therapist:I think you are right; we discovered that you have quite a few friends who like you. What would be a thought that captures all of the evidence? Suzanne:Well, I guess, even though I haven’t yet made friends at my new school, I had friends in the past and there really is no reason I won’t have friends in the future. Is Suzanne’s balanced thought better than the one you came up with? My clients often come up with far better balanced thoughts than I could ever have “told” them. Your job as a therapist is now easy—you just need to reinforce and consolidate the balanced thought. There are two tasks left before completing the thought record. First, ask your client how much she believes the thought from 0 to 100 percent. Even if she gives a fairly low score, it is still a start to believ- ing a new balanced thought. Second, ask your client if she believed the balanced thought, how would this affect her feelings, and ask her to rerate her original feelings. Suzanne believed her balanced thought 75 percent. She rerated her feelings Nervous: 5, Worried: 5, and Embarrassed: 4.

CONSOLIDATE THE BALANCED THOUGHT You have just spent a great deal of time and effort creating a balanced thought. It is worth spending a bit more time to consolidate this thought. First, be sure to smile and express interest in your client’s balanced thought. Your enthusiasm is reinforcing. Second, review the balanced thought in as many ways as you can. Here are some suggestions. •Say the balanced thought out loud and add a compliment. For example, I might repeat the balanced thought and say, “I like the way the balanced thought captures all of the evidence.” •Ask your client if she would like to write down the balanced thought so that she can remember it. My clients have written their balanced thoughts on coping cards, kept the balanced thoughts on their phones, or made the balanced thought into their screen saver. •Ask your client to repeat the balanced thought out loud. Depending on the balanced thought, I might ask my client to try a more assertive tone, or a more compassionate, gentle tone. •Ask your client to regularly review the balanced thought. I find it helpful to specify a set time to review, such as first thing in the morning. Develop a metaphor or an image. Often a balanced thought is fairly long and complex and can be hard to remember. It can be helpful to create an image of the evidence that is the most compelling for your client and attach it to the balanced thought. An image that symbolizes the balanced thought, a metaphor, or even a shortened version can increase the emotional strength of the balanced thought and make it more memorable (Hackmann et al., 2011; Josefowitz, 2017). Here is Suzanne’s shortened version of her balanced thought: Hang in there, you will make friends again. Exercise 8.4: Suzanne Reviews Her Balanced Thought Practice reviewing a balanced thought. Video 8.4: Create Balanced Thoughts

USE BALANCED THOUGHTS TO CREATE A NEW IMAGE When Suzanne’s therapist initially asked her about her thoughts and images, Suzanne reported that she had an image of herself alone in the principal’s backyard while the other teachers talked to each other. Once you have examined the evidence against the hot thought and created a balanced thought, you can go back and directly modify your client’s original image. Given the close connection between imagery and emotion, this can be a very powerful intervention. Let’s see how Suzanne’s thera- pist helps her create a new image. Therapist:You started out with a very clear image of yourself standing in the principal’s backyard, awkward and alone, as the other teachers talked together. Suzanne:That’s right, I wasn’t even aware that I had that image until you asked. Therapist:Given the evidence that we just looked at, and your balanced thought, how accurate do you think your original image is? Suzanne:(laughing softly) Probably not accurate at all. Therapist:I think it would be really helpful if we could develop a more realistic image of what you think will happen. Could we try? Suzanne:When I look at the evidence, and I really think about it, a more realistic image would be of my standing in the principal’s backyard talking to the other teachers, or at least being part of the group, even if I am not talking. Suzanne’s therapist thought this was a good start for a new image. However, the initial negative image was very detailed and vivid. Suzanne’s therapist wanted the new image to be as compelling. Therapist:Can you tell me a little bit more about this new image? Suzanne:Well, I see myself standing there with my drink, and I am part of a small group. I am listen- ing as one of the other teachers says something. Therapist:Can you get a clear picture in your mind of this new image? Suzanne:Yes, I can see it clearly (smiling). Therapist:And how do you feel when you get this image? Suzanne:A lot more relaxed about going, and a lot less depressed. Almost makes me wonder if it could be a good experience. After they had developed this new image, Suzanne’s therapist asked her to consciously practice seeing the new image three times a day. They discussed specific times that Suzanne could practice. Her therapist told Suzanne that the practice could be very short, even a few minutes, but it was important to practice regularly.

USE BALANCED THOUGHTS TO MANAGE STRESS Balanced thoughts generally move your client away from extreme thinking, such as No one will like me, to more balanced thinking that generally helps with anxiety and depression as well as self-esteem. Balanced thoughts provide a more resilient attitude toward life’s stressors. As we discussed earlier, most clients have typical negative thoughts that tend to recur. This means that the balanced thoughts you develop for one situation will most likely also be relevant to other situations. When Suzanne’s therapist asked if there were other situations where she had the thought No one will want to be my friend, Suzanne said she had this thought “all the time.” Her therapist asked for examples, and Suzanne replied that she often had these thoughts when she was alone at school during recess and lunch and at the end of the day when she left without saying good-bye to anyone. If you look at all of these situations, the thought No one will want to be my friend leads to Suzanne feeling depressed and withdrawing from the other teachers, making it almost impossible to make friends, leading to a vicious cycle where it seemed true that no one wanted to be her friend. Suzanne’s therapist asked her, “Instead of thinking, No one will want to be my friend, if you thought your new balanced thought, Hang in there, you will make friends again, how do you think you would feel?” Suzanne smiled as she responded that she would be less depressed. Suzanne and her therapist problem solved how she could remember her new balanced thought in the other situations when she starts thinking, No one will want to be my friend. Suzanne’s therapist also encouraged her to notice if she had any unrealistic images in these situations. Sometimes, completing a thought record influences how your client wants to behave. After Suzanne developed a balanced thought, she turned toward her therapist and said, “I have been really silly about the barbecue. I would like to go. It would be good to meet the other teachers, and there is no reason to be so anxious.” Let’s see how Suzanne’s therapist could help her use her balanced thought. Therapist:When you think about it, you would like to go to the barbecue. Suzanne:I think it would be a good thing to do. I want to make friends at my new school, and it’s just silly to avoid social events because of my anxiety. Therapist:After we did the thought record, you came up with a really good balanced thought; do you remember what it was? Suzanne:Yes, it was, Hang in there, you will make friends again. Therapist:That’s right. I am wondering if you could remember your balanced thought when you think of going to the barbecue, if that would help with your anxiety. Suzanne:I think it would. Therapist:Sounds like a great plan.

CHECKLIST OF COMMON PROBLEMS WITH THOUGHT RECORDS Thought records are generally an effective intervention; however, some are more helpful than others. Below is a checklist you can use to check that a thought record is well done. You can find a copy of Checklist of Common Problems with Thought Records at http://www.newharbinger.com/38501. G* Is the situation a factual description of what occurred? G* Did my client identify and rate his or her feelings? G* Did my client identify his physical reactions? G* Is the behavior a factual description of what my client did? G* Is the thought my client wants to focus on a hot thought? G* Is the thought about self, others, or the future? G* Is the thought related to his or her negative feelings? G* Does the evidence against address the hot thought? G* Does the balanced thought address the hot thought? It is important that the evidence you gather challenge the hot thought you are working on. For example, a colleague had passed Raoul in the hall and had not said hi. Raoul thought, My colleague is avoiding me. His evidence against his thought was, My bowling buddies are happy to see me. This evi- dence will help Raoul feel better, but it is not related to the thought, My colleague is avoiding me. In this situation you need to keep exploring Raoul’s thoughts using Questions to Identify Evidence Against Negative Thoughts to find evidence related to the hot thought you are working on. It is equally important that the balanced thought directly address the hot thought. For example, if the original thought was about self, the balanced thought needs to be about self; if the original thought was about others, the balanced thought needs to be about others. When Raoul was assigned to work with junior colleagues, his original thought was My boss doesn’t respect me. After examining the evi- dence for and against, his initial balanced thought was I work very hard and do a good job. This is a generally helpful thought that will increase Raoul’s positive mood. If I were his therapist, I would be delighted that he was able to have such a positive thought about himself. However, the hot thought was about others (his boss), and the balanced thought needs to also be about others. A better balanced thought would be, Even though I was asked to work with junior colleagues, this does not mean my boss does not respect me. There is a lot of evidence that my boss still respects me and my work. It is helpful to keep this list in mind when examining your clients’ thought records. Take a moment after your session is over and on your own review your client’s thought record, using the checklist. After you have used it a few times, it will become second nature.

Exercise 8.5: Common Problems with Thought Records Practice using the checklist for identifying common problems in thought records.

Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to a Clinical Example Complete the following exercises.

Exercise 8.1: Suzanne Is Upset with Her Husband Exercise 8.2: A Therapist Is Having a Bad Day Exercise 8.3: Suzanne Is Asked to Be a Maid of Honor Exercise 8.4: Suzanne Reviews Her Balanced Thought Exercise 8.5: Common Problems with Thought Records Apply What You Learned to Your Own Life I think you only become a committed CBT therapist when you experience how helpful it can be to identify your own negative thoughts, step back and examine the evidence, and then develop a balanced thought. Homework Assignment #1 What Is the Evidence? This coming week, when you have a strong emotional reaction, try to identify the situation, identify and rate your feelings, and then identify your thoughts. Choose one thought to examine using Questions to Identify Evidence Against My Negative Thoughts. Record your answers on the following worksheet.

Examine the Reality of Your Thoughts Thought I want to examine: Evidence for My Thought Evidence Against My Thought Conclusion or thoughts that consider all the evidence: Homework Assignment #2 How Probable Is My Prediction? This coming week when you are anxious, notice your negative predictions. Rate the probability that each will occur, look at the evidence, and then rerate the probability. Try to use the How Probable Are My Predictions worksheet.

Homework Assignment #3 Is There Another Interpretation? This coming week when you are upset by what someone did to you or by a situation, ask yourself if there is a more benign interpretation. Ask yourself if you are considering all of the facts of the situation. Are you blaming yourself for something you have no control over? Try to use the Other Ways of Understanding the Situation worksheet. Apply What You Learned to Your Therapy Practice It is time to start asking your clients to examine the evidence for their thoughts. Try to help a client identify her trigger situation and then identify and rate her feelings and thoughts. Once you have iden- tified a central thought, introduce the idea of looking for evidence and use the Questions to Identify Evidence Against My Negative Thoughts. Make sure that the evidence is concrete and addresses the hot thought. Use the Examine the Reality of Your Thoughts worksheet to record your client’s responses.

Let’s Review Answer the questions under each agenda item. Agenda Item #1: What are thought records? • What are the essential steps in a thought record? Agenda Item #2: Explain looking for evidence. • How could you introduce looking for evidence to your clients? Agenda Item #3: Find evidence that supports negative thoughts. • Why is it important to look for facts that support negative thoughts? Agenda Item #4: Find evidence against negative thoughts. • What are three questions that will help gather information against a client’s negative thoughts? Agenda Item #5: Develop balanced thoughts. • How could you consolidate a balanced thought?

What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

CHAPTER 9 Problem Solving—Finding a Better Way My hope is that you’re becoming more aware of your own thoughts. Did you try looking for evidence for one of your hot thoughts? Did you try writing out the evidence for and against a client’s hot thought? What did you learn from the homework? If you did not try any of the homework from the last chapter, take a moment to think of a difficult situation from last week. Identify your hot thought, and now look for the evidence. Set the Agenda In this chapter I am going to cover problem solving. We’ll also see how a problem-solving approach can help Raoul and Suzanne address the various issues they bring up in therapy. Agenda Item #1: What is problem solving? Agenda Item #2: Develop a positive problem orientation. Agenda Item #3: Identify your client’s problems. Agenda Item #4: Brainstorm solutions. Agenda Item #5: Choose a solution. Agenda Item #6: Develop coping thoughts. Work the Agenda One of the strengths of CBT is the universality of the approaches. All people encounter problems, and everyone can benefit from a step-by-step approach to solving them. Agenda Item #1: What Is Problem Solving? Problem-solving therapy was originally developed by D’Zurilla and Goldfried (1971), and although it has been revised over the years (D’Zurilla & Nezu, 2006), the core process and principles have remained essentially the same.

OVERVIEW OF THE PROBLEM-SOLVING PROCESS Problem solving involves both an attitude that problems can be solved or at least improved, and a process based on a specific set of skills. The process of problem solving has four distinct steps. For many clients, you will want to go through the whole problem-solving process step by step; however, for some clients, you may use only parts of the process. Below are the four steps.

1. Identify the problem and set realistic goals.
2. Generate new solutions. This is often called brainstorming.
3. Evaluate the different solutions and decide which one to try.
4. Try one of the solutions: evaluate the consequences and decide whether the problem is solved or whether you need to continue to problem solve. You can find the Problem-Solving Worksheet at http://www.newharbinger.com/38501. The work- sheet summarizes the steps and includes helpful questions for each section. You can use the worksheet as a guide for therapy as well as a handout to give your clients.

THE THEORY BEHIND PROBLEM SOLVING The theory underlying problem solving is that clients’ emotional distress is due to poor problem- solving skills which lead to dysfunctional ways of coping. Poor problem solving leads to more problems, which in turn are poorly solved. Clients quickly find themselves dealing with multiple problems and it becomes a vicious negative cycle. Problem solving stops the vicious cycle and helps clients find better ways to cope (D’Zurilla & Nezu, 2010). Problem-Solving Theory Good Problem Solving = Better Coping = Improved Life and Better Mood When you help your client find solutions to his problems, you are also saying, “You matter, I care about your welfare, and together we can figure out how to address your problems.” These are very pow- erful messages. For many clients the whole problem-solving process feels new and empowering. IS PROBLEM SOLVING EFFECTIVE? Let’s look at the research. Good problem-solving skills are consistently associated with better overall emotional adjustment, and poor problem-solving skills are associated with more distress and poorer adjustment (D’Zurilla & Nezu, 2010). For example, poor problem-solving skills are related to drug and alcohol addiction, criminal behavior, and psychological distress. The good news is that indi- viduals with good problem-solving skills are less likely to become depressed after a stressful event (Nezu, Nezu, Saraydarian, Kalmar, & Ronan, 1986). Over the past three decades, a large number of studies have demonstrated that problem solving is an effective treatment for depression (Bell & D’Zurilla, 2009), anxiety, and a variety of other mental health problems (D’Zurilla & Nezu, 2010; Malouff, Thorsteinsson, & Schutte, 2007). Problem solving has also helped people learn to cope with serious physical illnesses such as diabetes (Glasgow, Toobert, Barrera, & Stryker, 2004) and cancer (Nezu, Nezu, Felgoise, McClure, & Houts, 2003). Interventions that focus on developing a positive problem-solving attitude as well as teaching problem-solving skills seem to be the most effective (Bell & D’Zurilla, 2009). Research Summary Positive Problem-Solving Orientation + Problem-Solving Skills = Effective Treatment Agenda Item #2: Develop a Positive Problem Orientation A positive problem orientation is a core element of good problem solving. The table below com- pares the beliefs of individuals with positive and negative problem orientations (Nezu, Nezu, & D’Zurilla, 2013). Char acteristics of a Positive and Negative Problem Orientation Positive Problem OrientationNegative Problem Orientation • Problems are a challenge. It is possible to improve most situations.• Problems are unsolvable and frightening. It is useless to try to improve most situations. • One has the ability to successfully solve problems or make the situation better.• One does not have the ability to successfully solve problems or make the situation better. • Successful problem solving takes time, effort, and persistence. Initial failure is part of finding a solution.• Initial failure means the problem cannot be solved.

Individuals with a positive problem orientation see difficulties as normal life challenges and try to find solutions to their problems. Individuals with a negative problem orientation tend to either avoid their problems or approach them with an impulsive or careless problem-solving style. Clearly, a positive orientation is better, but how do you help your clients develop one? Modeling optimism and having faith in your client’s ability to problem solve is one of the most effective ways to help your client develop a positive problem orientation. Here are some phrases I use to encourage a positive problem-solving orientation: •Let’s see if we can find a way to solve your problems. •I wonder if there is something you can do that will help this situation. •I know it feels hopeless, but I wonder if we could find a way to make things even a little better for you. •I’m not sure we’ve looked at all of the possible solutions. Would you be willing to try to problem solve? Such relatively simple interventions communicate that you believe in your client’s ability to find a better solution, and that together you will be able to improve his life. You will also find that as your client uses the problem-solving process successfully, his problem orientation will start to automatically become more positive. Let’s see how Raoul’s therapist helps him develop a more positive problem orientation. Raoul was telling his therapist about his poor relationship with his boss, who gave him a poor work evaluation. Raoul:I feel so depressed when I think of going to work. I used to like going to work, but I feel so awkward and anxious with my boss since I received the poor work evaluation. I think we have a terrible relationship. It just seems hopeless to do anything about it. Therapist:I hear you’re thinking that it is hopeless to try and change your relationship with your boss, is that right? His therapist has identified a negative problem orientation: It is hopeless to try and change the relationship with his boss. Raoul:Definitely, what can I do? Therapist:I am wondering if you would be willing to put aside the thought that it is hopeless to do anything and see if we could find some better ways to cope with the situation, to help you feel better. Raoul:What do you mean? Therapist:Well, when you tell yourself that it’s hopeless, how does that affect your behavior? Raoul:I just avoid him, and keep doing the same old thing. Therapist:And does avoiding help? Raoul:No, in fact, it is getting worse. I just feel more and more awkward. Therapist:I am wondering if you would be willing to work with me to see if we could problem solve some different ways of coping with your boss that might improve the situation. Raoul:I would be willing, but I don’t think we will find any. Therapist:You may be right, but I want to see if we put our heads together if we could find a better way for you to cope. Notice how the therapist acknowledges that Raoul might be right but asks him to try problem solving. The therapist is modeling a calm, thoughtful approach to the problem. Agenda Item #3: Identify Your Client’s Problems Before your client can solve his problems, he needs to identify them. Defining the problem and setting realistic goals are the first components of a problem-solving skill set. Problems can be a one-time event, such as a divorce or a serious health problem. They can be situations that happen fairly regularly, such as disciplining a child who refuses to do chores, fighting over finances with a partner, or dealing with constant daily difficulties such as a long commute to work, chronic pain, or loneliness. Sometimes it is very clear that a client needs help problem solving. A client may start therapy saying, “I don’t know what to do about X,” or one of your client’s thoughts may be, What else can I do? or I don’t know how to handle this. In other cases, it can be more difficult to identify your client’s need to problem solve. Clients with a negative problem orientation often avoid their problems but feel anxious. It is helpful to teach a client who tends to avoid that if he is anxious, he should ask himself whether there is a problem he is not looking at.

PROBLEM DEFINITION The more specific and concrete the problem, the easier it will be to think of helpful solutions. For example, “I don’t communicate well with my partner” is a very vague problem and hard to start solving, whereas, “My partner and I don’t agree on how to discipline our children” is much clearer and an easier problem to address. Raoul had started his therapy session by saying in a low voice, “I feel so depressed when I think of going to work. I used to like work, but I feel so awkward and anxious with my boss since I received the poor work evaluation. I think we have a terrible relationship. It just seems hopeless to do anything about it.” At this point, Raoul’s problem is not very specific. His therapist uses the questions under “Questions to Help Define the Problem” in the Problem-Solving Worksheet to help Raoul become more specific and concrete. Sometimes you may want to use all of the questions, and sometimes only a few may be relevant. You can find Raoul’s answers in the table below.

R aoul Defines His Problem Questions to Help Define the ProblemRaoul’s Answers What happened or did not happen that bothers your client?1. Raoul’s boss handed him his poor work evaluation, but his boss has never talked to him about it. 2. Tension between Raoul and his boss 3. Presently, almost no casual contact with his boss 4. Boss never asks for his opinion, never chat together, boss often ignores him Who is involved? Where does the problem happen? When does the problem happen?The problem involves Raoul and his boss; it happens at work during the day. Why is this problem difficult for your client?1. Raoul feels ashamed about the poor work evaluation. 2. Raoul feels judged, hates work, has trouble concentrating, and thinks everyone knows about his problems with his boss. 3. Raoul does not know what to do about the poor evaluation. What does your client currently do to handle the problem? Is your client avoiding or acting in an impulsive manner?Raoul tries to avoid interacting with his boss. In the past, Raoul used to drop by his boss’s office in the morning for a five-minute chat; he used to ask his boss for his opinion on a project. Now Raoul goes straight to his desk. What does your client hope will happen as a consequence of his/her behavior?Raoul hopes “things will go back to normal.”

Exercise 9.1: Nasir Has a Busy Clinic Practice defining your clients’ problems.

SETTING GOALS Both Raoul and his therapist now have a much better sense of his problems. The next step is setting goals. Goals need to be specific and concrete, realistic, and possible to accomplish. You also want to articulate both short-term and long-term goals. For example, a short-term goal might be becom- ing more assertive with your boss and asking for an extra two weeks of holiday time during the Christmas season, but that might conflict with the long-term goal of being seen as a team player and getting a promotion. Often after your client answers the questions to help define the problem on the Problem-Solving Worksheet, his goals are clear. If your client’s goals are not clear, the following questions may be helpful. •How would your client like the situation to change or be different? •How would your client like other people in the situation to change or be different? •How would your client like to change or be different? When Raoul’s therapist asked how he would like the situation to change, Raoul responded that he wanted “everything to go back to normal.” This is not a very specific goal. His therapist then asked how he would like his boss to change and if there were ways that he would like to change. Raoul explained that generally he wanted to have a good relationship with his boss again. He wanted his boss to joke with him and talk to him easily. He also wanted to be comfortable asking his boss for his opinion about projects. As Raoul articulated his goals, he realized that he also wanted to understand his negative work evaluation better. When a client slows down and examines his problems and goals, he often real- izes aspects of the problem that are important to him that he had not focused on before. You can also identify goals by paying attention to what your client hopes will happen as a conse- quence of his current behavior. As ineffective as their behavior may be, most people act in a way that they hope will make their situation better. In Raoul’s case his therapist could have asked, “What are you hoping will happen when you avoid your boss?” Once you have identified your client’s goals and explored what he hopes will happen as a conse- quence of his behavior, it is important to examine the actual consequences of his behavior. Unless your client understands that his behavior is ineffective, he will not be motivated to problem solve. In Raoul’s case, he hoped that by avoiding his boss everything would “go back to normal.” When his therapist asked Raoul what were the consequences of avoiding, Raoul quietly acknowledged that it was not helping, and was in fact making things worse.

EXPLAIN PROBLEM SOLVING TO YOUR CLIENT Once you have established that what your client is currently doing is not working, it is a good time to explain problem solving. You want to give your client an overview of the process and instill hope that problem solving can help. Here is how I explain problem solving (you can find a copy of this script at http://www.newharbinger.com/38501): We have been talking about your problem and how hopeless you feel. Sometimes people get into negative cycles and don’t see alternative possibilities. I am wondering if you would be willing to see if we could find some other ways of coping with your problem. I want to explain a process called problem solving. We start with identifying a specific problem and then we brainstorm to try to think of different possible solutions. We are looking for as many solutions as we can find, without judging them. Once we have thought of some alternative ways of han- dling your problem, I want to spend some time evaluating the different solutions to see if there is one that makes more sense. Would you be willing to try? Your Turn!

Practice in Your Imagination: Explain Problem Solving I would like you to imagine explaining problem solving to a client. Before you start, rate from 1 to 10 how comfortable you feel explaining problem solving. At the end of the exercise, rate your level of comfort again to see if it changed. Now, let’s try this exercise. Choose a specific client who you think would benefit from a problem-solving approach. Imagine that your client has identified a problem and you want to explain problem solving. Try to get a picture of him or her in your mind. Imagine yourself in your office with your client. See your office; notice the sounds and smells in the room. Read over how I suggest explaining problem solving while imagining yourself saying the words. You can also use your own phrases. Really hear and feel yourself explaining problem solving. Imagine explaining problem solving two more times with the same client. Each time, imagine that your client responds positively. Video 9.1: Define the Problem and Set Goals Agenda Item #4: Brainstorm Solutions The next phase involves helping your client find new solutions for his problem. Finding new solu- tions to problems is difficult—if clients knew of better ways to manage their lives, they would already be doing things differently. Problem solving involves asking your client to step outside of his usual mind-set. You want to engage in a process called brainstorming, which means coming up with as many varied solutions as you can. When brainstorming, it is helpful to follow these three principles: •Quantity: Try to generate as many solutions as possible. •Variety: The greater the variety of solutions, the more chances that you will have a good idea. •Deferred Judgment: Write down all solutions that come to mind, no matter how silly, irrele- vant, or outrageous. Include a few far-fetched and seemingly impossible solutions; they can help your client think outside the box. Sometimes combining a far-fetched solution with another solution can lead to a good solution.

FINDING NEW SOLUTIONS It can be very hard not to jump in and solve your client’s problems. Ideally, brainstorming new solu- tions is a collaboration between therapist and client. The more your client can discover his own solu- tions, the more empowering the process will be. I start with asking my client for his suggestions. Often, all I need to say is, “I wonder if there are some other ways of handling this situation.” If I think of a specific strategy that my client did not mention, I usually say, “I have an idea that might help. Let’s see if you like it.” If my client likes the suggestion, I encourage him to apply the strategy to his specific problem. For many of your clients, the process of stopping and consciously looking at their problems will naturally lead to thinking of new, effective solutions. However, some clients find it hard to think of alternative ways of handling their problems. Try the “Questions to Help Find New Solutions” list on the Problem-Solving Worksheet. Below are the questions. •What are some different ways you could handle your problem? •What would you suggest to someone who had this problem? •What do you think a friend or someone who cared for you would suggest if he or she knew that you had this problem? •How have you handled similar situations in the past? •How do you overcome obstacles in other areas of your life? •Is there any positive information that you are ignoring that could be helpful in solving this problem? •Is there an aspect of the problem that cannot be changed and that you have to accept? (The challenge is to accept what cannot be changed and find coping strategies for what can be changed.) Let’s see how Raoul’s therapist helps him brainstorm. Initially Raoul has some difficulty finding alternative solutions. However, his therapist maintains an optimistic attitude and sticks to problem solving. Therapist: Right now you are avoiding your boss, and you were saying that it doesn’t seem to be improving the situation. Let’s see if we can think of some other things you could do. I want us to write down everything we think of. In this early stage, we’re looking for quan- tity and variety of solutions. Every idea is a good idea. Later we’ll figure out which one we want to use. Notice how his therapist explains the principles of quantity, variety, and deferred judgment. Raoul:Anything I can think of just seems impossible. Therapist:You may be right, but let’s see if we can think of what you could do to improve your rela- tionship with your boss. Notice that Raoul’s therapist acknowledges that he might be right but maintains an optimistic attitude. Raoul:I think that the best solution may be to get out of the department and ask for a transfer. Therapist:So one option is to ask for a transfer. Any other options you can think of? Raoul:I could just keep doing what I am doing; it is not going so badly. I’ve also thought of asking a friend who works in another department if he had any ideas. Therapist:We have a couple of solutions; let’s write them down. First, ask for a transfer; second, keep doing what you are doing; and third, ask a friend for advice. I’m going to ask you some questions to see if they help you come up with any other solutions. I’m wondering…if a colleague had this problem, what would you suggest to him? Notice how Raoul’s therapist starts with a summary statement to indicate she heard Raoul, and then follows up with a question from the “Questions to Help Find New Solutions” list. Raoul:That’s easy, but I don’t think it would work for me. Therapist:You might be right, but let’s look at what you would suggest in any case. Raoul:Well, the first thing I would suggest is that my colleague stop avoiding his boss and behave in a friendly manner.

Your Turn! Help Raoul Find New Solutions Raoul’s suggestion that he stop avoiding his boss and behave in a friendly manner is a good overall strategy, but it is not very concrete. Look at the three possible responses below and pick the one that will help Raoul be more specific and concrete.

1. Great suggestion. I wonder if you started generally participating more in meetings whether that would be helpful.
2. When you think of being friendlier, what are your thoughts?
3. If your colleague wanted to stop avoiding his boss and be friendlier, what are some things he could do? Response #3 is the most likely to help Raoul develop specific and concrete solutions. In response #1, the therapist is solving the problem for Raoul. Response #2 would be a good question if we had a specific, concrete solution, but it is too soon in the problem-solving process. Therapist: If your colleague wanted to generally stop avoiding his boss and be friendlier, what are some things he could do? Raoul: (laughing slightly) Well, I guess I would suggest saying hello to his boss before meetings, speaking up at meetings, and probably letting his boss know how some of his projects are going. Therapist: Could we put these down as possible solutions for you? (Raoul nods and smiles.) You’ve come up with quite a long list. Look at the three possible responses below and pick the one that will help Raoul continue to find alternative solutions.
4. I’m wondering whether we could find more solutions. What would someone who knew you well suggest as a solution?
5. What are the obstacles to starting to speak up at meetings?
6. Let’s make a plan for when you could start speaking up more at meetings. Response #1 is the most likely to help Raoul continue to find solutions. Responses #2 and #3 would be good responses if Raoul had already picked speaking up at meetings as a solution; however, he has not yet finished listing all of his possible solutions. Therapist: I’m wondering whether we could find more solutions. What would someone who knew you well suggest as a solution? Raoul: Honestly? I think my wife would suggest that I wait until the next evaluation, which is in six months, before I do anything. My daughter would suggest that I make an appointment with my boss to talk about the poor work evaluation. But that’s totally impossible for me to do. I would just be too anxious. Often when clients think of an assertive response, they immediately back away. It just feels too hard. That’s what happened when Raoul thought of talking to his boss about his poor work evaluation. It is worthwhile spending some time exploring what exactly your client could say. Often when clients have a concrete scenario, the assertive response feels more doable. Here is Raoul’s list of possible solutions: •Keep doing what I am doing •Ask for a transfer to another department •Ask a friend for advice • Talk to my boss before meetings, participate in meetings, and tell my boss how my projects are going •Wait for next evaluation •Arrange a meeting with my boss to discuss my evaluation

Agenda Item #5: Choose a Solution For many clients, calmly evaluating different solutions is a new and empowering experience. You want your client to evaluate the likelihood that the different solutions will either resolve or improve the problem. I teach my clients to ask themselves the following questions from the Problem-Solving Worksheet so that they can make an informed choice. •What are the short-term and long-term benefits of each solution? •What are the short-term and long-term drawbacks of each solution? If my client finds the concept of benefits and drawbacks too abstract, I ask, “If you use this solution, what are some of the good things that might happen and what are some of the bad things that might happen?” We make a chart and write down the answers; clients can then take the chart home and spend more time thinking about the decision. Below are some of the questions that I ask to encourage clients to think about the short-term and long-term consequences of each solution. •How will this solution affect me, other people, and the situation? •How will I feel after implementing this solution? •Is this solution consistent with my values? Will implementing this solution be important to me in terms of acting on my values? •Does the solution generally feel doable? •Does the solution feel doable in terms of time and effort required? Raoul has a large number of solutions; it’s hard to evaluate all of them. His therapist asked him to pick three solutions to evaluate. Below is how Raoul completed his evaluation. You can download the worksheet Benefits and Drawbacks of My Solutions at http://www.newharbinger.com/38501.

Benefits and Dr awbacks of My Solutions SolutionShort-Term BenefitShort-Term DrawbackLong-Term BenefitLong-Term Drawback Ask for a transferWill get me out of the officeI have to tell my boss, and until I leave it will be worseIt might lead to a better situationI lose some of my seniority if I change departments A change might be good Applying for a transfer is difficult, hard to get a good reference, can take a long time Talk more with boss; discuss projects, etc. Relationship might improve Fairly easy to do Meet with boss to Might resolve discuss poor work the issue evaluation Next job might be worse Does not address the poor work evaluationRelationship might improveStill do not understand poor work evaluation Might make it worse; could find out boss very critical of my workIdeally will help with relationship and work performanceMight make it impossible to stay in job High anxiety

Once Raoul and his therapist had evaluated the three solutions, his therapist asked him to sum- marize the benefits and drawbacks of each solution. Asking for a transfer: It might make me feel good initially, but it will be a lot of work and may not lead to a better solution. Plus, I lose my seniority. Talk more with the boss: It might help with the relationship. There is no real risk. Only problem is that it does not address the poor work evaluation. Meet with boss to discuss poor work evaluation: The most high risk and the hardest. Might be the best solution, but might make it hard to stay. When Raoul evaluated the different solutions, it was clear that asking for a transfer was not a good idea. He decided he wanted to start with dropping by his boss’s office to chat and also try talking to his boss about different projects he was working on. He wanted to see what happened when he started talking more to his boss before deciding whether he wanted to discuss his poor work evalua- tion with him.

Video 9.2: Brainstorm and Choose a Solution MAKE A PLAN Next, your client needs to develop a plan for implementing the solution he chose. Make sure that the plan is specific and concrete. It is helpful to write out what your client will actually do. Next, specify a first step to the plan and a time and date when your client will try the first step to the solution. You also want to check if there are any obstacles to the plan, and try to address them. Raoul decided he wanted to try dropping by his boss’s office the next day. He had meetings on Monday, Wednesday, and Friday, and he would make a point of getting there early to chat with his boss before the meeting. PREPARE FOR THE WORST Sometimes your client wants to try a solution where there is a realistic possibility of a negative outcome. For example, my client Julia decided to disclose to her partner that she had been sexually abused as a child, even though she knew there was a realistic possibility her partner would blame her for the abuse. Other clients have raised various difficult issues with their bosses, partners, and friends, hoping to improve the relationship, but instead the discussion resulted in increased tension. You want to be sure your client understands the realistic risk of a negative reaction and is prepared for that should it occur.

USE IMAGERY TO PRACTICE Rehearsing using imagery is an opportunity to practice the new solution and to check if there are any obstacles. I ask my client to imagine doing the new solution in his mind. I encourage my client to close his eyes, and I describe him carrying out the new solution. I ask him to see and feel himself in the situation, and if the solution involves talking, to hear himself and the other people. After he has imag- ined doing the solution once, I ask him to open his eyes and I ask if there were any obstacles, or if he would like to change anything. We address the obstacles. I then ask him to imagine doing the new solution two more times and incorporate any changes he wanted. I ask my client to rate how doable the solution is before and after practicing in his mind. When Raoul imagined dropping by his boss’s office to chat, he realized it would be easier if he had a specific question about a file that he wanted to ask. His therapist incorporated that into the next two imaginal rehearsals.

YOUR CLIENT TRIES HIS NEW SOLUTION Think of your client’s new solution as an experiment that will provide additional data, rather than the one right way to proceed. Often clients prematurely dismiss a solution because the outcome wasn’t perfect. Results need to be evaluated on a continuum rather than a “perfect or else failure” yardstick. It is helpful to decide ahead of time how your client will evaluate whether his new solution is success- ful. If the solution did not work out, or if aspects of the problem remain, you need to continue to problem solve. It may also be helpful to reevaluate what aspects of the problem can and cannot be changed. The reality is that many of life’s difficulties take time and effort to address, and often there is no perfect solution. It is also important to teach your client to give himself a pat on the back for trying his new solution. Even if the new solution did not work out, trying indicates a willingness to attempt to solve the problem rather than staying stuck. I model a positive problem orientation. Depending on what happened, some of the statements I use are, “That went well,” “Trying is an important first step,” and “Even though it wasn’t perfect, it is a step in the right direction.”

SUZANNE PROBLEM SOLVES If you remember, in the last chapter we helped Suzanne manage her anxiety about going to the barbecue by looking at her hot thought and developing a more balanced thought. Her worry had decreased sufficiently that she decided to go to the barbecue. However, she still worried that she would not know what to say and that the other teachers would not talk to her. Her therapist thought it would be helpful to problem solve what Suzanne could do to make the barbecue easier for her. They came up with a number of strategies, including offering to help with any food preparation and the cooking; thinking of some questions she could ask that might start a conver- sation, such as how long the other teachers had been at the school and whether they had children; approaching the other teachers, introducing herself, and standing there as part of the group; focusing her attention on what the other teachers were saying; and spending some time playing with the princi- pal’s young children. When Suzanne evaluated the different solutions, she picked offering to help with the cooking, thinking of some questions she could ask to start a conversation, and then approaching one of the teachers at the party and starting to talk. She felt a lot better once she had a plan. Agenda Item #6: Develop Coping Thoughts Once your client has decided how he wants to handle the problem, and has a plan, it can be useful to develop coping thoughts that help him focus on the task and manage any negative feelings. Highly critical thoughts about ourselves or others not only make us feel bad, but also distract us from the present moment, making it harder to handle a stressful situation. In a coping thought model, you and your client actively develop thoughts that help your client execute his plan and manage his negative emotions. Coping thoughts tend to be short and provide directions as to what to do in a specific situation. Here is the general process that I use to develop coping thoughts:

1. Identify the behavior your client wants to accomplish and his plan.
2. Check if your client’s current thoughts are interfering with or sabotaging his plan.
3. Develop coping thoughts.
4. Use imagery to practice your client’s coping thoughts.

IDENTIFY THE BEHAVIOR YOUR CLIENT WANTS TO ACCOMPLISH In addition to being part of a problem-solving plan, coping thoughts can be used for any specific behavior your client wants to accomplish. For example, I have used coping thoughts to help my client Elyse stop procrastinating, sit down, and complete her tax return; I have also used coping thoughts to help clients drink only one glass of wine a night, start an exercise program, use relaxation for pain control, and raise an awkward topic with a friend or family member. You can also use coping thoughts to help clients manage their feelings of anxiety or of being overwhelmed. You want to be sure the behavior is specific and doable. If Elyse does not know how to complete her tax return, all the coping statements in the world will not help her.

IDENTIFY CURRENT THOUGHTS THAT ARE INTERFERING WITH THE PLAN Sometimes when clients think of a solution to their problem, they are optimistic; however, often negative, sabotaging thoughts interfere with their ability to implement their plan. I usually ask my client what might interfere with his plan, and specifically whether there is anything he is likely to say to himself that would sabotage the plan. I want to make sure my client understands the impact of his thoughts on his ability to complete his plan. Let’s see if Suzanne has any thoughts that will sabotage her plans for how to handle the barbecue. Therapist:Suzanne, I am wondering, when you think of helping with the food at the barbecue, or starting to talk to one of the other teachers, what thoughts go through your mind? Suzanne:Helping with the food at the barbecue is easy, a really great idea. When I think of going up to the other teacher and starting a conversation, I get pretty anxious. Suzanne has identified a feeling, but we are looking for sabotaging thoughts. We know from our four-factor model that thoughts lead to feelings. Therapist:What are some of your thoughts that go with your anxious feeling? Suzanne:I guess I think that no one will find my questions interesting, and that it was probably a mistake to go to the party. Suzanne’s therapist wants her to see how these thoughts might sabotage her plan. Therapist:When you have these thoughts, how does it affect your plan to start talking to the other teachers? Suzanne:It makes it really hard and makes me not want to go or just stand there quietly, instead of trying to talk. I sometimes draw a diagram to help my client see how his thoughts are sabotaging his plan. Many clients find it helpful to visualize the process. This can be especially helpful if a client wants to accom- plish his plan but then doesn’t carry out the plan and doesn’t understand what got in the way. Figure 9.1 shows what Raoul’s therapist drew for Raoul to help him understand the impact of his thoughts on his procrastinating around writing a report.

Thoughts Situation Sits at desk to work on project This is so hard, I will not do a good job, no one respects me anymore. Thoughts FeelingsBehavior AnxiousDo other work, leave desk I will never finish the project, I am a failure. Figure 9.1. Raoul avoids a project.

Exercise 9.2: Suzanne Goes to the School Fair Practice using a diagram to explain the consequences of your client’s thoughts. Once you have identified your client’s negative sabotaging thoughts, you use a coping thought model to ask him to put aside these thoughts. Unfortunately, if you tell your client to stop a thought, it just bounces back stronger. However, your client can learn to ignore his interfering thoughts, especially if he has developed coping thoughts. You can’t think of coping thoughts and interfering thoughts at the same time.

HELP YOUR CLIENT DEVELOP COPING THOUGHTS The next step is to develop thoughts that help your client cope with the situation and manage his disruptive feelings. Below are questions to help your client develop coping thoughts. You can download a Questions to Develop Coping Thoughts handout at http://www.newharbinger.com/38501. •What could you say to yourself that would help you cope with this situation? •What advice could you give a friend in terms of helpful coping thoughts? •What would someone who knows you well suggest as helpful coping thoughts? •If you were in a more optimistic mood, what might you think? •When you have coped successfully in the past, either with a similar or a different type of situ- ation, what have you told yourself? Once you have a list of coping thoughts, write them down. Coping thoughts generally fall into three categories: placing the situation in a realistic perspective, focusing on the task at hand, and man- aging anxious or overwhelming feelings. Different types of thoughts will be helpful in different situa- tions. Let’s look at some examples of thoughts in each category. You can download a copy of Examples of Coping Thoughts at http://www.newharbinger.com/38501.

Examples of Coping Thoughts Place the Situation in a Realistic PerspectiveFocus on the TaskManage Anxiety • Try not to take this too seriously.• You have a plan.• Anxiety is not dangerous. • Do the first step of your plan.• It doesn’t matter if my heart is pounding. • Focus on the task.• I can take some deep breaths. • This is just one situation. • If this situation doesn’t work out, there will be others. • Don’t blow this up out of proportion. • It does not have to be perfect. • It will pass. • One step at a time• Anxiety is normal. • Even if I’m upset, I can do my plan.• Remember your rational thoughts. • You don’t have to listen to worry thoughts. Suzanne, together with her therapist, identified a number of thoughts she could use as coping thoughts to help her start talking to one of the other teachers. They included Stick to your plan, Just ask a question, There are only three other teachers, and Don’t listen to anxiety. Use imagery to practice. Once your client has developed coping thoughts, you take him through his plan again in his imagination, this time adding coping thoughts. After we have practiced once, I ask if there is anything he would like to change and if any of the coping thoughts were particularly helpful or not that helpful. I make any changes and then we practice two more times in his imagination. When Suzanne rehearsed her plan and coping thoughts in her imagination, she particularly liked the thoughts Just ask a question and Don’t listen to anxiety.

YOUR TURN! Help Raoul Develop Coping Thoughts Raoul decided that he wanted to call one of his colleagues whom he had been avoiding and suggest that they have lunch together. He was fairly anxious about calling, and rated his anxiety at a 6 out of 10. His thoughts were I haven’t had lunch with him in a long time; he will think it weird that I phone him. How could you help Raoul develop coping thoughts that would help him call his colleague? Look at the three possible responses below and pick the one that will help Raoul develop coping thoughts.

1. How could you contact your colleague to ask him out for lunch?
2. I think it is important that you tell yourself to stop thinking these thoughts; they are clearly stopping you from calling your colleague.
3. I am wondering if you could try to put these thoughts aside and see if we could come up with some thoughts that will help you call your colleague. Response #3 is the next step in developing coping thoughts. Response #1 will help Raoul develop a specific plan of what he will do, but it will not help develop coping thoughts. In response #2, the thera- pist is telling Raoul to try to stop his thoughts. This will backfire—when we try to stop thinking a thought, we just think about it more. Therapist: I am wondering if you could try to put these thoughts aside and see if we could come up with some thoughts that will help you call your colleague. Raoul: What do you mean? Look at the three possible responses below and pick the one that will help Raoul develop coping thoughts.
4. If a friend were anxious about inviting a colleague for lunch, what would you suggest that he tell himself?
5. Your problem is that you are not positive enough.
6. Just say to yourself—be positive! Response #1 is the best answer. It uses the question “What advice could you give a friend in terms of helpful coping thoughts?” and applies it to Raoul’s situation. In responses #2 and #3, the therapist is trying to use positive thinking. The problem is that positive thinking doesn’t work because it is too general and doesn’t address the specific behavior the client wants to do. Video 9.3: Develop Coping Thoughts Video 9.4: Use Imagery to Practice Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to a Clinical Example Complete the following exercises.

Exercise 9.1: Nasir Has a Busy Clinic Exercise 9.2: Suzanne Goes to the School Fair Apply What You Learned to Your Own Life For the following homework assignment, you can use the guided audio file to help you go through each step; I think it is more effective than reading the exercise.

Homework Assignment #1 Practice Using the Problem-Solving Steps Accompanying audio file: Solve Your Own Problems Think of a problem that is currently troubling you. Don’t choose something huge, as it may be too chal- lenging for an initial attempt at problem solving. Choose a problem that is sufficiently large that you care about it, but sufficiently small that there is a chance you could solve it. Go through the four problem-solving steps in order using the Problem-Solving Worksheet as a guide. Problem-Solving Steps:

1. Identify the problem and set realistic goals. Remember to ask yourself what you hope will be the consequences of your current behavior.
2. Generate new solutions. Try to think of at least three. Don’t evaluate them until you have completed your list.
3. Evaluate the different solutions and decide which one to try. Remember to look at both the short-term and long-term benefits and drawbacks.
4. Try one of the solutions: evaluate the consequences and decide whether the problem is solved or if you need to continue to problem solve. Apply What You Learned to Your Therapy Practice This coming week I would like you to try to apply the problem-solving process with a client. Homework Assignment #2 Help a Client Problem Solve Start by asking your client to identify the problem that is causing his or her distress. See if you can engage your client in a problem-solving process. Remember, all you have to do is the following: identify the problem and how your client is currently coping, identify his goal, brainstorm alternative solutions, choose a solution to try, and make a specific and concrete plan. You may also want to try asking your client to rehearse his new plan in his imagination. Fill in the form below so you can monitor how you are doing.Client Identify the Problem and Set Goals Brainstorm New Solutions Evaluate and Choose a Solution Make a Plan

Let’s Review Answer the questions under the agenda items. Agenda Item #1: What is problem solving? • How can you explain problem solving in one or two sentences? Agenda Item #2: Develop a positive problem orientation. • What is the difference between a positive problem orientation and a negative problem orien­- ta­tion? Agenda Item #3: Identify your client’s problems. • How can your clients use their anxiety to identify a problem? Agenda Item #4: Brainstorm solutions. • What are the three principles of brainstorming solutions? Agenda Item #5: Choose a solution. • What are two criteria for evaluating a solution? Agenda Item #6: Develop coping thoughts. • What are two categories of coping thoughts? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Chose a specific client.)

CHAPTER 10 Behavioral Activation—Action Plans for Depression In the last chapter we covered problem solving. Did you notice your clients’ problem orientation? Did you have a chance to try problem solving in your own life or with any clients? What was it like to con- sciously evaluate different solutions? Was it hard not to jump in and solve your clients’ problems? Set the Agenda In this chapter you will learn how to help your clients who have depression by increasing their activity level to improve their mood. The technical term for this intervention is behavioral activation. Agenda Item #1: How does behavioral activation work? Agenda Item #2: Help your clients understand their depression. Agenda Item #3: Monitor your clients’ daily activities. Agenda Item #4: Plan activities that increase positive moods. Agenda Item #5: Graded task assignments. Agenda Item #6: Increase well-being. Work the Agenda Behavioral activation is primarily a treatment for depression. It is based on the premise that when your clients change their behaviors, and increase activities that promote pleasure and a sense of compe- tence, their mood will improve.

Agenda Item #1: How Does Behavioral Activation Work? You can think of depression as a cycle that is caused and maintained by avoidance and a lack of positive reinforcement. Depression starts with changes in a client’s life that lead to a decrease in events that she enjoys and an increase in unpleasant events. As a result of these changes, your client’s overall mood declines and activities she used to enjoy are less pleasurable. Clients start avoiding activities such as seeing friends and family and pursuing hobbies, exercise, or leisure activities. The more clients avoid activities that might lift their mood, the less contact they have with positive reinforcements. The less contact with positive reinforcements, the more down they feel and the less they feel like doing anything (Martell, Dimidjian, & Herman-Dunn, 2010). When clients become less active, their overall routine is disrupted, which may lead to sleep prob- lems, poor appetite, and generally feeling out of sync with their environment, all of which exacerbate depression (Dimidjian, Barrera, Martell, Muñoz, & Lewinsohn, 2011). The more your clients are caught in this cycle of depression, the more they disengage from their normal life and the more likely they are to develop secondary problems. For example, the student who is too depressed to attend baseball prac- tice may eventually be kicked off the team. Figure 10.1 shows how the cycle of depression works. Trigger: Difficult Situation or Life Changes Decrease in positive events; Increase in negative events Secondary problems; Disrupted routines Avoid activities Low mood and fatigue Thoughts: I don’t enjoy anything; I am tired and need to rest. Figure 10.1. Cycle of depression.

BREAKING THE CYCLE OF INACTIVITY AND DEPRESSION Behavioral activation interrupts the cycle of depression by directly targeting avoidance and encour- aging clients to engage in mood-boosting activities. Clients identify activities that (1) are enjoyable, (2) increase their confidence or sense of mastery, or (3) are functional in that they decrease the negative consequences of avoidance. The therapist works with clients to schedule these activities into their week in a step-by-step manner and uses the problem-solving process to address any obstacles (Martell et al., 2010). As clients start to engage in pleasurable activities, their mood improves. As clients feel better, they have more energy, they stop wanting to avoid activities, and they engage in healthy routines. In short, a mood-boosting cycle starts. Behavioral Activation Theory Pleasurable Activities + Problem Solving = Behavioral Antidepressant OVERVIEW OF BEHAVIORAL ACTIVATION The formal goal of behavioral activation is for your clients to return to their pre-depression level of functioning. I prefer to tell my clients that our goal is to help them have a life they enjoy. The focus is to actively encourage clients to engage in activities even though they “feel” like avoiding or resting. It seems to me that folk wisdom often captures the essence of behavioral activation. My Aunt Tanya, who is eighty-eight, always told me, “No matter what, get up every morning and put on your makeup, and before you go to bed at night, have a sip of vodka.” In other words, according to Aunt Tanya, no matter how you are feeling, get up and face the world, and before the day ends, do something nice for yourself. Generally, the behavioral activation process unfolds in the following order.

1. Understand your client’s depression in relation to changes in his or her daily activities.
2. Monitor your client’s daily activities.
3. Plan activities that increase positive mood.
4. Monitor your client’s mood before and after activities.
5. Problem solve obstacles.
6. Establish healthy routines and prevent setbacks. IS BEHAVIORAL ACTIVATION EFFECTIVE? Even though I have practiced behavioral activation for many years, when a client with severe depression comes into my office, I often find myself thinking that behavioral activation will not be enough. How can adding pleasurable activities be sufficient to help this very depressed client? But rather than believing my automatic thoughts…I look at the evidence!

Over the past three decades, numerous studies, including a number of meta-analyses, have consis- tently demonstrated that behavioral activation is an effective treatment for mild, moderate, and severe depression (Dimidjian et al., 2011; Soucy-Chartier & Provencher, 2013). This is true for children, teens, and adults of all ages. Behavioral activation alone has been found to be as effective as treatments that include both behavioral and cognitive interventions, such as identifying and challenging negative thoughts (Dimidjian et al., 2006; Richards et al., 2016). There is some indication that if clients are severely depressed, therapy provided over a sixteen-week period that includes only behavioral activa- tion is more effective than therapy that includes behavioral and cognitive interventions. Behavioral activation is also an effective intervention for relapse prevention (Dobson et al., 2008). A recent study found that clients with complicated bereavement also responded positively to behavioral activation (Hershenberg, Paulson, Gros, & Acierno, 2014). Research Summary Clients with mild and moderate depression: Behavioral activation should be a component of treatment. Clients with severe depression: Behavioral activation should be the first intervention.

Agenda Item #2: Help Your Clients Understand Their Depression A client who is depressed often starts therapy saying, “What is wrong with me? I used to be so strong” or, “I think I am going crazy, I just feel like crying all day.” You want to help your client under- stand that her depression is related to a lack of mood-enhancing activities and is not a personal failure. You can use the cycle of depression as a model for gathering information that will help your clients understand the factors that caused and maintain their depression. If your clients understand that their depression is related to a lack of pleasurable activities in their lives, they will be more motivated to engage in mood-boosting activities. This is important, as you are going to ask your clients to engage in activities even if they don’t “feel like it.” Start with looking at the changes in your client’s life that preceded her depression, in particular, decreases in reinforcing and/or pleasurable activities and increases in unpleasant activities. You also want to look at how your client coped with these changes, and the role of avoidance. The two main questions I ask my client are:

1. What life changes occurred prior to your depression?
2. How did these changes affect your daily life activities in relation to an increase or decrease in pleasurable activities?

SUZANNE’S CYCLE OF DEPRESSION Suzanne started therapy saying she didn’t know what was wrong with her. She had a great house, great kids, a good job, and a great husband, but she was just so overwhelmed that she didn’t enjoy life anymore. She cried softly as she told her therapist that she wasn’t coping. In chapter 2 we listed the stressors and recent changes in Suzanne’s life that happened prior to her depression.

1. Suzanne started teaching at a new school. The school is a thirty- to forty-minute commute from home; she does not know the other teachers, who form a tight group.
2. Her mother-in-law is no longer able to babysit.
3. Genia, her best friend, moved away. Let’s see how her therapist uses the two questions we just identified to understand Suzanne’s depression. Therapist:It sounds like there have been a lot of changes in your life. I am wondering if we could spend a moment and think about how each change has affected your life. Which one should we look at first? Suzanne:Well, I think the really big one is the new school. Therapist:I think it would be helpful to look at how your life has changed since starting at the new school. I want to look at activities you stopped doing, and activities you started doing because of the new school. The therapist instills hope by starting with, “I think it would be helpful.” Notice her therapist did not ask Suzanne how she feels about the new school. She asked her to look at how her life is different. Suzanne:One of the biggest changes is the morning. I used to walk to school; it was about fifteen minutes each way. I now spend forty-five minutes commuting. The extra thirty minutes I used to have meant that I had time to get the kids ready in the morning. Now everything has to be ready the night before. The kids have to be completely ready to be dropped off at my neighbor’s home by 7:30. It’s really hard getting them up, dressed, and fed. My neighbor takes them to school. My husband leaves early for work and can’t help. Therapist:That sounds like a really big change to your morning routine. Suzanne:Yes, I used to enjoy the mornings—it was a nice time with the kids, and I liked the walk to school. Now it is just so stressful. The therapist makes a supportive comment, and Suzanne goes on to elaborate how her life has changed. Therapist: I want to start making a list of the ways your life has changed. I think it will help us under- stand your depression and how to help you. What would you put down? Notice how her therapist instills hope. The therapist asks Suzanne what she would put on the list. Suzanne:Well, I guess, I no longer have the fifteen-minute walk to school, I no longer have a nice time with my kids in the morning, and actually, I rarely eat breakfast, I am so frazzled. I am often starving by the time I get to school. Therapist:I think that’s a really good list of all the things that you are no longer doing. What about anything that you now do because of the new school that you were not doing before? Suzanne:Well, I guess I have to be really organized the night before, which I find hard. I make my daughter’s lunch, put out the kids’ clothes, and make sure I am all organized for school. Also, I have to be really strict with the kids, as I am on a tight schedule. Which means I yell more to get them going in the morning. I also have the long drive to work, which I hate. I spend the whole time in the car thinking about what a bad mom I’ve become, how I yelled at the kids once again, and how I wish I were back at my old school. It’s just awful. Therapist:Sounds like a lot of changes. When we look at how different your morning is now to how it used to be, what are your thoughts? Note that the therapist first asked Suzanne what had changed, second asked her how the change had affected her daily life, and third asked her what she thought when she looked at the changes. Suzanne: Well, no wonder I am depressed; it sounds like an awful way to start the morning. By examining how her morning has changed, Suzanne has shifted from “something is wrong with me that I am depressed,” to realizing that the changes in her morning routine may be contributing to her depression. Therapist: I think you said something important. Seems like the change in school caused a lot of other changes in your life and had a negative effect on your morning routine and mood. I think we are discovering some important information. I want to see if there are other ways that starting at the new school has impacted your life.

Notice how Suzanne’s therapist reinforces her awareness that her morning routine is impacting her mood. Also notice how the therapist keeps Suzanne on track with the task. Suzanne used to spend time with other teachers, who were her friends, and now she sees few of her friends. She had enjoyed being involved in the school play and had received a lot of positive feedback from many people in the school. She was well known as a popular teacher. At her new school she par- ticipates in no extracurricular activities and knows none of the other teachers socially. She gets home late from work, tired and frazzled from the drive. Suzanne had not realized that since her mother-in-law had become ill and could no longer babysit, she and her husband had practically stopped going out in the evening. It had been ages since they had seen many of their friends. Suzanne also realized that since Genia had moved away, she had stopped her weekly walks and talked to her friend much less. Suzanne was surprised when she looked at the impact of all the changes in her life.

Exercise 10.1: Raoul’s Cycle of Depression Practice using the cycle of depression to understand your clients.

USE A WRITTEN SUMMARY After I have explored with my client how her life has changed, I find it helpful to provide a written summary. Sometimes I draw the cycle of depression and together we look at how it is related to my cli- ent’s specific situation. Other times I use the Understand Your Depression worksheet, which you can download at http://www.newharbinger.com/38501. The worksheet gives your client an overview of how her activities have changed since she became depressed. When Suzanne looked at her Understand Your Depression worksheet, it made sense that the changes in her activities were affecting her depression. Understand Your Depression

1. Changes or stressors in your life prior to your depression? New school, mother-in-law no longer babysitting, and Genia, her best friend, moving away.
2. Since these changes or stressors, how have your activities changed? Complete the form below. Increased Since Life Changes or StressorsDecreased Since Life Changes or Stressors Activities I enjoy or that provide pleasure or masteryNoneWalk to school; nice time with children in the morning; going out with husband and seeing friends; Sunday walk with Genia; talking to Genia Activities I do not enjoyGetting ready the night before; long drive to work; getting up early and getting children readyNone ExerciseNo walk to school, no Sunday walk Spending time with friendsStopped seeing school friends, Genia moved away Spending time with familySee mother-in-law more, as she has been illLess time with children in the morning; less time with husband overall Leisure or hobbiesNoneNo school play; no other extracurricular activities None Smoking, overeating, alcohol or drug use Routines related to eating and sleeping No breakfast routine, often fall asleep in front of TV

USE AN ANALOGY I sometimes use a flower analogy to help my client understand her depression. This analogy was inspired by Melanie Fennell’s virtuous and vicious flowers (Fennell, 2006). I explain that feeling happy is similar to a brightly colored flower with lots of petals. I then draw a flower with a circle in the middle and petals around the circle. I ask my client to fill in each petal with an activity she did before she became depressed that she enjoyed or gave meaning to her life. I look for healthy routines; social activi- ties with colleagues, friends, and family; activities that are pleasurable or meaningful; and activities that lead to a sense of competence or mastery. Once my client has completed filling in her flower, I ask her to draw an X through all the petals that have changed since the depression. Usually, almost all of them are gone. What was once a full bloom is often only a few petals. With some clients, instead of a flower I draw a picture of a wall. I use bricks to build a strong wall; if you take out too many bricks, the wall will fall, or have big holes. Suzanne’s therapist used the flower analogy, and Suzanne was surprised to see her flower. Her depression was making more and more sense to her. Her therapist explained that together they would help Suzanne start to add petals back into her life so that she could start to feel better. Suzanne said this was a good idea, but added that she couldn’t imagine where to begin. Her therapist assured her they would work together and go slowly. Your Turn! Understand Mayleen’s Depression Below is a description of Mayleen, a fifty-eight-year-old woman who has come to therapy because she is currently depressed. Try to complete the Understand Your Depression worksheet with the information below. You can see my answers in the appendix. Mayleen is a successful sculptor. She lives alone, has never married, and has no children. Two years ago her mother became ill, and Mayleen has been very involved in her care. Mayleen’s mother lives alone in the town where Mayleen grew up, about three hours away. Mayleen left when she was eighteen and no longer has any friends or other family who live there. She spends four days a week visiting her mother and attending to her needs, looking after the house, and taking her to doctor’s appointments. Mayleen is happy that she is able to care for her sick mother but feels lonely when she visits. She and her mother watch a lot of daytime TV, which Mayleen finds boring. Over the two years that her mother has been ill, Mayleen has become increasingly depressed and feels guilty about not spending all her time caring for her mother. She has stopped seeing many of her friends, has given up exercise, and has almost completely stopped sculpting, as she believes there is no time for these activities, and she is so tired most of the time.

Video 10.1: Explain Depression Agenda Item #3: Monitor Your Clients’ Daily Activities Behavioral activation involves asking your clients to engage in pleasurable activities. Sounds easy. The difficulty is that depressed clients don’t feel like doing anything. They will tell you, “Nothing helps.” You are going to ask your clients to act according to a plan rather than according to how they feel. If your clients can see the connection between an increase in their activity level and an increase in their mood, they will be more motivated to add pleasurable activities to their lives, even if they don’t “feel” like doing them. The easiest way for clients to see the connection between their mood and specific activities is to monitor their daily activities and rate their moods. I ask clients to complete a Daily Activities Schedule (available at http://www.newharbinger.com/38501), where they write what they do, hour by hour, and rate their mood. I usually complete the first day of the Daily Activities Schedule during the therapy hour. That way, I am sure my clients understand what to do. (If the session is early in the morning, we complete it for the previous day.) Then for homework I assign the Daily Activities Schedule for the rest of the week. Here is how I introduce the Daily Activities Schedule. I explain both the rationale behind the intervention and what we will be doing. I think it is important to understand how you spend your days, and if your mood changes with the types of activities that you do. I have a Daily Activities Schedule where you can write down what you do throughout the day, and rate your mood. That way, we can see whether there are times during the day when you feel better, and times when you feel worse. We are going to try and increase the times you feel better and learn how to cope with the times when you feel worse. Does this make sense to you? Let’s take today and see if we can complete the schedule together. Is that okay with you? What time did you wake up? If you had to rate your mood from 1 to 10, with 10 being the most depressed you have ever been, and 1 being not at all depressed, where would you rate your mood when you woke up today? I then take my client through her day, rating her mood during each activity.

Your Turn! Practice in Your Imagination: Explain a Daily Activities Schedule Before you start, rate from 1 to 10 how comfortable you are explaining a Daily Activities Schedule to a client who is depressed. At the end of the exercise, rate your level of comfort again to see whether it changed. Now, let’s try this exercise.

Choose a client who is depressed and who you think would benefit from using behavioral activa- tion. Try to get a picture of him or her in your mind. Imagine yourself in your office with your client. See your office; notice the sounds and smells in the room. Imagine that you want to introduce a Daily Activities Schedule. Read over how I explain using a Daily Activities Schedule while imagining your- self saying the words. You can also use your own phrases. Imagine getting out the Daily Activities Schedule and explaining it to your client. Now, imagine explaining the Daily Activities Schedule two more times with the same client. Each time, imagine that your client responds positively. WHAT DID YOUR CLIENT LEARN? The next step is to use the Daily Activities Schedule to help your client discover an activity/mood relationship and to decide which times of day to target and which activities to introduce or expand. I start with asking my client about the general experience of completing the Daily Activities Schedule and then ask whether she learned anything in the process. I then go over Questions to Explore a Mood/ Activity Relationship (Martell et al., 2010). When I first started doing behavioral activation, I kept these questions next to me. You can download a copy at http://www.newharbinger.com/38501. • Do you see an activity/mood relationship? •What activities help you feel better? •What activities or situations are connected to a low mood? •What time periods are you most at risk for a low mood? •Do you have any routines that help you maintain a positive mood? •Is there anything you are avoiding? Below is the Daily Activities Schedule that Suzanne completed and brought to therapy. She rated her depression from 1 to 10, I being not at all depressed and 10 being the most depressed she had ever been.

Drop off kids (8)Drive to work (9)Teach (6) 7:008:009:00 2:00 Teach (5) Sports day (4) Teach (5) Teach (5) Take kids to park (4) Teach (5) 1:00 Clean house; errands (4) Lie in bed (9) Saturday Lunch (5) Recess and lunch (7) Teach (5) Drive to work (7) Drop off kids (7) Wake kids (7) Friday Recess and lunch (8) Recess and lunch (7) Teach (5) Drive to work (7) Drop off kids (9) Wake kids (6) Thursday 12:00 Help with food (4) Sports day at school (4) Wednesday Visit mother-in- law (4) Recess and lunch (8) Teach (5) Drive to work (9) Drop off kids (9) Wake kids (8) Tuesday 11:00 10:00 Wake kids (8)6:00 Monday (1 = not at all depressed; 10 = very depressed) Suzanne’s Daily Activities Schedule Lunch (5) Play with kids (4) Phone friend (3) Lie in bed (9) Sunday

Meeting to discuss winter holiday assembly (4)Drive home (7)Pick up kids; make dinner (7)Dinner with kids and husband (5)Put kids to bed (7)Phone Genia (4)Get ready for next day (8)Bed 3:004:005:006:007:008:009:0010:00 Bed Get ready for next day (6) TV with husband (4) Husband puts kids to bed (4) Dinner alone with kids (7) Pick up kids; make dinner (6) Pick up kids, watch TV (6) Drive home (9) Bed Get ready for next day (5) Play game with husband (4) Put kids to bed with husband (5) Dinner with kids and husband (4) Pick up kids; make dinner (7) Drive home (6) Clean up with other teachers (4) Bed Get ready for next day (7) Chat with neighbor (4) Put kids to bed (7) Dinner alone with kids (7) Pick up kids; make dinner (6) Drive home (6) Meeting to discuss winter holiday assembly (4) Put kids to bed with husband (4) Friends house for dinner with kids (4) Bed Bed Watch TV with TV and games husband with husband (4) (3) Put kids to bed with husband (4) Dinner at friend’s house (4) Pick up kids; make dinner (7) Pick up kids, watch TV (6) Drive home (6) Bed Get ready for Monday (7) Put kids to bed (5) Parents came for pizza dinner (4) Park with friend (4)

WHAT DID SUZANNE LEARN? Before looking at Suzanne’s answers to Questions to Explore a Mood/Activity Relationship, examine her week and see how you would answer the following questions. After each question, I have included Treatment Implications, where I encourage you to think about how you would use the answers to the questions in guiding future therapy. Do you see an activity/mood relationship? What activities help you feel better? What activities or situations are connected to a low mood? When Suzanne reviewed her Daily Activities Schedule, it struck her that she was doing almost nothing fun. She was surprised that when she was more active, her mood improved. In particular, socializing with other people helped her feel better. Suzanne also noted that she felt better when her husband was home and that she felt fairly good most of the time at school. Suzanne had always thought that she felt better on the weekends because she slept more and was away from school. After looking at her Daily Activities Schedule, she wondered if she felt better because she was more active and spending time with her husband, friends, and family. Suzanne noted she was very depressed during her drives to and from school. She explained that she spent most of the drive thinking about how horrible the morning had been and how she wished she was back at her old school. Watching TV at night with her kids and without her husband was also a low time. She also noted how much she disliked getting ready for the next day and how hard she found the morning routines. Treatment implications: How would you use Suzanne’s answers to the questions above to reinforce the importance of adding pleasurable activities to her life? What time periods are you most at risk for low mood? Suzanne noted that mornings were particu- larly bad. When she wakes up, she lies in bed and thinks about what a bad mother she is and how her husband must be fed up with her. She has images of him leaving her and of being alone and miserable. Suzanne had not realized how depressed she was every morning and how hard it was for her to get the kids ready on a tight time schedule. She also noted that the nights she was home alone with the kids were particularly hard, and she was often depressed. Treatment implications: What time period would you target first for adding pleasurable activities? Do you have any routines that help you maintain a positive mood? Suzanne could not see any rou- tines that helped her feel better. She realized how different that was from the previous year, when she had a good morning routine, walked to school, and regularly saw friends. Her therapist noticed that she put her children to bed at a regular and appropriate time. Suzanne and her husband also went to bed at a regular time and early enough that they got eight hours of sleep. Her therapist thought that these were real strengths and important routines. Treatment implications: How would you use this information in therapy? Is there anything you are avoiding? Suzanne could not think of anything she was avoiding. She men- tioned that she did not go out with her friends much anymore, but that was because she was so tired all of the time. Treatment implications: From a behavioral activation perspective, do you think she is avoiding friends?

Agenda Item #4: Plan Activities That Increase Positive Moods After looking at her schedule, Suzanne agreed it would be a good idea to start a mood-boosting plan. Her therapist explained that when you are depressed, doing pleasurable activities is like taking medicine—you do it because you know it will help, not because you want to. As a therapist, you need to encourage your clients to follow their mood-boosting plan rather than their depressed feelings. ACTIVITIES THAT ENCOURAGE MASTERY AND PLEASURE In behavioral activation you want to increase activities that provide your client with a sense of mastery or competence and pleasure. However, such a general statement does not provide much guid- ance for therapy. I suggest activities in the following categories to help boost a client’s mood. It is impor- tant to remember that this is a very individualized process, as activities that provide a sense of mastery or competence and pleasure are different for every individual. Activities of daily living. First and foremost, I want to be sure that my client is accomplishing the basic business of living, including feeding herself, cleaning her clothes, getting enough sleep, doing basic chores, and addressing responsibilities to family, friends, or work such as taking care of children or completing minimal work tasks. For example, Suzanne is often too frazzled to eat breakfast and arrives at school starving. She often eats a chocolate bar or is hungry all morning. It would be important for her therapist to help Suzanne make an effort to eat breakfast. Social contact. People vary in how much and what kind of social contact they want, but everyone needs some. When clients become depressed, they usually withdraw from family and friends. It can be hard to re-engage. You want to start slowly with small steps. Exercise. There is increasing evidence that regular exercise boosts your mood and can counter depressed feelings (Trivedi et al., 2011). Exercising outdoors may lift your mood even more than exercis- ing indoors (Barton & Pretty, 2010). This makes total sense to me; I am far happier walking outside on a beautiful spring day than using the treadmill in the gym. In fact, I am even happier if I walk outside with a good friend…and pick up a coffee (and maybe even a cookie!). Clients vary tremendously in how much exercise they want to do. Generally, any increase in activ- ity is good. With some clients I have started by encouraging them to go outside for five minutes. Pleasurable activities. When clients are depressed it can be hard to find activities that they find plea- surable. Here are some suggestions. •Build on existing activities. Identify mood-boosting activities your client is already doing and expand the activity. For example, if your client enjoyed talking to a friend about the recent political situation, can she see this friend more often? Can she contact another friend? Maybe the stimulation of discussing politics increased her mood. Could she read the newspaper or listen to a podcast? •Try activities your client used to enjoy before she was depressed. She may be surprised at how much she still enjoys them. Just make sure your client doesn’t expect to enjoy these activities as much as before. •Use the Pleasurable Activities List, which you can download at http://www.newharbinger. com/38501. The list can start clients thinking about possible activities they don’t usually do but might like to try. •Choose activities that lead to a sense of mastery or competence. People tend to enjoy doing things they are good at. You also want to address any avoidant behavior that is likely to create additional problems, such as avoiding completing a work project or enrolling children in camp. •Encourage activities that are consistent with your client’s values and are meaningful. For example, volunteering may be enjoyable because it is related to a client’s values. Practice being mindful. I encourage my clients to gently put aside their critical mind and allow them- selves to concentrate on the activity in the moment. For example, if a client is walking outside, I encourage her to notice the fresh air, see the flowers, and feel the wind. Don’t tell your client to stop thinking negative thoughts. When we tell ourselves to stop thinking something, the thought bounces back stronger. Some of my clients like the idea of taking a holiday from their negative thoughts.

GUIDELINES FOR EFFECTIVE ACTIVITY PLANS Suzanne wanted to start with an activity that would have an immediate effect on her mornings, as she arrives at school already very depressed. She decided to try listening to music and podcasts in the car on the way to work as a way to boost her mood. Suzanne also wanted to add telephoning Genia, her best friend; contacting Rita, her friend from her previous school; and seeing her mother-in-law. She set a time when she would call Rita and Genia. Rather than set a specific time to see her mother-in-law, Suzanne wanted to see how her weekend developed. Sometimes it is helpful to set specific times for activities, but sometimes clients want a more flexible schedule. If we were flexible in terms of when an activity would get done, and my client didn’t do the activity, the next week I try to set a specific time. Suzanne was not optimistic that these would make much difference to her mood, but she was willing to try. Though these activities sound great, often clients don’t do the activities they plan. Activities that follow the guidelines below have a better chance of being done. You can find a Guidelines for an Effective Activity Plan handout at http://www.newharbinger.com/38501. •Was the plan developed collaboratively with your client? •Is the plan specific and concrete? •Is the plan doable? •Is the plan naturally reinforcing? •Can the plan be part of a regular routine? Developed collaboratively. I start by asking, “What would be a good activity to add to your week that would help you start to feel better?” Clients often have very good suggestions; however, sometimes they need help thinking of good activities. If you suggest the activity, try to involve your client in tailoring your suggestions to her situation. The key is to develop the activity with your client, not for your client. Suzanne’s therapist was careful that the activities were either Suzanne’s idea or developed together. Specific and concrete. Use the same criteria we used to decide whether homework was sufficiently specific and concrete: Is there a specific behavior your client is going to do? How often will your client do the activity? Where and when will your client do the activity? Suzanne’s activities are specific and concrete. Suzanne wanted some flexibility in planning to see her mother-in-law. That seemed fine to her therapist. Not every activity has to be rigidly scheduled. Doable. Start at your client’s current level of activity, not where she would like to be, or where she used to be. Start small, so that your client can experience success. I always ask if the activity “feels doable.” I also check if my client has everything she needs to complete the activity. Ask if your client foresees any obstacles and problem solve how to overcome them. When Suzanne’s therapist checked if the activities felt doable, Suzanne said that listening to music while driving to and from school felt doable. However, the idea of finding a podcast, downloading it, and then concentrating on someone talking felt overwhelming. They decided she would focus on lis- tening to music. Naturally reinforcing. Choose activities that are intrinsically enjoyable or that your client will receive positive reinforcement for doing. For example, fifteen minutes of playing a board game with your child is more naturally reinforcing than fifteen minutes of doing dishes. This is particularly important in the beginning, when you want your client to experience positive results and stay motivated. The activities Suzanne and her therapist chose were naturally reinforcing. Suzanne likes music and enjoys spending time with Rita, Genia, and her mother-in-law. Regular routine. Many of my clients initially suggest planning a big, faraway event, such as a vacation for next December. However, positive, routine activities sustain a positive mood more than one-time, big events. Examples of routine activities include a regular date with a friend or a weekly exercise class. A good routine is like a good structure that maintains a good mood. The activities Suzanne and her therapist picked could become part of her routine.

YOUR TURN! Develop Mood-Boosting Activities for Anna Anna recently graduated from a community college program and has been living at home with her parents for the past six months while she looks for work. She is increasingly depressed. She completed a Daily Activities Schedule, which she reviewed with her therapist, who wanted to add activities that would increase pleasure or a sense of mastery or competence. Anna noticed that her lowest mood is around 5:00 p.m. She is alone in the house, and her parents do not get home for another two hours. She spends the time surfing the web and ruminating. Her therapist tells her to stop ruminating and that surfing the web is not helping her. Anna used to like running, but she has not run for over a year. Her therapist suggests that Anna go back to running, starting with three times a week for an hour. Anna likes the idea. Together they decide that Anna will run Monday, Wednesday, and Friday for an hour at 5:00 p.m. Now try the following exercise:

1. Evaluate her therapist’s interventions in relation to the Guidelines for an Effective Activity Plan, and complete the following table. You can see my answers in the appendix. Suggested Activity Developed Collaboratively Specific and Doable Concrete Naturally Reinforcing Regular Routine Run three times a week for an hour
2. After you assess the current plan, design a more effective one.

Exercise 10.2: Jamar Is Feeling Depressed Practice assessing whether planned activities are likely to be effective. Video 10.2: Plan Mood-Boosting Activities MONITOR YOUR CLIENT’S MOOD BEFORE AND AFTER ACTIVITIES If you ask your clients who are depressed if they will enjoy an activity, they will probably say no. Clients who are depressed don’t enjoy activities as much as they used to. However, clients tend to enjoy activities more than they think they will. Often, starting the activity is the hardest part. Rating moods before and after a pleasurable activity provides your client with important data on how adding mood-boosting activities to her life affects her moods. I usually ask clients to complete the Predict Your Mood worksheet, shown below. (You can download a blank copy at http://www.newharbinger. com/38501.) After clients try an activity, if their mood ratings improved, I ask what they learned. I want my clients to see that even though they believe that they will not enjoy an activity, their predictions are not necessarily accurate. Let’s see how Suzanne completed the Predict Your Mood worksheet for two of the activities she was going to try and how her therapist used the worksheet. Predict Your Mood Date and Activity How much will Mood Before I enjoy this Activity activity? (rate from 1–10;How much did I enjoy this activity? Mood After Activity (rate from 1–10; 1 = not at all; 10 = a lot)1 = very happy; 10 = very depressed)(rate from 1–10; 1 = not at all; 10 = a lot)(rate from 1–10; 1 = very happy; 10 = very depressed) Monday: Listened to music in the car3755 Called friend, Rita376–74

Therapist:Looks like you did a great job of completing the Predict Your Mood worksheet. When you look at your responses, what do you notice? Suzanne:Well, for one thing, in both cases my mood went up. Therapist:Could you tell me more about that? The therapist wants to expand and consolidate Suzanne’s awareness of the activity/mood relationship. When her therapist asks for details, Suzanne remembers the experience and it becomes more salient. Suzanne:Well, I actually enjoyed listening to music. I chose some really upbeat old songs that I like. I think it distracted me from my bad morning. Therapist:So listening to music was a good idea. What about talking to Rita? Suzanne:That was also more enjoyable than I expected. We had a really good talk and caught up. She told me she missed me, and all my friends have been asking about me. Her therapist uses a summary statement to consolidate the experience. Therapist: I hear Rita missed you, and your other friends also miss you. Hmm (therapist gently smiles). Let’s look at the accuracy of your predictions. What did you initially predict? (They look at the Predict Your Mood worksheet.) Notice how Suzanne’s therapist is not giving Suzanne the answers but is asking her for the information and letting her draw her own conclusions. Suzanne:I predicted that I would not enjoy listening to music and calling Rita very much. I gave both a 3. Therapist:And what actually happened? Suzanne:(laughing a bit) Well, I actually enjoyed listening to music quite a bit; I gave it a 5. And I enjoyed talking to Rita way more than I expected; I gave it a 6 to 7—it was great to catch up. Therapist:And what does that say about your predictions? Suzanne:I guess I was wrong. Video 10.3: Monitor Mood Before and After Activities OVERCOMING ROADBLOCKS: YOUR CLIENT DID NOT TRY THE PLANNED ACTIVITY Despite your best efforts, your client will not always do the agreed-upon activities. First, ask your client what got in the way. Sometimes it is a simple answer. Next, ask what went though her mind when she thought of doing the activity. Did she think it was too hard? Did she think it would not help, or did she have other thoughts? I go back to the fundamental principle: Follow your mood-boosting plan rather than your depressed feelings. Remember, for depression, activity is like medicine. There is some evidence that clients who make a public commitment to doing an activity are more likely to follow through (Locke & Latham, 2002). If my client has supportive family members or friends, I encourage her to share her plans. I then problem solve how my client could do the activity the next week, or modify the activity so that it is more doable. I make sure I remain encouraging and optimistic and convey my belief that treat- ment will work. The first week, Suzanne listened to music every day on the way to and from work. However, at her next appointment, she told her therapist that she had stopped listening to music, that this past week she was just “too down.” Her therapist reviewed what Suzanne had learned from her Predict Your Mood worksheet. She decided to try again. Suzanne laughed and said she would have to listen to music “even with her depressed hat on.” Her therapist thought this was a great image, and used it often in therapy.

WHAT IF I HAVE ONLY A FEW SESSIONS? The research on behavioral activation has generally evaluated a protocol that involves sixteen weeks of treatment, and often two sessions a week for the first eight weeks (see, for example, Dimidjian et al., 2006). However, many therapists see clients for only a few sessions. If I have only a couple of ses- sions, I start with exploring what my client is no longer doing that she used to enjoy. I then explain the activity/mood relationship. Either in the first or second session, we work together to identify specific pleasurable activities she could start doing. I make sure the activities make sense given my client’s current level of activity. I try to target a period of the day when her mood is particularly low. If possible, I encourage social contact, as there is such strong evidence that it is a mood booster. PREVENTING RELAPSE To maintain a positive mood, your client needs to have good routines. What is involved in a good routine is different for every person, but it generally includes a structure to the day, socializing, some exercise, activities that are meaningful and connected to your client’s values, and some fun. I use the analogy of creating a strong structure for a building. If the supporting beams are rotten and weak, even if you have good drywall and a beautiful paint color, you will have an unstable house. I teach my clients that after therapy ends, if they start to get depressed again or are going through a stressful time, they should examine their daily routine. I encourage them to notice their worst times of the day and think about how they can make those times better. I also encourage them to try adding even small mood-boosting activities throughout the day. I also use activity scheduling to prevent depression with clients who are going through a particu- larly difficult time. If you have ever gone through a difficult time, I am sure people have told you to “take care of yourself.” This is good advice, but very general. I examine pleasurable activities my client has stopped doing because of the stress and see if we can add them back into her life, or add other activities that she enjoys. Together we make a specific plan that is doable and can be part of my client’s routine. Agenda Item #5: Graded Task Assignments Graded task assignments are used primarily when your client is avoiding important tasks that feel overwhelming. It is often a component of activity scheduling, problem solving, and treating procrastination. Graded task assignments involve looking at a whole activity and breaking it down into smaller pieces, or chunks. These smaller chunks feel doable in a way that the whole task does not. Your client starts with completing the first chunk and progresses to additional chunks. It can be helpful to limit the amount of time a client spends on each task to make it feel more manageable. By breaking tasks down into specific chunks, your client can feel she is progressing as she completes each task. It can also be helpful to set a specific time when the tasks will be done. For graded task assignments to be effective, the tasks have to be very specific and concrete behav- iors. For example, if a client is procrastinating over filing his taxes, the first task might be spending twenty minutes reviewing the tax form, the second task might be spending half an hour gathering income statements, and the third task might be entering the income information he gathered on the tax form. You don’t need to set out all the steps, but it is helpful to specify the first few.

YOUR TURN! Use Graded Task Assignments Below are examples of clients who are feeling overwhelmed. Their therapists want to use graded task assignments as an intervention. Look at their first task and decide if it is sufficiently specific and con- crete, doable, and time-limited. I will do the first one; you do the next two. You can find my answers in the appendix.

1. Cynthia’s boss asked her to be in charge of the site visit when members of the head office come to inspect their unit. She is feeling very overwhelmed. She and her therapist thought a good first task would be reorganizing the filing system to make it more systematic.
2. Richard wanted to invite his whole family—about fifteen people—for Thanksgiving dinner. He is feeling very overwhelmed. His therapist and he thought that spending thirty minutes making a list of the food he wanted to cook would be a good first task.
3. Alexandra wanted to find a part-time job. She is feeling very overwhelmed and tells her thera- pist she does not know where to start. She and her therapist thought that exploring her options for work would be a good first step.

TaskSpecific and Concrete?Doable?Time-Limited and Specific Time for Task? Cynthia:No. Not clear what the criteria are for a systematic filing system; first action is not clearNot sure who will do this and what exactly the person/people will do; hard to know if it is doableNo time limit given; will Cynthia work for 10 minutes or the whole day? Reorganizing the filing system Richard: Make a list of food I want to cook Alexandra: Explore options for work No specific time for starting the task

Agenda Item #6: Increase Well-Being The goal of behavioral activation is to decrease depression; however, most clients want to feel good, not just “less bad.” Positive psychology seeks to identify factors that lead to a happy, engaged, and meaningful life. The focus is on developing interventions that promote well-being rather than on alle- viating depression (Seligman, Steen, Park, & Peterson, 2005). Most CBT therapists I know incorporate some of the following interventions into behavioral activation. Though less robust than the research demonstrating the effectiveness of behavioral activation, there is some evidence that these interven- tions may increase happiness (Duckworth, Steen, & Seligman, 2005; Sin & Lyubomirsky, 2009). ACTIVITIES THAT INCREASE WELL-BEING Socialize with friends and family. Social contact is the single factor most consistently related to hap- piness (Leung, Kier, Fung, Fung, & Sproule, 2013; Parks, Della Porta, Pierce, Zilca, & Lyubomirsky, 2012). Increasing positive social interaction is also one of the most effective interventions to increase happiness (Seligman et al., 2005). Keep a journal of positive experiences. Write down one to three positive experiences a day. I ask my clients to take a moment to remember the experience fully and to see it occurring again in their mind’s eye. Savor the moment. Make a conscious effort to enjoy a pleasant moment. It is helpful to focus on one’s senses to stay present. For example, if a client plans to take a walk, remind her to notice the flowers or the fresh air. Express gratitude. Write one to three things to be grateful for every day. This is also called “counting one’s blessings.” I ask my client to take a moment to remember the blessing fully and to appreciate that it was in her life. Another form of expressing gratitude involves consciously telling, or writing to, others to say that you appreciate them or what they have done. Practice acts of kindness. Consciously do a kind act you would not normally do. This may involve consciously acting in a kind manner to someone you would not normally be kind to, or doing an addi- tional kind act to someone you would normally be kind to. Ask your client to notice the other person’s reaction to her acts of kindness. Often people smile, say thank you, or react in a positive manner, which in turn will contribute to your client’s feeling happy. It’s nice when someone smiles at you. Think optimistically. Identify a potentially stressful upcoming event and then describe the best pos- sible outcome. The more detailed the description, the more emotionally engaged your client, and the more positive her mood. Encourage your client to write the description and to form a detailed image in her mind of the positive outcome. Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework.

Apply What You Learned to a Clinical Example Complete the following exercises.

Exercise 10.1: Raoul’s Cycle of Depression Exercise 10.2: Jamar Is Feeling Depressed Apply What You Learned to Your Own Life Therapists often talk about the importance of self-care. The exercises below are an opportunity for you to take some of the interventions from this chapter and, instead of using them with your clients, apply them to your own life—and in the process take care of yourself. Homework Assignment #1 Add an Activity to Your Life That You Enjoy Identify a low time in your day. Think of a small, doable activity you could add that you would enjoy or that provides a sense of competence. Use the Predict Your Mood worksheet, available at http://www. newharbinger.com/38501. When I did this exercise, I realized my husband and I used to have a favorite TV series we watched Monday evenings. The series ended, and instead of watching TV together, we each did our own chores. Watching a favorite show with my husband versus doing chores—which do you think boosts my mood more? We picked a new TV series to watch. Homework Assignment #2 Increase Your Happiness Look over the list of interventions that increase happiness:

1. Socialize with friends and family.
2. Keep a journal of positive experiences.
3. Savor the moment.
4. Express gratitude.
5. Practice acts of kindness.
6. Think optimistically.

Pick one intervention and try it for a week. Do the following: (1) rate your overall mood before and after each time you practice the intervention; (2) rate your overall mood at the beginning of the week and at the end of the week. Apply What You Learned to Your Therapy Practice For this next assignment, pick a client whom you know well and who is depressed. Homework Assignment #3 Complete the Understand Your Depression Worksheet with a Client Using the information you already know about your client, complete the Understand Your Depression worksheet. How did this exercise help in understanding your client? Remember, you can download the worksheet at http://www.newharbinger.com/38501. Homework Assignment #4 Try Behavioral Activation Choose one of the following interventions, and try it with a client this coming week. You can find the worksheets on the website.

1. Introduce the Daily Activities Schedule and complete the first day in session.
2. With your client, pick an activity to add to his or her life that will promote pleasure or mastery. Use the Predict Your Mood worksheet to evaluate whether the activity had an effect on your client’s mood.

Let’s Review Answer the questions under each agenda item. Agenda Item #1: How does behavioral activation work? • What is the main idea in behavioral activation? Agenda Item #2: Help your clients understand their depression. • How can you use the flower analogy to help your clients understand depression? Agenda Item #3: Monitor your clients’ daily activities. • What is the purpose of the Daily Activities Schedule? Agenda Item #4: Plan activities that increase positive moods. • What are two types of activities you might want your clients to add to their lives to help them feel better? Agenda Item #5: Graded task assignments. • What are graded task assignments? Agenda Item #6: Increase well-being. • What are two interventions that evidence indicates would increase well-being? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

CHAPTER 11 Exposure Therapy—Clients Face Their Fears In the previous chapter we covered behavioral activation. Did you have a chance to ask a client to monitor his or her daily activities? What about adding mood-boosting activities to a client’s life, or your own? Did you try graded task assignments to help a client break down an overwhelming task? If you did not have a chance to do the homework, think of a mood-boosting activity you could add to your own life this week. Choose a small, doable activity. Schedule it into your week. Then try it, and notice the effect on your mood. Set the Agenda In this chapter we are going to learn how to use exposure therapy to help your clients face situations they have been avoiding. Agenda Item #1: What is exposure? Agenda Item #2: Prepare to do exposure. Agenda Item #3: Implement exposure. Agenda Item #4: Do postexposure debriefing. Agenda Item #5: Discuss relapse prevention. Work the Agenda As with all interventions, to use exposure effectively, it’s critical to begin with a clear understanding of how and why it works.

Agenda Item #1: What Is Exposure? Exposure therapy is a treatment for anxiety based on gradual, planned, repeated exposure to what we fear, starting with easy situations and progressing to more difficult situations. It is based on the premise that the more we face our fears, the less anxious we become and the more we learn we can cope. I want to start by telling you a story related to exposure from my own life. I am at Disneyland. My kids want to ride the really big roller coaster. We wait in line. I start to get anxious; the roller coaster looks pretty scary. I wonder, Are there lots of accidents? It occurs to me that if planes can crash, roller coasters can also crash. We get to the front of the line, I look at the roller coaster, and I have one of the most intense anxiety reactions of my entire life. I turn to my husband, with panic in my voice, and say, “I am absolutely not going on that thing!” If I do not get on the roller coaster, what will happen to my fear? Next time, will I be more or less likely to go on a roller coaster? How will I feel about my ability to cope with roller coasters? How will I feel about my ability to cope with scary rides generally? I am embarrassed to say, I turned around, made my way back through the long line, and did not go on a roller coaster for many years. If I wanted to get over my fear of roller coasters, what would you suggest? Here is my plan: Start with a really small roller coaster, and ride it a few times until I am com- fortable. Next, try a slightly larger roller coaster. Once I am comfortable with this larger roller coaster, try an even bigger one. Basically, my plan for overcoming my roller coaster anxiety is exposure therapy. Exposure therapy involves identifying the feared object or situation your client is avoiding and making a plan to face the fear. Your client starts exposure with objects or situations that elicit little fear and stays in the situation until either habituation occurs or he learns that he can cope with the situa- tion. Your client then progressively faces situations that elicit more fear. Exposure Therapy Overcome Anxiety = Face Your Fears

THE THEORY BEHIND EXPOSURE There are basically two theoretical models that explain exposure: habituation (Foa & Kozak, 1986) and exposure as a behavioral experiment (Clark & Beck, 2010; Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). My own sense is that both models are accurate and reinforce each other. Habituation is based on the observation that when an anxiety-provoking stimulus is consistently paired with a neutral consequence, the fear response eventually extinguishes. Let’s look at my roller coaster example. The roller coaster is the anxiety-provoking stimulus. I think about riding a roller coaster and I get anxious. If I frequently ride a roller coaster and consistently nothing bad happens, riding the roller coaster becomes paired with a neutral consequence (nothing bad happening). If I ride often enough, I will habituate to the roller coaster and no longer be afraid. In our daily lives, exposure occurs naturally, all the time. Can you remember a situation where you were initially anxious, but as you got used to the situation, your anxiety diminished or disappeared? Maybe it was your first night in a new house, driving on the highway, or jumping off a diving board? By staying in the situation until you were no longer afraid, you were naturally doing exposure therapy. Exposure can also be understood as a behavioral experiment that tests your client’s negative fear predictions (Clark & Beck, 2010; Craske et al., 2014). If you remember, anxiety is about expecting bad things to happen. Anxiety is fueled by your client’s overestimation of the danger of a situation and an underestimation of his ability to cope with both the situation and his feelings of anxiety. Clients often predict that something awful will happen or that their anxiety will become intolerable. For example, I believe that if I go on a roller coaster, there is a good chance that it will fall off the rails (this is an exag- gerated belief in the danger of roller coasters). I also believe that I will become so anxious that I will be unable to stop screaming (this is an exaggerated belief in my inability to cope). The exposure task is an experiment that tests the accuracy of your client’s negative predictions. By facing his fears, your client learns that the situation is not dangerous and that he can cope with both the situation and his feelings of anxiety. Your client will also learn that when feared situations are faced, over time, anxiety diminishes. By the way, I did go on a roller coaster recently; it did not crash, I did scream, and by the end of the ride I actually enjoyed it!

HOW AVOIDING MAINTAINS FEARS The key treatment component in exposure is to stop avoiding and to repeatedly confront your fears until you are no longer afraid. When we avoid situations, initially our anxiety decreases as we leave the feared situation. However, in the long term our anxiety increases because when we avoid we never learn that the situation is not dangerous and that we can cope. Over time, the number of situations we fear expands. We are caught in a self-fulfilling cycle. Take a look at Figure 11.1, the Cycle of Avoidance; you can see how avoiding leads to more avoiding and more anxiety and becomes a vicious cycle. Anxiety-Provoking Situation Never tests whether predictions are accurate Prediction: Situation is dangerous; I cannot cope. Consequence: Less contact with anxiety- provoking situations Anxiety Avoid anxiety- provoking situation Figure 11.1. Cycle of avoidance. Can exposure therapy help Suzanne? At this point in therapy, Suzanne is doing better. She has been listening to music on the way to work and arriving in a better mood. She has also started socializing again with her old friends. As her mood has lifted, her relationship with her husband has improved and her mornings with the children have become less difficult. So generally things at home are going better. However, she still dislikes her new school and hardly interacts with the other teachers. Let’s see if expo- sure therapy can help her. First let’s check if the cycle of avoidance applies to Suzanne. Situations that involve interacting with other teachers have become increasingly anxiety provoking for Suzanne. She believes that the other teachers do not want to be her friend and that even if she tried they would not like her (negative predictions). She is coping by avoiding almost all social contact. Since she avoids social contact, she never gets to check whether her negative predictions are accurate. In addition, if Suzanne is avoiding the other teachers, how do you think they react to her? Most likely they leave her alone, which rein- forces her thought that they are unfriendly. Suzanne is caught in a vicious cycle.

Exercise 11.1: Suzanne Avoids the Other Teachers Practice applying the cycle of avoidance. Role of safety behaviors. Anxiety is maintained not only by avoidance, but also by what are called safety behaviors; I think of them as “fake” safety behaviors. Fake safety behaviors increase how safe you feel; they do not actually decrease the danger of the situation. Real safety behaviors, such as wearing a seat belt or looking both ways before crossing the street, do in fact increase your safety. For example, if I was only willing to get on a roller coaster with my daughter, having my daughter with me in the roller coaster is a fake safety behavior—if the roller coaster crashes, will it help if my daughter is with me? The problem with safety behaviors is as long as you use them, you never learn that you can cope without them. The best way I know to explain safety behaviors is to tell you one of my favorite jokes. Harry is walking along the street, when he sees his old friend George. George is shaking his head from side to side saying, “shush, shush.” Harry goes up to George and says, “George, great to see you, but why are you saying, ‘shush, shush’?” George pauses. “I am keeping the zebras away.” Harry is a bit stunned. “But George, there are no zebras in America!” George smiles and says, “See, it works!” So, why have I told you this silly joke? Saying “shush, shush” is George’s safety behavior. Because he always says, “shush, shush,” he never learns that if he stops, there still will be no zebras in America. It can take a while to learn to recognize safety behaviors. They generally fall into four categories (Abramowitz, Deacon, & Whiteside, 2011): Avoidance. Never putting your hand up in class to avoid sounding stupid; avoiding elevators because you fear they will fall. Checking, reassurance seeking, and rehearsal. Repeatedly checking if the door is locked; spend- ing hours searching the Internet for information on every small ache and pain; mentally rehearsing what you say in casual conversations to be sure you do not look silly. Compulsive rituals. Washing your hands for half an hour after you go to the bathroom; needing to check twelve times that the windows are closed before you go to bed. Safety signals (objects you carry or have near you to be sure you are safe, even though the chances of needing them are slight or they could not really help). Having another person or an animal with you; making sure your cell phone is in your pocket with your finger on the emergency button in case you need to call for assistance. The problem with safety behaviors is that they interfere with everyday functioning, and some safety behaviors actually make things worse. For example, a client is worried about germs and washes his hands for half an hour every time he goes to the washroom. This interferes with his ability to get his work and other tasks done, and, if excessive, can cause irritation and skin problems. A client with social anxiety is worried that she looks messy and awkward. While talking to a friend she constantly checks her hair. The constant checking makes her hair look messy, annoys and distracts her friend, and makes the client look awkward.

During exposure therapy, clients give up their safety behaviors in a planned, systematic manner so they can see that it is possible to cope without them. Identify your clients’ safety behaviors. Sometimes when clients describe their anxiety, they include their safety behaviors. For example, when a client of mine described her fear of flying, she mentioned that she always has two or three glasses of wine before getting on the plane, to numb the anxiety. The wine is her safety behavior; she believes she needs it to tolerate the anxiety of flying. You can also ask your clients directly about their safety behaviors. Next time one of your clients is describing her anxiety, try using Questions to Assess Your Client’s Safety Behaviors, available as a handout at http://www.newharbinger.com/38501. •Are there things or situations you avoid because of your anxiety? •Are there things you do to make yourself feel safe, or to be prepared in case of danger, such as carrying things or being with certain people? •Is there anything you do to make yourself feel comfortable in situations where you feel anxious? YOUR TURN! Identify Suzanne’s Safety Behaviors See if you can help Suzanne identify her safety behaviors. Therapist: We’ve been talking about how anxious you feel around the other teachers at work, and generally how hard it’s been for you to make friends. I am wondering if there are things you do to make yourself feel more comfortable when you are with them. Suzanne: Well, I guess I have just been trying to avoid everyone as much as possible. Look at three possible responses below and pick the one that will help Suzanne identify her safety behaviors.

1. What are some of your thoughts when you feel anxious?
2. Is there anything you do to make yourself feel more comfortable in situations where you have to interact with the other teachers?
3. What are some of the worst situations for you, when you feel the most anxious? Response #2 is the best response to help Suzanne identify her safety behaviors. Response #1 would be a good response if you wanted to explore her thoughts, but that is not the task at the moment. Response #3 would be a good question if you were starting to develop a hierarchy of situations, but not for identifying safety behaviors.

Therapist: Is there anything you do to make yourself feel more comfortable in situations where you have to interact with the other teachers? Suzanne: If I really have to interact with them I try very hard to say something smart or funny. I will often rehearse a comment in my mind before saying it. Therapist: Anything else that you do to feel comfortable? Suzanne: Well, I usually wait until someone asks me a question before speaking. That way I don’t have to talk as much. Suzanne identified two safety behaviors. The first is to rehearse in her mind what she will say before speaking. Do you think this will make her more or less fluent as a speaker? More or less anxious? The second safety behavior is waiting to talk until someone asks her a question. Is that likely to make her more or less engaged in the conversation? One of the difficulties with safety behaviors is that there can be a fine line between coping and safety behaviors. For example, before cutting a piece of wood it is good practice to double check your measurements; however, checking six times becomes a safety behavior. Some safety behaviors are benign. For example, if my daughter is happy to come with me on roller coasters, and I will only go on a roller coaster if she is with me, this is a benign safety behavior. The assessment issue is whether the behavior interferes with your client’s functioning or causes her to avoid a situation that is not dangerous in reality.

Exercise 11.2: Maia Was Attacked Practice identifying safety behaviors. IS EXPOSURE EFFECTIVE? The answer is yes; in fact, exposure therapy is considered the most effective treatment we have for fear and anxiety disorders (Clark & Beck, 2010). Exposure has been used effectively for a variety of anxiety-related disorders, including panic disorder, obsessive-compulsive disorder (OCD), social anxiety disorder, PTSD, health anxiety, and specific phobias (Abramowitz et al., 2011; Clark & Beck, 2010). Despite its effectiveness, exposure therapy does not work 100 percent of the time. Some clients do not respond, and for some clients, after successful treatment, fears return. Researchers are exploring factors that predict who will respond and how to make exposure more effective. OVERVIEW OF EXPOSURE THERAPY There are three types of exposure: in vivo, virtual, and imaginal. In vivo exposure involves expo- sure to what you actually fear. For example, if you fear needles, exposure tasks would involve an actual needle. Virtual exposure involves using the Internet, or another medium, to simulate the experience you fear. Often exposure to fear of flying relies on virtual exposure. Imaginal exposure is when your client uses his imagination to experience the situation. It is used primarily when in vivo or virtual exposure is not feasible. Trauma work usually relies on imaginal exposure to help clients face their trauma memories. A word of caution: if your clients have poor impulse control, difficulty controlling their substance use, or suicidal ideation or urges, or if they engage in self-injurious behavior when under stress, it is generally not recommended to use exposure until they are stabilized (Taylor, 2006). Exposure therapy generally occurs in three phases: preparing to do exposure, implementing expo- sure, and debriefing after exposure. Agenda Item #2: Prepare to Do Exposure Before you actually implement exposure, you want to prepare your client by going through the fol- lowing steps:

1. Identify the fear your client wants to address.
2. Help your client understand how avoiding maintains his fears.
3. Explain exposure.
4. Develop a hierarchy of feared objects or situations. IDENTIFY THE FEAR YOUR CLIENT WANTS TO ADDRESS You can use exposure in almost any situation where your client copes by avoiding. Suzanne was socially anxious, and in particular she was anxious about interacting with other teachers and colleagues at her new school. Below is a list of other types of fears you could treat with exposure. Take a moment to think of your clients and whether any of their fears fit into these categories. •Fear of living creatures: Clients may fear dogs, insects, or human beings who remind them of an individual who hurt them. •Fear of inanimate objects: Many clients fear germs, toilet seats, blood, or needles. •Fear of specific situations: Clients may fear going to the dentist, public speaking, all kinds of social situations, and places that remind them of where they were hurt. •Fear of specific thoughts, memories, or images: Clients with PTSD fear remembering the trauma; clients with OCD have specific thoughts that they try to avoid. •Fear of specific physiological reactions: Clients can fear the sensation of having to cry, the physical symptoms related to going to the bathroom, or vomiting. Individuals with panic dis- order fear the physical symptoms of anxiety.

AVOIDING IS NOT THE SOLUTION Exposure is hard work. Unless clients understand the negative consequences of avoiding, they will not be motivated to engage in exposure. Many clients are so used to avoiding that they minimize the impact on their lives. I find the following questions helpful: •How is avoiding a problem for you? •If you were not avoiding this situation, how would your life be different? What would you be doing differently? •Why is it important to you to stop avoiding? When Suzanne’s therapist explored the consequences of avoiding social contact with the other teachers, Suzanne realized that she was lonely and felt isolated. You can also increase motivation to engage in exposure tasks by linking cessation of avoiding to your client’s values. An important value for Suzanne is being friendly and having good relationships with other people. When Suzanne saw the connection between interacting with the other teachers and acting on her values, her motivation to stop avoiding social contact at school increased. Especially if clients are hesitant to engage in exposure, I examine how the exposure task is related to values that are important to them.

EXPLAIN EXPOSURE Exposure involves asking clients to do what they fear most. They need to trust you. I tell my clients that I will not ask them to do anything they do not want to do. I fully explain exposure and communi- cate my optimism. I often say, “This will initially be hard, but I think you will be glad you did it.” I model a matter-of-fact attitude toward anxiety: anxiety is unpleasant but not dangerous. I let my clients know that anxiety will decrease as they avoid less and face their fears. I cannot promise to elimi- nate anxiety, but I can help them learn to cope with their anxiety. Below is how I generally explain exposure to my clients, of course, tailoring the explanation to each client. You can find Explain Exposure to Your Clients at http://www.newharbinger.com/38501. We have been talking about how you avoid situations that make you anxious. We have also talked about how avoiding these situations has not helped and has actually caused you some difficulties. We have also talked about how being able to do the activity you have been avoid- ing is related to some very important values for you. (Only say this if you have been able to make the link to your client’s values.) I think exposure therapy would be a very helpful treatment for you. Exposure therapy involves facing your fears. We will make a list of the situations that make you anxious, starting with situations that are fairly easy and going up to situations that are hard for you. We will start with the easiest and see if together we can help you learn to cope with the situation. Once you have learned to cope with the easiest situation, we will progress to more difficult ones. We will work together and go at whatever pace works for you. How does that sound to you? (I pause to check if my client has any questions.) As you face your fears, you will learn not to be afraid. I want to talk a bit about anxiety. You will feel some anxiety as we do the exposure tasks. But that’s okay; you need to feel some anxiety for exposure to be effective. We’ll go slowly. Also, the more we face what makes us anxious, the less anxious we feel. This means that the more you do the exposure tasks, the less anxious you will feel and the more you will learn to manage your anxiety.

YOUR TURN! Practice in Your Imagination: Explain Exposure Therapy I would like you to imagine explaining exposure therapy to a client. Before you start, rate from 1 to 10 how comfortable you feel explaining exposure therapy. At the end of the exercise rate your level of comfort again to see if it changed. Now, let’s start this exercise. Chose a client who you think would benefit from using exposure therapy. Try to get a picture of him or her in your mind. Now, imagine yourself in your office with your client. See your office; notice the sounds and smells in the room. Imagine that you want to explain exposure therapy. Read over the words I suggested while imagining yourself saying them. You can also use your own phrases. Really hear and feel yourself explaining exposure therapy. Imagine explaining exposure therapy two more times with the same client. Each time, imagine that your client responds positively. DEVELOP A FEAR HIERARCHY A fear hierarchy is a list of situations that are increasingly anxiety provoking for your client. Fear hierarchies usually include objects or situations that are either increasingly similar in some way to the feared stimulus or involve physically approaching the feared stimulus. For example, if a client is afraid of spiders, a hierarchy of similar stimuli might include looking at a picture of a spider, touching a plastic spider, looking at a real spider, and finally touching a real spider. If a client was avoiding a street where she had been assaulted, a hierarchy based on physically approaching the feared stimulus might start with standing four blocks away, progressing to standing three blocks away, then two blocks away, and eventually standing on the street where the assault occurred. I ask clients to give me examples of situations they find fairly easy, moderately hard, and very dif- ficult. Here is Suzanne’s list of anxiety-provoking situations related to engaging in more social situa- tions at school. Her therapist asked her to list three situations for each level of difficulty. Fairly easy: •Saying hello to other teachers I pass in the hall when I arrive at school •Saying hello to another teacher on the way to recess •Saying hello to the teacher next to me at assembly

Moderately hard: •Eating in the lunch room and sitting down at a table with the other teachers •Starting a conversation with the teacher next to me at assembly •Asking for help with a school-related task, for example how to use the copier or where a resource is located Very difficult: •Asking another teacher to have lunch with me •Making a comment at a staff meeting •Volunteering to participate in the school play and letting the other teachers know that I have experience When creating fear hierarchies, clients rate the difficulty of the tasks and their anxiety using sub- jective units of distress, or SUDS. A SUDS of 100 is the most anxious your client has ever been, and a 0 is not at all anxious. Using SUDS ratings helps clients keep track of their level of anxiety. You can download an example of a fear hierarchy that I used with a client who was afraid to go into a subway car after an accident. (See Sean’s Fear Hierarchy at http://www.newharbinger.com/38501.)

Exercise 11.3: Aiden Uses a Knife Again Practice developing a fear hierarchy. Video 11.1: Develop a Fear Hierarchy Agenda Item #3: Implement Exposure You are now ready to start doing exposure. This phase involves developing effective exposure tasks, identifying your client’s negative predictions, and actually doing exposure. DEVELOP EFFECTIVE EXPOSURE TASKS Exposure tasks should be sufficiently easy to ensure success, but sufficiently difficult that your client learns that exposure works. I usually start with a task that has a SUDS rating of around 30 to 40.

There are three criteria for good exposure tasks:

1. The task is sufficiently specific and concrete that it is clear to your client what he will do as well as when and where he will do the task, and he will be able to measure whether he was successful.
2. The task specifies an action your client will do, and not how he will feel.
3. The task is under your client’s control. Let’s look at a couple of tasks and see if they meet these criteria. TaskSpecific and Concrete?Action the In Client’s Client Can Do? Control? Conclusion: Is This an Effective Task? Impress my boss with a good questionNo, not clear what he will do, when or whereNo, not clear what he will doNo, can’t control No whether your BETTER TASK: boss will be Ask one question impressed at staff meeting. Walk in the area where I was assaultedNot sufficiently specific. Where will client walk? For how long?Yes, client can walkYes, in client’s control No BETTER TASK: Walk for fifteen minutes, three blocks from where the assault took place.

YOUR TURN! Develop Effective Exposure Tasks Look at the two exposure tasks below and decide whether they are (1) sufficiently specific, (2) an action that the client can do, and (3) under the client’s control. If you do not think they are good tasks, develop a better task. You can find my answers in the appendix. Task Specific and Concrete? Action the In Client’s Client Can Do? Control? Conclusion: Is This an Effective Task? Stand in front of the elevator in my building for 5 minutes every day Look at photos on the Internet of cars similar to the one that hit me FIRST EXPOSURE TASK If possible, either conduct the first exposure task with your client in your office or go with your client to the situation he fears; that way, you can be sure that your client understands the process and you are there for support. In my many years of doing exposure, I have played with plastic spiders and plastic knives; stood in front of elevators, subways, and streetcars; and looked at photos of cars, knives, and vomit. The Internet is fabulous for exposure therapy—you can find photos and videos of almost anything! For her first exposure task, Suzanne suggested starting with saying hello to teachers she passed in the hall on the way to class in the morning. Her SUDS rating was a 40. The task is specific and involves an action that Suzanne will do. However, her therapist thought the task was not sufficiently specific, and it would be hard to measure whether she was successful. They decided she would say hello to at least three teachers, five days a week in the morning on the way to class.

MOVE UP THE HIERARCHY Once a client has accomplished the first task on the hierarchy, we develop the next step collabora- tively. I ask my client what would be a good next task. Generally I aim for tasks with SUDS of 40 or 50, though sometimes clients want to try a task with a higher SUDS rating that they feel is doable. Traditionally, you would not move up the hierarchy until your client’s anxiety in response to the present task had decreased by 50 percent. However, recent research (Craske et al., 2014) suggests that this may not be necessary. I usually move up the hierarchy when my client indicates he is ready and can manage the next task. MAKE EXPOSURE EFFECTIVE There are some specific factors that can help make exposure tasks more effective. Tasks should be frequent and prolonged. Do you think it would be more effective for me to ride a roller coaster three times a day for five days in a row or once a week for fifteen weeks? Probably three times a day for five days. What about a two-minute ride or a fifteen-minute ride? It is important to repeat the exposure task a number of times to consolidate the learning experience. Tasks should be varied and done in multiple contexts. Do you think I should ride one roller coaster at one amusement park over and over, or a variety of roller coasters in a variety of amusement parks? Various roller coasters in various amusement parks will be more effective. Exposure should be mindful. Clients often distract themselves during exposure to avoid really facing their fears. When a client is mindful, he is present in the moment (Teasdale, Williams, & Segal, 2014). Many of my clients say mantras, space out, close their eyes, or pretend they are not there. I use various grounding techniques to help clients stay present (Dobson & Josefowitz, 2015). For example, I watch my client’s eyes to make sure he is looking at the anxiety-provoking stimuli, and during exposure I ask him to label what he sees, to feel the ground beneath his feet, and to notice any sounds. I also ask my client to notice and label his feelings or thoughts without needing to change the thoughts or the physi- cal sensations. Safety behaviors should be eliminated gradually over the course of exposure therapy. Eliminating safety behaviors is part of the fear hierarchy (Rachman, Shafran, Radomsky, & Zysk, 2011). For example, a client kept a clonazepam in his pants pocket as a safety signal whenever he had to fly. As he became more comfortable with flying, he moved the clonazepam to a bag at his feet, then to a bag in the over- head compartment, and finally, he flew without the clonazepam. For my roller coaster exposure, I would start with riding roller coasters with my daughter (being with my daughter is my safety behavior) and then go on them by myself. Between-session exposure tasks should be assigned. It may not be possible to conduct the exposure tasks with your client, as the anxiety-provoking stimuli may not be easily accessible. This occurred in Suzanne’s case, where the exposure task involved behavior that would take place at school. A lot of exposure work is done between sessions, as homework. If we completed an exposure task during therapy, my client’s homework is usually to do the same task on his own. This enables the client to consolidate the work we did together.

Video 11.2: Exposure Therapy IDENTIFY YOUR CLIENT’S NEGATIVE PREDICTIONS Remember that you can think of exposure as a behavioral experiment. This means you ask your client to predict what will happen during the exposure task. The exposure task is a test to see if the prediction was accurate (Craske et al., 2014). Remember, in chapter 6 we defined anxiety as expecting bad things to happen and we used the following equation to understand anxiety. Anxiety = Overestimate Danger or difficulty of situation + Overestimate Likelihood of situation occurring + Underestimate Your ability to cope Figure 11.2. Understand anxiety. I want clients to predict what will occur and how they will react so that we can examine the accu- racy of their predictions and change the anxiety equation. Clients often have “realistic” predictions and “worst-case” predictions. I ask for worst-case predic- tions because I want to test whether the belief that is driving the anxiety is accurate. I look for two types of predictions: first, what is my client’s worst fear, or what is he most worried will occur? I then ask my client to rate the likelihood of his prediction occurring. Second, I ask my client to predict his worst fear about how he will react—about how he will feel, about the symptoms of these feelings, and about what he will do. I then ask him to rate the likelihood of this occurring. It is important that the predictions are sufficiently concrete that your client can judge the accuracy of his predictions. Often a client’s prediction involves how he or other people will feel. Try to specify the behaviors your client predicts will happen as a consequence of the feelings; predictions that are behaviors are easier to assess than predictions that involve feelings. For example, if a client predicts he will be anxious, ask what he is afraid he will do because of his anxiety, or what symptoms he is afraid he will have. For example, is he afraid he will talk too quickly, or blush, or have a crushing feeling in his chest? If a client predicts that a friend will be bored, ask how he will know that the friend is bored.

Below are some examples of predictions. Exposure TaskWhat are you most worried will How am I most worried I will occur? (Likelihood 0–100%) react? (Likelihood 0–100%) Stand in the subway station and watch a trainSomeone will throw himself on the track and get killed. (80% likely)Look at a drawing of a cockroach for 15 minutesI will find it too difficult to do. (50% I will be so anxious that I will run likely) out of the room screaming or faint. (40% likely) Ask a question in classThe teacher will say it is a stupid question. (60% likely)I will freeze and stumble on my words. (95% likely) Ask a friend to go to the moviesMy friend will not want to go. (90% likely)If my friend says no, I will be quiet on the phone and stay home feeling depressed the rest of the day. (90% likely) I will be so anxious that I will lose control and throw myself on the track. (50% likely) If we do go out, I will have nothing to say and will be quiet the whole evening. (80% likely) Below are some questions to help your clients identify their predictions. You can download Questions to Identify Your Client’s Predictions During Exposure at http://www.newharbinger.com /38501.

I start with saying, “When you think of doing the exposure task,” •What is your worst-case scenario? •What is your worst fear about what will happen, including how other people will react? •What is your worst fear about how you will feel, including your worst fear of the symptoms you will have? •What is your worst fear about what you will do or how you will behave? •What do you imagine will happen? Do you see it happening? (Clients often have images of what will occur during the exposure task.) Suzanne’s therapist asked her what was the worst that could happen if she said hello to the teachers in the hall. Suzanne responded that she would be anxious and rated her anxiety a 5 out of 10. Her worst-case scenario was that she would say hello in a hesitant and awkward manner and her face would turn bright red. She rated the likelihood of being hesitant at 75 percent and turning bright red at 45 percent. Suzanne’s therapist then asked for her worst-case scenario of how she expected the other teachers to react. Suzanne responded that the other teachers will “ignore me and walk past me without saying anything.” She had a clear image of two teachers in particular smirking at her. Suzanne now has a concrete prediction that she can assess. Suzanne’s therapist wrote down her worst-case predictions and her likelihood ratings so that they had a record to refer back to. In exposure therapy you do not verbally challenge your client’s predictions, no matter how far- fetched they may seem. You write them down and use the exposure task as an experiment to test whether the prediction is accurate. Agenda Item #4: Do Postexposure Debriefing Once your client has completed the exposure task, you want to discuss what he learned. MONITOR OUTCOME OF EXPOSURE TASKS It is helpful if your client can monitor, on a written worksheet, the outcome of his exposure task and his anxiety level. This provides data that can be used to challenge his predictions. I ask clients to monitor their anxiety every five minutes if the task involves staying in a situation for a prolonged period of time, or until their anxiety decreases. In Suzanne’s case, she recorded her anxiety at the beginning and the end of the task. Below is Suzanne’s monitoring worksheet. Task: Say hello to three teachers a day on the way to class in the morning. Number of Teachers Said Hello To Anxiety (SUDS) Start of TaskEnd of Task Monday34040 Tuesday34035 Wednesday43025 Thursday52010 Friday51010

COMPLETE THE POSTEXPOSURE DEBRIEFING The next step is to debrief or explore what your clients learned from the exposure task. I use the anxiety equation we looked at earlier as the conceptual model that guides my debriefing. You want to review: •The accuracy of your client’s initial predictions •The danger or difficulty of the situation •Your client’s ability to cope with the task and with his anxiety •What happens to anxiety with exposure In debriefing, you are gathering evidence and looking for facts that will enable your client to evalu- ate the accuracy of his prediction. I usually use the Are My Predictions Accurate? worksheet, which you can download at http://www.newharbinger.com/38501. Let’s look at how Suzanne and her therapist completed the worksheet. Are My Predictions Accur ate? Exposure TaskYour Predictions (Likelihood of Happening: 0–100)Gather DataWhat Did You Learn? Specific?1. Worst that could happen?1. What occurred?1. Was my prediction accurate? (Yes or No) Action you will do? Under your control? 2. Worst I could feel? 3. Worst behavior I could do? 4. Images of what will happen? 2. How did I feel? 3. How did I behave? 4. Was my image accurate? 2. How dangerous or difficult was the task? 3. Could I cope with the task and my anxiety? 4. What happened to my anxiety with exposure?

Say hello to three 1. Other teachers will 1. Other teachers said teachers in hallway ignore me, walk past hello and smiled. on the way to me, and two At least one teacher class, five days a teachers will smirk a day stopped and week. (90% likely). chatted. No one smirked. 2. I will be anxious (8/10). 2. I felt anxious in the beginning, but by 3. I will say hello in the end I was fine. a hesitant and awkward manner 3. I was not hesitant or (75% likely) and my awkward and my face will get bright face was not red. red (45%). 4. My image was not 4. Clear image of accurate. teacher smirking

1. No
2. The task was not very difficult, and became easier.
3. I could cope with my anxiety and still do the task.
4. The more I did the task, the easier it became.

You will use the data you collected to debrief and assess whether your client’s predictions were accurate. I explore both my clients’ ability to stay in the anxiety-provoking situation and their ability to tolerate anxiety. Anxious clients often use their anxiety as a sign that they need to avoid the situation. I want my clients to learn that they don’t need to listen to their anxiety but rather can make decisions about how they want to behave. You also want to reinforce that anxiety will decrease with exposure. Let’s look at how we might debrief with Suzanne. Notice how her therapist helps Suzanne reach her own conclusions and then reinforces the conclusions. Was Suzanne’s prediction accurate in relation to the danger or difficulty of the situation? Therapist:Do you remember what you predicted would occur if you went up to teachers and said hello? Suzanne:Yes, I predicted that they would ignore me, and two teachers would smirk. Therapist:And what occurred? Suzanne:Almost all of them smiled and said hello back. Therapist:Hmmm, what do you make of that? The therapist is asking Suzanne to reach her own conclusions. Suzanne:I guess my prediction was wrong; people were friendly. Therapist:(smiling) Can you say that again? The therapist is reinforcing Suzanne’s conclusions by asking Suzanne to repeat her conclusion. Suzanne:(laughing slightly) People were friendly. Therapist:I think that is a very important observation. Was Suzanne able to cope with the task and her anxiety? Therapist:When you started the task, on the first day, where was your anxiety? Suzanne:It was at a 40. Therapist:And were you still able to say hello to the other teachers and accomplish the task? Suzanne:Yes, I was. Therapist:The fact that you were able to say hello to teachers even though you were anxious, what does that tell you about needing to avoid if you are anxious? Suzanne:I guess I can still do things, even if I am anxious. It seems that just because I am anxious, I don’t have to avoid.

YOUR TURN! Continue Debriefing with Suzanne Try using what you’ve learned to help Suzanne understand the effects of exposure on her anxiety. Therapist: I’m curious what happened to your anxiety over the course of the week as you said hello to the other teachers. Suzanne: Well, it got easier and easier, and my anxiety went down. Look at the three responses below. How could you help Suzanne reach her own conclusions about the effect of exposure on anxiety?

1. I think that’s great. This is exactly what we would expect from exposure therapy. The more you do a task, the easier it will be and the less anxious you will be.
2. Given that your anxiety went down, what did you learn about what happens to anxiety when you do exposure?
3. What helped you confront the task? Response #2 is the best response to help Suzanne reach her own conclusions. Response #1 would be a good response after Suzanne had reached her own conclusions in order to reinforce them. Response #3 would be a good question if you wanted to understand how Suzanne had motivated herself.

CONSOLIDATE WHAT YOUR CLIENT LEARNED After you have debriefed the exposure task, you want to help your client consolidate what he learned. I use three approaches: developing a more accurate prediction, imaginal rehearsal, and review. To develop a more accurate prediction, I refer to my client’s original prediction and then ask what would be a more accurate prediction, given what occurred during the exposure task. I encourage my client to write down his new prediction. Next I use imaginal rehearsal to review the outcome of the exposure task and the new prediction. In Suzanne’s case her new prediction was that the teachers would be friendly when she said hello. Her therapist asked her to create an image and see the various teachers smiling at her and saying hello. Her therapist then asked Suzanne to review this memory three times a day as part of her homework. Video 11.3: Debrief After Exposure Agenda Item #5: Discuss Relapse Prevention One of the difficulties with exposure treatment is that fears can return after treatment (Craske & Mystkowski, 2006). I explain to clients that exposure is similar to exercise. Even if you exercise every day and get into really good shape, you have to keep exercising or you will not stay in shape. Exposure is similar; you have to keep practicing for the benefits to last. At the end of therapy, I explain the prin- ciples of relapse prevention: •Continue to face situations you previously avoided. Remember: anxiety is not a reason to avoid. •The more you face your fears, the easier it becomes. Remember: anxiety is normal and expo- sure works. Homework: Practice CBT Before continuing with the next chapter, take some time to try the homework. Apply What You Learned to a Clinical Example Complete the following exercises.

Exercise 11.1: Suzanne Avoids the Other Teachers Exercise 11.2: Maia Was Attacked Exercise 11.3: Aiden Uses a Knife Again

Apply What You Learned to Your Own Life After you have completed the homework assignments below, pause and take a moment to think about what you learned about yourself. Then, think about the implications of your experience with these exercises for your therapy with clients. Homework Assignment #1 Identify Your Own Safety Behaviors Think of a situation in the past month where you were anxious. What did you do to make yourself more comfortable? For example, did you carry an object or be with a certain person? Did any of your strate- gies involve avoidance, checking, reassurance and rehearsal, compulsive rituals, or safety signals? What was the consequence of your safety behavior? Homework Assignment #2 Develop a Fear Hierarchy Try to think of any situations that you have been avoiding. It could be a social situation or a specific fear.

1. Develop a fear hierarchy for your problem. Think of situations that are fairly easy, moderately hard, and very difficult.
2. Choose a first task; make sure it is concrete, an action that you can perform, and in your control.
3. Make a prediction of what will occur if you do the first task.
4. Now, it is up to you to try the task. Apply What You Learned to Your Therapy Practice For this next assignment, think of a client whom you are currently working with and who suffers from anxiety.

Homework Assignment #3 Identify Your Client’s Safety Behaviors Once you have chosen a client, complete the following steps.

1. Ask one or two questions from the handout Questions to Assess Your Client’s Safety Behaviors. • Are there things or situations you avoid because of your anxiety? • Are there things you do to make yourself feel safe or to be prepared in case of danger, such as carry things or be with certain people? • Is there anything you do to make yourself feel comfortable in situations where you feel anxious?
2. If your client is avoiding, ask how avoiding is a problem in his life.
3. Once you have identified your client’s safety behavior, explain safety behaviors and explore the consequences of the client’s safety behavior. Homework Assignment #4 Develop a Fear Hierarchy Think of a client who is avoiding and who you think would benefit from facing his or her fears.
4. Develop a fear hierarchy with this client. Identify situations that are fairly easy, moderately hard, and very difficult.
5. Identify a first exposure task. Make sure it is concrete, an action your client will take, and under his or her control.
6. Ask your client to predict what he or she thinks will occur.
7. Steps 1 through 3 may be enough for your first experience with developing a hierarchy. However, if you feel you are ready, and it would be helpful to your client, ask your client to try this first task.
8. Check whether your client’s predictions were accurate.

Let’s Review Answer the questions under each agenda item. Agenda Item #1: What is exposure? • What is the central theory of exposure? Agenda Item #2: Prepare to do exposure. • What two things do you want to do before you start exposure? Agenda Item #3: Implement exposure. • What are three factors that make for an effective exposure task? Agenda Item #4: Do postexposure debriefing. • Why is it important to have a postexposure debriefing? Agenda Item #5: Discuss relapse prevention. • What are two important things to tell your clients about relapse prevention? What Was Important to You? What idea(s) or concept(s) would you like to remember? What idea(s) or skill(s) would you like to apply to your own life? What would you like to try this coming week with a client? (Choose a specific client.)

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.

APPENDIX Answers to YOUR TURN! Exercises Chapter 1 Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior Situation, Thought, Feeling, Physical Reaction, or Behavior? Staying up late and studyingSituation No matter what I do, no one likes me.Thought I feel tense all over.Physical reaction Even if I study hard, I will still fail.Thought I am so happy.Feeling My boss hates my work.Thought I am late for work.Situation

How Thoughts Influence Feelings and Behavior Below is how I completed figure 1.4. Maria's Thoughts Situation Maria and Jane attend a conference. This will be awful. No one will talk to me. Everyone will think I am stupid. Jane's Thoughts This is a good opportunity to network and meet new people. It will be fun to have something different to do. Feelings Anxious Behavior Sits in a corner by herself Physical Reactions Sick stomach Feelings Excited Behavior Mingles with other attendees Physical Reactions Pleasant excitement Identify Clients’ Thoughts, Feelings, Physical Reactions, and Behavior Situation: Boyfriend arrived thirty minutes late, did not let her know he would be late Sara’s Thoughts: I hate it, he doesn’t care about me; I am worthless; what else can I do?; he takes me for granted. Sara’s Feelings: Depressed, irritated Sara’s Physical Reactions: Tense Sara’s Behavior: Gives dirty looks, acts cold

Maria’s Symptom Maintenance Cycle Below is how I completed Maria’s symptom maintenance cycle. Feelings SituationThoughts Attend a conference where she knows no oneThis will be awful. No one will talk to me. Everyone will think I am stupid. No one talks to her, never gets experience of people liking her Anxious Behavior Sits in a corner by herself Physical Reaction Sick stomach Consequences No one talks to her; does not meet anyone

Chapter 2 Raoul’s Stressors and Strengths R aoul’s Stressors and Strengths Family Difficulties or StressorsStrengths or Areas of Resilience • No information• Long-term marriage • Children live out of town• Wife encouraged him to bowl, suggests caring relationship • Close enough relationship with daughter that she noticed his distress and was able to convince him to go for therapy Friends and Social Contacts• No information• No information Recreation & Organizations• No information• Past five years, part of a bowling league Work or School• Recently passed over for a promotion• Has maintained steady employment for twenty years • Recent poor work evaluation• Works in a demanding area that requires understanding of taxes • Previously enjoyed work • Risked applying for a promotion • History of good work evaluations Health Finances • Sleep difficulties• Moderate drinking • Anxiety• Health “good” • Postponed retirement• Some indication that financially responsible • Planning for retirement Changes • Financial worries • No information

Chapter 3 Identify Specific, Measurable Goals Assess Whether the Goal Is Gener al or Specific and Measur able GoalsIs This Goal General or Specific and Measurable? Talk to my boss about getting paid for working overtimeSpecific and measurable Be less demanding of my friendsGeneral Stop smoking by the end of the monthSpecific and measurable Take better care of my healthGeneral Get along better with my parentsGeneral Do a pleasant activity with my partner on a weekly basisSpecific and measurable Learn better parent management skills for when my eight-year- old has a temper tantrumSpecific

Chapter 4 Evaluate Suzanne’s Homework Suzanne’s therapist says, “I would like to give you some homework. I think it would be really helpful if you could try to do some fun things with your children this coming week.” Helpful Homework GuidelinesDoes Suzanne’s Homework Meet This Guideline? The homework is developed collaboratively.No, the therapist suggested the homework at the last minute. There is no opportunity for Suzanne to have input. The homework is specific and concrete.No, no clear idea what Suzanne will do. The homework is related to the session.Yes, Suzanne had been talking about her feelings related to not doing fun things with her children and indicated she would like to start again. The homework is doable.We don’t know, as there is no specific task.

Chapter 5 Separate the Facts about the Situation from the Thoughts about the Situation Examples of SituationsFacts about the SituationClient’s Thoughts about the Situation Instead of doing homework, I was lazy and went out with friends.Instead of doing homework, client went out with friends.I was lazy. My boss told me I did a good job, but he didn’t really mean it.Boss said client did a good job.He didn’t really mean it. My child is not normal; he is not crawling at age five months.Client’s child is not crawling.My child is not normal. The huge mess my husband left in the kitchen.Not clear what the husband did; therefore, you don’t have any facts. You would need to gather facts.My husband left a huge mess in the kitchen.

Chapter 6 Identify Suzanne’s Thoughts about Self, Others, and the Future

1. He didn’t give Andrew his bath. This is a fact. It is true that her husband did not give Andrew his bath. This thought is not an evalu- ation but a statement of fact.
2. No matter what I do, it won’t make a difference. This thought is about the future. She thinks the future will be the same as the present.
3. He doesn’t care about me or the kids. This thought is a judgment about her husband. Therefore, it is about others.
4. You can’t count on men. This is a general rule about men. Therefore, it is about others.
5. I’m a completely inadequate mother. This thought is a negative judgment about herself. Therefore, it is about self.
6. Why do I have to do everything in the house? I ended with a trick question. This is a question. We are going to look at questions in more detail. However, for this exercise, there are a number of implied thoughts that you would want to help your client make explicit. It is a thought about self, as Suzanne is really saying, “I have to do everything in the house,” but it is also a thought about others, as the implication is “My husband does nothing.”

What Thoughts Go with These Feelings? The correct answer is in bold.

1. Cameron is feeling furious. What might he be thinking? •Our team will never have another chance to play in the semi-finals. •That guy is an animal; he should be punished; it’s unfair. This thought is most likely to lead to feeling furious. It is about rules being broken, and being treated unfairly. • If we lose, it is all my fault.
2. Annette is feeling disappointed. What might she be thinking? •I will never get a decent job; my life is over. •They should have hired me; what idiots! •I had hoped to get the job, but at least I was second choice. This thought is most likely to lead to disappointment. Disappointment is related to sadness, but it is not a strong feeling. The other thoughts are too extreme for disappointment.
3. Orly is feeling guilty. What might he be thinking? • I am a bad friend; I should have gone; I bet I hurt Roy’s feelings. This thought is most likely to lead to guilt as it is about breaking a moral rule. •My friend is probably furious at me. •I bet Roy will not want to be my friend anymore.

Identify the Cognitive Distortion

1. If I don’t get this job, my life will be over. Cognitive distortion: catastrophizing
2. To be a good therapist, you have to give it your all and be there 100 percent of the time for your clients. Cognitive distortion: shoulds
3. I’m sure that no one will ever want to hire me after this last fiasco of a job interview. Cognitive distortion: overgeneralizing
4. If I don’t help all of my clients, I am an inadequate therapist. Cognitive distortion: polarized thinking
5. I know that my last client canceled because she thinks I’m a bad therapist. Cognitive distortion: personalizing and mind reading
6. A colleague told me he wondered if the group check-in should be a bit shorter next time. That was a terrible mistake I made in the first group. Cognitive distortion: magnifying; could also be catastrophizing

Chapter 8 Help Cynthia Reach Her Own Conclusions Below are some questions you could ask.

1. Can you tell me about your relationship with John?
2. Are there ways that John shows he cares about and respects you? (If Cynthia did not mention their sexual relationship) In your sexual relationship, are there ways John shows he cares about and respects you?
3. How do Mike and Chris treat you? Can you give me some examples?
4. Have Mike and Chris ever made any comments indicating that they respect you? Could you give me examples?
5. When you think of the evidence from John, Mike, and Chris, what does it tell you about your belief that men are only interested in you for sex?

Chapter 10 Understand Mayleen’s Depression Mayleen’s Understand Your Depression worksheet Increased Since Life Changes or StressorsDecreased Since Life Changes or Stressors Activities I enjoy or that provide pleasure or masteryTaking care of motherStopped sculpting Activities I do not enjoyDriving to see mother Going to mother’s doctor’s appointments (mixed: enjoy as sense of purpose and consistent with values, but do not enjoy activity) Looking after the house TV ExerciseStopped exercise Spending time with friendsStopped seeing many friends Spending time with family Leisure or hobbies Smoking, overeating, alcohol or drug use Routines related to eating and sleeping No friends when with mother More time with mother

Develop Mood-Boosting Activities for Anna Suggested ActivityDeveloped CollaborativelySpecific and ConcreteDoableNaturally ReinforcingRegular Routine Run three times a week for an hourNoYesNoYes, if she could do itYes Run three times a week for an hour. This is a concrete plan, and it is naturally reinforcing because Anna likes to run. It could also be part of a routine. The problem is that it is probably not doable. Very few people could go from no exercise to running for an hour three times a week. Plus, if she has not exercised in a while, an hour of running may be physically too much. In conclusion, it is not a good plan. A more effective plan: To develop a more effective plan, you would start with asking Anna what she would like to add to her life and how she would like to change the period of time around 5:00 p.m. If running was of interest to Anna, it would be important for her to start slowly. Depending on how long it has been since Anna has exercised, it might make sense to start with walking, or a combina- tion of walking and running.

Use Graded Task Assignments TaskSpecific and Concrete?Doable?Time-Limited and Specific Time for Task? Cynthia:No. Not clear what the criteria are for a systematic filing system; first action is not clearNot sure who will do this and what exactly the person/people will do; hard to know if it is doableNo time limit given; will Cynthia work for 10 minutes or the whole day? Yes, this is a specific task.Yes, though you would have to checkYes, a time limit was set, but no specific time was specified when the task would be done No, it is not clear how Alexandra would explore her options for work.Because as task is unclear, hard to know if it is doableNo time limit and no specific time set for task Reorganizing the filing system Richard: Make a list of food I want to cook Alexandra: Explore options for work No specific time for task

Chapter 11 Develop Effective Exposure Tasks TaskSpecific and Concrete?Action the Client Can Do?In Client’s Control?Conclusion: Is This an Effective Task? Stand in front of the elevator in my building for 5 minutes every dayYesYesYesYes Look at photos on the Internet of cars similar to the one that hit meNo. We do not know which photos he will look at. There is a great range of cars that are “similar” to the one that hit the client.YesYesNo, because it is not sufficiently concrete and specific

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Nina Josefowitz, PhD, is a psychologist in private practice and has taught a graduate-­level course on cognitive behavioral therapy (CBT) for over fifteen years in the Counselling and Clinical Psychology Program at the Ontario Institute for Studies in Education (OISE) at the University of Toronto. Josefowitz has offered workshops in CBT throughout Ontario and internationally. She has appeared in court numerous times as an expert witness in cases involving interpersonal violence. Josefowitz was on the Council of the College of Psychologists of Ontario for nine years, and president of the college from 2001–­2003. She has published in the areas of trauma, women’s issues, ethics, the therapeutic relation- ship, and a variety of issues related to CBT. Her most recent interests include incorporating imagery into CBT. David Myran, MD, (1949–­2016) was a geriatric psychiatrist and assistant professor in the department of psychiatry at the University of Toronto. For many years, he was director of the Geriatric Psychiatry Outreach Team at Baycrest Health Sciences—­a University of Toronto-­affiliated hospital, where he served as a staff psychiatrist. Myran was also a CBT supervisor for psychiatry residents at the University of Toronto. Myran published and presented at professional conferences on a wide number of topics, including psychological treatment for irritable bowel syndrome, a range of topics within geriatric psy- chiatry, the therapeutic relationship, and depression. His interests also included using telehealth to provide psychiatric services to older adults who are housebound. Foreword writer Zindel V. Segal, PhD, is professor of psychology at the University of Toronto Scarborough. He is coauthor of Mindfulness-­Based Cognitive Therapy for Depression and The Mindful Way through Depression.

Index AB Aabir Explores His Images exercise, 131 about this book, 2–4 active learning, 3 activities: monitoring daily, 204–208; planning mood-boosting, 209–215 affect regulation, 90 agendas: collaboratively setting, 67–69; working in a session, 69 Aiden Uses a Knife Again exercise, 232 all-or-nothing thinking, 110 analogy use, 203 anger, understanding, 108 anxiety: exposure therapy for, 223–245; how to understand, 106–107; safety behaviors and, 226–228, 243, 244. See also fears Are My Predictions Accurate? worksheet, 239–240 assumptions, 18, 111 audio files, 4; on explaining a Daily Activities Schedule, 204–205; on explaining exposure therapy, 231; on explaining goal setting to clients, 47–48; on explaining looking for evi- dence, 148; on explaining problem solving, 180; on identifying cognitive distortions, 118; on introducing the Understand Your Reaction worksheet, 89–90; on using questions to explore client problems, 27. See also Practice in Your Imagination exercises automatic thoughts, 9, 248; core beliefs and, 18, 19, 249–250, 252; identifying, 122–124 avoidance: cycle of, 224–225; questions for consid- ering, 230; safety behaviors as, 226balanced thoughts, 163–167; consolidating, 165; creating a new image using, 166–167; managing stress using, 167; questions for developing, 163 Beck, Judy, 155 behavioral activation, 196–221; cycle of depression and, 197–198; daily activity monitoring in, 204–208; graded task assignments in, 215–217; and helping clients understand their depres- sion, 199–204; homework assignments on, 219– 220; increasing well-being through, 218; planning mood-boosting activities in, 209–215; research on effectiveness of, 198–199; steps in process of, 198 behavioral experiments, 224 behaviors: cognitive distortions and, 115–116; coping thoughts related to, 188; describing spe- cific and concrete, 98; examples of vague vs. specific, 95; four-factor model for understand- ing, 10; helping clients identify, 94–96; influ- ence of thoughts on, 12; linking thoughts to, 135–137; problems maintained by, 16–17 beliefs. See core beliefs Benefits and Drawbacks of My Solutions worksheet, 185 black-and-white thinking, 110 brainstorming solutions, 180–183 C Carol Wants to Apply for a Job exercise, 132 catastrophizing, 111 CBT. See cognitive behavioral therapy286 check-in process, 62–66; components of, 63–64; dialogue example, 65; staying focused in, 64, 66 Checklist of Common Problems with Thought Records handout, 168 clarifying questions, 122 cognitive behavioral therapy (CBT): building blocks of, 7–11; definition of, 1; explaining to clients, 39; fundamental principles of, 1; homework on practicing, 259–260; self-appli- cation of, 3; study on effectiveness of, 2 cognitive distortions, 109–116; common types of, 110–112; dysfunctional behaviors and, 115– 116; exercises for identifying, 112–113, 116; helping clients identify, 113–114; homework assignments on, 117–118, 120; worksheet for identifying, 114, 117 collaboration: in agenda setting, 67–69; in home- work development, 70 Common Problems with Thought Records exer- cise, 168 compulsive rituals, 226 consequences of behaviors, 95 content specificity, 106 coping thoughts, 187–191 core beliefs: automatic thoughts and, 18, 19, 249– 250, 252; clinical implications of, 20–21; downward arrow technique and, 252; identi- fying with clients, 248–252; psychosocial history and, 250–251; thoughts influenced by, 18–21; three types of, 18 Cycle of Avoidance diagram, 225 D Daily Activities Schedule, 204–208 daily living activities, 209 depression: behavioral activation for, 196–221; CBT developed as treatment for, 1; daily activity monitoring for, 204–208; diagram on cycle of, 197; helping clients understand, 199– 204; planning mood-boosting activities for, 209–215; relapse prevention for, 215; thoughts indicative of, 107–108 CBT Made Simple Develop Effective Exposure Tasks exercise, 234, 277 Develop Mood-Boosting Activities for Anna exercise, 211–212, 275 Dewei Uses Marijuana Again exercise, 69 Diana Wants to Go to College exercise, 127 doorknob therapy, 67 downward arrow technique, 252 dysfunctional behaviors, 115–116 E emotions. See feelings empathy, 25, 96–97 environment, in four-factor model, 8 Eulela Has a Very Bad Week exercise, 66 Evaluate Suzanne’s Homework exercise, 71–72, 268 evaluative thoughts, 103–105 Examine the Reality of Your Thoughts worksheet, 146, 170 Examples of Coping Thoughts handout, 190 exercise, physical, 209 exercises (practice), 4; for behavioral activation, 212; for developing helpful goals, 55; for eval- uating the Understand Your Reaction work- sheet, 137; for explaining consequences of thoughts, 189; for exploring images and thoughts, 131, 132; for exposure therapy, 226, 228, 232; for focusing on problems and strengths, 38; for helping clients reach their own conclusions, 162; for identifying cogni- tive distortions, 113, 116; for identifying prob- lems with thought records, 168; for identifying specific behaviors, 95; for identifying the meaning of situations, 127; for identifying thoughts about self, others, or the future, 106; for identifying trigger situations, 87, 89; for problem solving, 178; for reviewing balanced thoughts, 165; for using CBT theory to under- stand clients, 14, 15, 16, 18, 19, 20, 21; for weighing evidence against hot thoughts, 154; for working with depressed clients, 201, 212; for working within a session structure, 66, 69, 72. See also YOUR TURN! exercises Explain CBT to Your Client handout, 39 Explain Goal Setting handout, 47 Explain the Structure of a Therapy Session handout, 61 exposure therapy, 222–245; effectiveness of, 228; explaining to clients, 230–231; fear hierarchy for, 231–232, 243, 244; homework assign- ments on, 243–244; implementing exposure in, 232–238; negative predictions about, 236– 238; postexposure debriefing in, 238–242; preparing to do, 229–232; relapse prevention and, 242; tasks used in, 232–235, 238; theory behind, 223–224; types of, 228–229G FH facts vs. thoughts, 87–88 false alarms, 158 fears: categories of, 229; exposure therapy for, 223–245; hierarchies of, 231–232, 243, 244; how avoidance maintains, 224–225. See also anxiety feedback, requesting from clients, 73 feelings: distinguishing thoughts from, 9, 91; empathy toward thoughts and, 25; explana- tion of emotions and, 90; helping clients iden- tify, 90–93; images accompanying, 131; linking thoughts to, 135–137; physical reac- tions distinguished from, 9; rating process for, 92–93, 98, 108–109; thoughts related to, 12, 106–109, 127–128; worksheet for identifying, 138–139 Fennell, Melanie, 203 filtering, 110 Find the Facts exercise, 89 flower analogy, 203 focus, during check-in, 64, 66 four-factor model, 7–11; homework assignments on, 21–22; self-reflection exercise, 24; thera- peutic use of, 81–83, 137 future: predictions about, 111; thoughts about, 104, 108, 119 goals, 46–58; defining problems and setting, 179; developing specific and measurable, 48–55; examples of general vs. specific, 49; home- work assignments on, 56–57; introducing clients to, 46–48; prioritizing order of, 47, 55 Good Sleep Guidelines, 258 graded task assignments, 215–217 gratitude, expressing, 218 Greenberger, Dennis, 147, 155 Guidelines for an Effective Activity Plan handout, 210 Guidelines for Helpful Homework handout, 70 guilt, understanding, 108 habituation, 223–224 handouts, 4; Checklist of Common Problems with Thought Records, 168; Examples of Coping Thoughts, 190; Explain CBT to Your Client, 39; Explain Exposure to Your Clients, 230; Explain Goal Setting, 47; Explain the Structure of a Therapy Session, 61; Good Sleep Guidelines, 258; Guidelines for an Effective Activity Plan, 210; Guidelines for Helpful Homework, 70; Identify Your Feelings, 90; Pleasurable Activities List, 210; Questions for a Balanced Thought, 163; Questions to Assess Your Client’s Safety Behaviors, 227; Questions to Develop Coping Thoughts, 189; Questions to Develop Helpful Goals, 51; Questions to Explore a Mood/Activity Relationship, 205; Questions to Explore Problems, 26; Questions to Explore Strengths, 33; Questions to Gather More Information about the Situation, 159; Questions to Help Set an Agenda, 67; Questions to Identify Evidence Against Negative Thoughts, 155; Questions to Identify Your Client’s Images, 131; Questions to Identify Your Client’s Predictions During Exposure, 237; Questions to Identify Your Client’s Thoughts, 134;288 Questions to Review the Therapy Session, 72; Thinking Traps, 110. See also worksheets happiness, increasing, 218, 219–220 Help Cynthia Reach Her Own Conclusions exer- cise, 162, 273 Help Neale Identify a Specific Situation exercise, 86–87 Help Raoul Develop Coping Thoughts exercise, 190–191 Help Raoul Find New Solutions exercise, 182–183 Help Raoul Stay Focused During the Check-In exercise, 66 Help Suzanne Make Her Goals More Specific exercise, 53–54 Help Suzanne Take a Close Look at the Facts exercise, 160 helpful questions, 124–129 history, psychosocial, 38–39 homework: developing helpful, 70–71; reviewing during check-in, 63 homework assignments: on behavioral activation, 219–220; on describing specific situations and behaviors, 97–98; on exploring client prob- lems, 41–42; on exposure therapy, 243–244; on identifying cognitive distortions, 117–118, 120; on identifying stressors and strengths, 40, 43; on looking for evidence, 169–170; on practicing CBT, 259–260; on problem solving, 192–194; on rating your own feelings, 98; on setting specific goals, 56–57; on structuring therapy sessions, 74–76; on Understand Your Reaction worksheet, 99–100; on using the four-factor model, 21–22 hopes, thoughts as, 132 hot thoughts, 103, 145, 147, 155, 163 How Probable Are My Predictions? worksheet, 157 How Thoughts Influence Feelings and Behavior exercise, 12–14, Identify a Client’s Stressors and Strengths work- sheet, 34–35 Identify Clients’ Thoughts, Feelings, Physical Reactions, and Behavior exercise, 15–16, 264 Identify Situations, Thoughts, Feelings, Physical Reactions, and Behavior exercise, 10–11, 263 Identify Specific, Measurable Goals exercise, 49–50, 267 Identify Suzanne’s Safety Behaviors exercise, 227–228 Identify Suzanne’s Thoughts about Self, Others, and the Future exercise, 105, 270 Identify the Cognitive Distortion exercise, 112– 113, 272 Identify Your Feelings handout, 90 if...then statements, 18 imagery, 129–131; exploring with clients, 130– 131; practicing coping thoughts using, 190; practicing new solutions using, 186; recreat- ing situations using, 129–130. See also Practice in Your Imagination exercises imaginal exposure, 229 in vivo exposure, 228 “Incorporating Imagery into Thought Records” (Josefowitz), 131 intermediary beliefs, 18 interpretations, alternative, 158–159, 171 Isabella Lists Her Worries exercise, 129 JKL Jamar Is Feeling Depressed exercise, 212 Jim Forgets His Wallet exercise, 106 Josefowitz, Nina, 1, 131 journal writing, 218 Julie Has a Terrible Week exercise, 113 “Just Ask” questions, 122 kindness, practicing, 218 labeling feelings, 90 learning, active, 3 Lee Learns to Ask a Question exercise, 18 life, simple rules about, 18 Linehan, Marsha, 31 looking for evidence: against negative thoughts, 151–163; explaining to clients the process of, 148; homework assignment on, 169–170; sup- porting negative thoughts, 149–151; thought records and, 147 M magnifying problems, 111 Maia Was Attacked exercise, 228 Maria’s Symptom Maintenance Cycle exercise, 17, 265 Mary Treats Her Son Badly exercise, 95 memories, painful, 150 Mind Over Mood (Greenberger & Padesky), 147 mind reading, 111 mindfulness, 210, 235 minimizing problems, 111 Miriam Wants a Better Marriage exercise, 55 mood: asking clients to rate, 63; planning activi- ties to boost, 209–215; related to thoughts, 133–134 mood-boosting activities, 209–215; examples of, 209–210; guidelines for planning, 210–211; monitoring mood before/after, 212–214; over- coming roadblocks to, 214–215 Mooney, Kathleen, 33 Myran, David, 1 N Nasir Has a Busy Clinic exercise, 178 negative paths, 81 negative problem orientation, 175 negative thoughts: finding evidence against, 151– 163; finding evidence supporting, 149–151 Notice Raoul’s Change in Mood exercise, 133–134 O online materials, 3–4 optimism, 176, 218 Other Ways of Understanding the Situation work- sheet, 161 others, thoughts about, 104, 107, 119 overgeneralizing, 110 P Padesky, Christine, 33, 147, 155 painful memories, 150 patterns of limited thinking, 110 pause button, 82 personalizing, 111 Persons, Jackie, 155 perspectives, alternative, 158–159 physical reactions: feelings distinguished from, 9; helping clients identify, 94; linking thoughts to, 135–137 pleasurable activities, 209–210 Pleasurable Activities List, 210 positive problem orientation, 175–177 positive psychology, 218 post-traumatic stress disorder (PTSD), 130 Practice in Your Imagination exercises, 4; for explaining a Daily Activities Schedule, 204– 205; for explaining exposure therapy, 231; for explaining goal setting, 47–48; for explaining looking for evidence, 148; for explaining problem solving, 180; for explaining session structure, 62; for exploring client problems, 27; for reviewing sessions with clients, 73; for understanding your reactions, 89–90 Predict Your Mood worksheet, 213 predictions: probability of negative, 156–158, 170; related to exposure tasks, 236–238; thinking trap on making, 111 probing questions, 122 problem solving, 173–195; brainstorming solu- tions in, 180–183; choosing a solution in, 184–187; developing coping thoughts for, 187–191; explaining to clients, 179–180; homework assignments on, 192–194; identify- ing problems for, 177–180; positive problem orientation for, 175–177; research on290 effectiveness of, 175; steps in process of, 174, 192; theory behind, 174 Problem-Solving Worksheet, 174 problems: defining with clients, 177–178; how behaviors maintain, 16–17; how thoughts maintain, 11–12; positive orientation to, 175– 177; prioritizing with clients, 31; process for understanding, 25–27, 28–30; questions for exploring, 26–27, 28–30, 41–42; setting goals for multiple, 47 prompting questions, 122 psychosocial history, 38–39, 250–251 Q questions: asking helpful, 124–129; for assessing safety behaviors, 227; for challenging hot thoughts, 155–156; for considering avoid- ance, 230; for developing balanced thoughts, 163; for developing coping thoughts, 189; for examining evidence against hot thoughts, 152; for exploring mood/activity relationship, 205; for exploring problems, 26–27, 28–30, 41–42; for exploring psychosocial history, 38; for exploring strengths, 33–34; for finding new solutions, 181; for helping to define prob- lems, 178; for identifying images, 131; for identifying predictions about exposure, 237; for identifying specific situations, 85–86; for identifying thoughts, 122, 124–129, 134–135; for reviewing therapy sessions, 72–73; for setting an agenda, 67; thoughts expressed as, 132 Questions for a Balanced Thought handout, 163 Questions to Develop Coping Thoughts handout, 189 Questions to Develop Helpful Goals handout, 51 Questions to Explore a Mood/Activity Relationship, 205 Questions to Explore Problems handout, 26 Questions to Explore Strengths handout, 33 Questions to Gather More Information about the Situation handout, 159 Questions to Help Set an Agenda handout, 67 CBT Made Simple Questions to Identify Evidence Against Negative Thoughts handout, 155 Questions to Identify Your Client’s Images handout, 131 Questions to Identify Your Client’s Predictions During Exposure handout, 237 Questions to Identify Your Client’s Thoughts handout, 134 Questions to Review the Therapy Session handout, 72 R Raoul’s Boss Is Difficult exercise, 87 Raoul’s Cycle of Depression exercise, 201 Raoul’s Stressor’s and Strengths worksheet, 37, 266 rating feelings, 92–93, 98, 108–109 Raymond Drinks Too Much exercise, 116 reactions: worksheet for understanding, 82, 89–90, 99–100, 124, 136, 137, 139–140. See also physical reactions reassurance seeking, 226 reflective statements, 122 rehearsal, 226, 242 relapse prevention: behavioral activation and, 215; exposure therapy and, 242 Renee Tries to Catch Up at School exercise, 72 reviewing therapy sessions, 72–73, 76 Richard’s Boyfriend Wants to End the Relationship exercise, 106 Roger Doesn’t Want to Go to the Doctor exercise, 16 Ruda Attends Playgroup exercise, 38 S safety behaviors, 226–228, 235, 243, 244 schemas. See core beliefs self: creating a new image of, 166–167; thoughts about, 104, 107, 119 self-assessment questions, 260291 Index Separating Facts from Thoughts worksheet, 88, 269 session structure. See therapy sessions shame, understanding, 108 Sharon Is Invited for Coffee exercise, 15 should statements, 108, 111–112 Shula Eats Dessert example, 115–116 situations: examples of vague and specific, 85; four-factor model for understanding, 8, 21–22; identifying specific and concrete, 84–87, 97; identifying the meaning of, 124–127; recreat- ing using imagery, 129–130; separating facts vs. thoughts about, 87–88. See also trigger situations sleep guidelines, 258 social contact, 209, 218 Socratic questioning, 147, 162 solutions to problems: brainstorming, 180–183; choosing, 184–187 Sophia Completes the Understand Your Reaction worksheet exercise, 137 strengths: exploring your own, 40; identifying client, 33–35, 43 stress management, 167 stressors: exploring your own, 40; identifying client, 32–33, 34–35, 43 SUDS ratings, 232, 235 Suzanne Avoids the Other Teachers exercise, 226 Suzanne Goes to the School Fair exercise, 189 Suzanne Is Asked to Be a Maid of Honor exercise, 162 Suzanne Is Upset with Her Husband exercise, 154 Suzanne Reviews Her Balanced Thought exer- cise, 165 Suzanne’s Stressors and Strengths worksheet, 34–35 symptom maintenance cycle, 17 T tasks, exposure, 232–235, 238 therapeutic relationship, 25, 96 Therapist Is Having a Bad Day exercise, 162 therapy sessions, 59–77; attitudes on structuring, 60, 75; basic components of, 60; collabora- tively setting an agenda for, 67–69; develop- ing helpful homework in, 70–72; explaining the structure of, 60–62; homework assign- ments on structuring, 74–76; in Raoul’s therapy, 256–259; requesting client feedback on, 73; reviewing with clients, 72–73, 76; starting with a check-in, 62–66; in Suzanne’s therapy, 253–256; working the agenda in, 69 thinking style, 110 thinking traps, 110–112; helping clients identify, 113–114, 120; worksheet for identifying, 114, 117. See also cognitive distortions Thinking Traps handout, 110, 120 thought records, 145–147, 168 thoughts: automatic, 9, 18, 122–124, 248–249; balanced, 163–167; as cognitive distortions, 109–116; coping, 187–191; distinguishing feel- ings from, 9, 91; empathy related to, 25; evalu- ating self, others, or future, 103–106, 119; examining the reality of, 146; feelings related to, 12, 106–109, 127–128; four-factor model for understanding, 135–137; hopes or ques- tions as, 132; hot, 103, 145, 147, 155, 163; images accompanying, 131; influence of core beliefs on, 18–21; looking for evidence about, 147, 148, 149–163; mood shifts related to, 133–134; problems maintained by, 11–12; questions for identifying, 122, 124–129, 134– 135; separating facts from, 87–88; worksheet for identifying, 138–139 trigger situations, 83–89; facts vs. thoughts about, 87–88; identifying specific and concrete, 84–87; worksheet for identifying, 83–84 U uncertainty, tolerance of, 158 Understand Janice’s Reactions exercise, 19 Understand Janice’s Vicious Cycle and Core Beliefs exercise, 20Understand Mayleen’s Depression exercise, 203, 274 Understand Your Depression worksheet, 202, 220 Understand Your Reaction worksheet, 82, 89–90, 99–100, 124, 136, 137, 139–140 unless I…statements, 18 Use Graded Task Assignments exercise, 216–217, 276 V video clips, 4; on brainstorming and choosing solutions, 186; on check-in and agenda setting, 69; on creating balanced thoughts, 166; on defining problems and setting goals, 180; on developing a fear hierarchy, 232; on developing coping thoughts, 191; on explain- ing CBT to clients, 39; on explaining depres- sion to clients, 204; on exposure therapy, 236, 242; on identifying feelings, physical reac- tions, and behavior, 96; on identifying thoughts, 128; on identifying trigger situa- tions, 89; on imagery for exploring thoughts, 131; on looking for evidence, 156; on moni- toring mood before/after activities, 214; on planning mood-boosting activities, 212; on probability of predictions, 158; on reviewing sessions and asking for feedback, 73; on setting specific therapy goals, 55; on taking a close look at the facts, 161; on understanding your client’s presenting problem, 31 virtual exposure, 228–229 W web resources, 3–4 well-being, increasing, 218, 219–220 What Are My Feelings and Thoughts? worksheet, 138–139 What Are My Thinking Traps? worksheet, 114, 117 What Is This Person Thinking? exercise, 14 What Is Your Trigger? worksheet, 83–84 What Thoughts Go with These Feelings? exer- cise, 109, 271 Wilson Feels Tense exercise, 72 worksheets: Are My Predictions Accurate?, 239– 240; Benefits and Drawbacks of My Solutions, 185; Examine the Reality of Your Thoughts, 146, 170; How Probable Are My Predictions?, 157; Identify a Client’s Stressors and Strengths, 34–35; Other Ways of Understanding the Situation, 161; Predict Your Mood, 213; Problem-Solving, 174; Separating Facts from Thoughts, 88; Understand Your Depression, 202, 220; Understand Your Reaction, 82, 89–90, 99–100, 136, 137, 139–140; What Are My Feelings and Thoughts?, 138–139; What Are My Thinking Traps?, 114, 117; What Is Your Trigger?, 83–84. See also handouts worries: images associated with, 131; listing, 128–129 XYZ Yonas Asks a Question exercise, 127 YOUR TURN! exercises, 3; answers to, 263–277; on behavioral activation, 204–205, 211–212, 216–217; on exposure therapy, 227–228, 231, 241; for focusing on client problems and strengths, 27, 37; for helping clients develop coping thoughts, 190–191; for helping clients reach their own conclusions, 162; for identify- ing cognitive distortions, 112–113; for identi- fying safety behaviors, 227–228; for identifying specific, measurable goals, 49–50, 53–54; for identifying the meaning of situations, 125– 126; for identifying thoughts about self, others, or the future, 105; for identifying trigger situations, 86–87, 88; on looking for evidence, 148, 160; on noticing mood shifts, 133–134; on problem-solving process, 180, 182–183; on thoughts related to feelings, 109; for understanding a client’s depression, 203; for understanding your reactions, 89–90; for using CBT theory to understand clients, 10–11, 12–14, 15–16, 17; on working within a session structure, 62, 66, 71, 73. See also exer- cises (practice)MOR E BOOK S from NE W HA R BI NGER PUBLICATIONS THE CBT ANXIETY SOLUTION WORKBOOK A Breakthrough Treatment for Overcoming Fear, Worry & Panic ISBN: 978-1626254749 / US $21.95 DBT MADE SIMPLE A Step-by-Step Guide to Dialectical Behavior Therapy ISBN: 978-1608821648 / US $39.95 THE COGNITIVE BEHAVIORAL COPING SKILLS WORKBOOK FOR PTSD Overcome Fear & Anxiety & Reclaim Your LifeTHE COGNITIVE BEHAVIORAL WORKBOOK FOR DEPRESSION, SECOND EDITION A Step-by-Step Program ISBN: 978-1626252240 / US $21.95ISBN: 978-1608823802 / US $24.95 HANDBOOK OF CLINICAL PSYCHOPHARMACOLOGY FOR THERAPISTS, EIGHTH EDITIONACT MADE SIMPLE An Easy-To-Read Primer on Acceptance & Commitment Therapy ISBN: 978-1626259256 / US $59.95 ISBN: 978-1572247055 / US $39.95 newharbingerpublications 1-800-748-6273 / newharbinger.com Follow Us (VISA, MC, AMEX / prices subject to change without notice) Don’t miss out on new books! 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Everything You Need to Know to Practice CBT C ognitive behavioral therapy (CBT) is a highly effective, evidence-based treatment for mental health issues—including anxiety, depression, obsessive- compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and more. If you’re a clinician new to CBT, this user-friendly professional resource offers a complete road map so you can start using it in your own Includes sessions. And if you’re already practicing CBT, this book will help sharpen your skills and increase your effectiveness with clients. downloadable audio exercises CBT Made Simple is written in a refreshingly straightforward and practical style, and designed to help you hone your skills before & sample client you start working with clients. Each chapter outlines a basic component of CBT with a focus on interactive and experiential session videos learning, followed by exercises to help you immediately practice the skills you’ve just learned. You’ll also find suggestions for effective questions, client dialogues, and clinical examples, in addition to downloadable exercises and online video demonstrations. This pragmatic guide offers everything you need to know about CBT: what it is, how it works, and how to apply it in session. NINA JOSEFOWITZ, PhD, is a psychologist in private practice. She teaches a graduate-level course on CBT in the Counselling and Clinical Psychology Program at the Ontario Institute for Studies in Education (OISE) at the University of Toronto. DAVID MYRAN, MD, (1949 – 2016) was a geriatric psychiatrist and former director of the Geriatric Psychiatry Outreach Team at Baycrest Health Sciences—a University of Toronto-affiliated hospital. Foreword writer ZINDEL V. SEGAL, P h D, is professor of psychology at the University of Toronto Scarborough. He is author and coauthor of several books, including The Mindful Way through Depression. newharbingerpublications w w w. n e w h a r b i n g e r . c o m