FACILITATOR’S NOTE

Mridhula Maha MSc, M.Phil.

Counselling psychologist
Founder and Director
Aruvadai psychological support service

She has finished her M.Phil from presidency college, M.Sc from women’s
Christian college, she has worked with diverse population in the field of
mental health, Her predominant work was with children in institutional
care and relationship issues with Adults. She is trained in CBT, DBT,
SFBT therapeutic approaches. She is an avid research lover and has
published many research papers. She is also a consultant in hospital and
a student counsellor in a residential school. She founded and is the
director at Aruvadai
Cognitive Behaviour Therapy (CBT)

We cannot solve problems by using the same kind of thinking

we used when we created them
-Albert Einstein
THERAPEUTIC TECHNIQUES IN COGNITIVE BEHAVIOUR THERAPY

OBJECTIVES

• Understanding components of CBT Case history intake form and documentation.

• Planning treatment and structuring sessions.
• Introducing cognitive model. Identifying and responding to dysfunctional cognitions.
• Cognitive conceptualization
• Identification and Modification of Core beliefs & intermediate beliefs.
• DCBT techniques- Cognitive & Behavioural
• Facilitating cognitive and behavioural change between sessions (homework)

Cognitive Behaviour Therapy (CBT)

CBT is the most commonly used psychological treatment for depression, as well as other mental –
health problems (e.g., anxiety. Panic. Phobias, stress, bulimia. OCD. Post-Traumatic Stress disorder.
Bipolar disorder, etc). This is a method for treating mental disorders based on both behavioural and
cognitive techniques.

History of CBT

• Developed by Aaron Beck (1987)

• Clients misinterpret certain life Situations, which leads to Cognitive distortions or “logical
Errors”
• Logical errors lead to emotional difficulties by distorting reality to validate previously
held negative beliefs.

Cognitive Behavioural Therapy Stages

Stage 1

Therapist & client agree on nature of problem & goals for therapy

Stage 2

Therapist challenges the client’s negative thoughts

Stage 3

Client engages in behaviour between sessions in an attempt to challenge these negative thoughts
Stage 4

Aim is for client to realise thoughts are irrational. Homework =diary kept

What does CBT involve?

• The Sessions Meet with a therapist for between 5 and 20, weekly, or Fortnightly sessions.
• Each session will last between 45 and 60 minutes.
• Some CBT therapists work with the techniques influenced by Beck and some work with the
techniques influenced by Ellis. Most draw on both.

Beck’s negative triad

Beck (1987) believes people become depressed because the negative schemas. World is seen
negatively through negative schemas

Negative schemas, together with cognitive bias/distortions, maintain the negative triad.

Diagnostic criteria for depression ICD-10 uses an agreed list of ten depressive
symptoms

Key symptoms

• Persistent sadness or low mood, and/or

• loss of interests or pleasure
• fatigue or low energy

A least one of these, most days, most of the time for at least 2 weeks if any of above present, ask about
associated symptoms:

• Disturbed sleep
• Poor concentration indecisiveness
• low self-confidence
• Poor or increased appetite
• Suicidal thoughts or acts
• agitation or slowing of movements
• guilt or self-blame
The 10 symptoms then define the degree of depression and management is based on the particular
degree

• Not depressed (fewer than four symptoms)

• Mild depression (four symptoms) (five to six symptoms)
• Moderate depression (five to six symptoms)
• Severe depression (seven or more symptoms, with or without psychotic symptoms)
• Symptoms should be present for a month or more and every symptom should be present
for most of every day

First Session Structure

• Formulate the case and create an initial cognitive conceptualization of the patient.
• Determine whether you will be an appropriate therapist
• Determine whether you can provide the appropriate “dose of therapy (eg. If you are able to
provide only weekly therapy but the patient requires a day program).
• Determine whether adjunctive treatment or services (such as Medication) may be indicated.
• Initiate a therapeutic alliance with the patient (and with family Members, if relevant).
• Begin to socialize the patient into the structure and process of therapy
• Identity specific problem list (& prioritise) E.g., Poor sleep, relationship difficulties etc
• Selling goals in collaboration with client.

Structure of a session
INITIAL PART OF SESSION I

1. Set the agenda (and provide a rationale for doing so)

2. Do a mood check
3. Obtain an update (since the evaluation)
4. Discuss the patient’s diagnosis and do psycho education

MIDDLE PART OF SESSION I

5. Identify problems and set goals

6. Educate the patient about the cognitive model.

7. Problem Solving, Consolidation of new information/strategies

END OF SESSION I

8. Provide or elicit a summary

9.Assignment of home practice. Troubleshooting of homework

10. Elicit feedback

Therapeutic Relationship-Therapist Skills

• Engagement (Therapeutic Alliance)

• Warmth and empathy Collaboration.
• Guided discovery-Socratic questioning
• Feedback and summarising
• Agenda setting -structure and focus
• Open and closed questioning

Positive regards (Refers to the counsellor’s support acceptance & respect towards client)

• Client revelations must be protected from therapists’ personal reactions especially

rejection or disdain
• Therapist expresses appreciation of the client as a unique and worthwhile person.
• Therapist embraces the client’s ethnic self as well as other experiences that have shaped
the client’s worldview.

Empathy (Understand the client’s experience. Emotionally resonate with client’s experience “as if it were
your own)
Refers to the counsellor’s state of mind. and ability to

• Be self-analytical
• Distinguish their personal Cultural assumptions from those of the client:
• Overcome
1. Prejudice
2. Stereotypes, and
3. Biases
• Become culturally self-aware.

Concept of Therapeutic Alliance

Therapeutic relationship and working alliance show that it Is an important factor in the outcome
of psychotherapy.

Three Components:

• Tasks: What they agree together to do to reach the client goal.

• Bonds: The positive interpersonal
• Attachment between therapist and client Of mutual trust, confidence, and acceptance
• Goals: what the client hopes to get from therapy. Objectives of therapy that both client and
therapist approve.

Paired Activity-Socratic questioning

• Form as pairs
• One person has to share a problem to the opposite pair.
• Each person takes 5 minutes.
• Consequently, the next person has to share a problem.
• Each person has to use Socratic questions to guide the clients.

Activity: Now it’s your turn!

Rotating Roles

This role-play gives you and your colleagues an opportunity to practise your counselling skills..

Role-play with one of your partners the new counselling skills you have learned.

A third partner will be an observer. After 5 minutes switch roles (15 minutes total).

Each observer will provide feedback at the end of role-play (5 minutes).

Threats to the relationship-therapists’ factors

If the therapist is:

• Intrusive

• Defensive

• Demonstrates negativity

• Inappropriate self-disclosure
IMMEDIACY: A key interpersonal skill

Immediacy is the skill to use reflections on the nature of what is going on between you and the client in
ways that are helpful to the client.

Often useful to ‘slow things down’ and invite the client to reflect with you – Can we just stop
and think what happened there? It seemed to me that … How did it seem to you?”

Need to think how emotionally open I can be with this client. It can be a priceless opportunity for them
to learn how they come over to others. Most social situations are not safe enough for this-therapy can
be.

COGNITIVE INTERVENTIONS

Restructuring thoughts and beliefs

• Guided discovery
• Thought diaries
• Challenging NATs (looking at evidence)
• Identifying core beliefs Addressing thinking errors
• Responsibility Pie
• Cost/Benefit Analysis
• Downward Arrow technique
• Tic Toc technique.
• Bubble-gum technique

Techniques to elicit automatic thoughts

Basic question. What was going through your mind just then?

1.Ask this question when you notice a shift in (or intensification) affect during a session

2.Have the patient describe a problematic situation or a time during which she experienced an affect
shift and ask the above question

3.If needed Have the patient use imaginary to describe the specific situation or time in detail (as if it is
happening now) and then ask the above question

4.If needed or desired have the patient role play a specific interaction with you and then ask the above
question
Other questions to elicit automatic thoughts

1.what do you guess you were thinking about?

2. Do you think you could have been thinking about_______ or_________?

3.Were you imagining something that might happen or remembering something that did?

4.what did this situation mean to you (or say about you)?

5.Were you thinking_______? (Therapist provides a thought opposite to the expected response)

Group Activity:

Write Down the ANT in these Given Situations Situation

Situations I: Shankar attends a campus interview and finds that he is not selected.

Situation 2: Akhil is unable to decide whether to get married or Pursue career

Situation 3: Gopi girlfriend has a password in her cell phone. She does not allow to use it Alternative
explanation game

Alternative explanation game

• He didn’t take the call. He does not have me

• My application was rejected I am no good
• My head is spinning. I am going to get paralysis
• I have always treated unfairly. The world is a bad place
• I failed thrice I am not fit to be a engineer.
• My son failed in test. I am a bad mother
• They did not listen to me. I must be boring
• You did not remember my birthday. You are careless
• I cannot get a job. I am useless
• She does not obey me. I am not a good mother

Questioning automatic thoughts

• What is the evidence? What is the evidence that supports this Idea? What is the evidence
against this idea?
• Is there an alternative explanation?
• What’s the worst that could happen? Could I live through it?
 • What is the best that could happen? What is the most realistic Outcome?
• What is the effect of my believing the automatic thought?
• What could be the effect of changing my thinking?
• What should I do about it?
• What would I tell_____ (a friend) if he or she were in the Same situation?
Cognitive distortions associated with distress and maladaptive behaviours

• Personalization and blame

• All or nothing thinking
• Labelling
• Over generalization
• Should statements
• Emotional reasoning
• Disqualifying the positive
• Magnification & Minimization
• Jumping to conclusion

Healthy vs. Unhealthy Emotion Emotions

(Emotions are not facts Emotions are just information. )

Emotional reasoning skills

A-B-Cs Triple Column Technique (5 steps)

• A: Activating Event
• C: Consequences (s) Emotional and/or Behavioural
• B-Beliefs(s) The meaning given to “A” that produced C

Step 1: Invite the client to tell his or her story about the presenting problem

Step 2: Ask for a recent specific occurrence of the problem (A -Column 1)

Step 3: Ask the client to relate his or her experience of the situation (C-Coltime 3)

A. How did you experience the situation? What was it like for you
B. Were there any disturbing feelings and/or behaviours?
Step 4. Ask the client to share about the “meanings” of the situation. (B-Column 2)

A. “What did the situation mean for you or about you?

B. “What thoughts and images crossed your mind?” .

C. “What did you say to or about yourself?”

Step 5: The Vertical downward Arrow Technique (Automatic Thoughts are in bold blue)

He did not receive my call

If this were true, what would it mean to or about you?

He is avoiding me

And if it’s true, what’s bad about it?

He does not care for me.

So, what if?

He does not like me

What’s the worst part of it?

He does not love me, nobody does…

What does that mean about you?

I am unlovable- (core belief)

Pie-Chart Technique For Challenging your Automatic Thoughts

• The ANT- Video Presentation.

• Responsibility pic chart- sheet exercise
• Activity-Do your own pic chart.

How to challenge the core beliefs.

Questions for generating alternatives/balanced core beliefs: 1. Is this always 100% true? So is this
a fact or assumption?
1.Is this always 100% true? So is this A fact or assumption

2. What are some alternative explanations?

3.What do you gain by holding to this “B”? What does it cost you?

4 Who will you be if you remove this belief?

1. What are the experiences that shows that this belief is not always 100% true? How will I benefit
by choosing an alternative belief?
2. How will I behave differently if I chose an alternative belief?

Cognitive Conceptualization Diagram

Relevant Childhood Data

CORE BELIEFS
 Conditional Assumptions/Beliefs/Rules

Coping Strategies

SITUVATION 1 SITUVATION 2 SITUVATION 3

Automatic Thought Automatic Thought Automatic Thought

Meaning of AT Meaning of AT Meaning of AT

Emotion Emotion Emotion

Behaviour Behaviour Behaviour

Cost benefit analysis

Utilized when:

1.I help clients stop engaging in unwanted behaviour

2. To choose to engage in the behaviour or refrain from engaging in it (decision making)

3.To change a negative belief

Used to challenge any negative automatic thought or dealing procrastination

TICS TOCS

Task interfering Task oriented

Cognition cognition

1.create the tic-toc table

Draw a line down the centre of a piece of paper to divide in half

Label the left-hand column “TICS” (Task-Interfering Cognition)

Label the right-hand column “TOCs” (Task-oriented cognition)

Record the thoughts that inhibit motivation

In the left hand column, TICS, record the thoughts that inhibit your motivation for a specific
task

3.Substitute more productive attitudes

In the right-hand column, TOCs, identify the cognitive distortion and substitute more objective,
productive attitudes

Behavioural Activation (BA) Treatment

• Self-monitoring of daily activities and mood

• Week-by-week scheduling of activities that bring patients a sense of pleasure or mastery
• Identifying and reducing avoidance behaviours that increase depressive symptoms.
• Used in conjunction with cognitive restructuring
• Help ensure that therapy is not over-focused on thinking
 • Rather than doing Starts with monitoring of activities and setting of goals for valued activities
for both pleasure and mastery (competence goals)

The Key Elements-Behavioural Experimentation

• Thought stopping-Intentional reframing

• Activity Scheduling (Reading, journaling)
• Pleasure Scheduling
• Identify Distortions through Self-Monitoring and Labelling Automatic Thoughts
• Test the Evidence.
• Challenge and Create New Beliefs.

Therapy sessions are really ‘training sessions’, between which the client tries out and uses what
they have learned.

Limitation of CBT

1. CBT is not useful for all patients

2. For example, CBT may be unsuitable for patients who have difficulty concentratingreg,
depression). This can lead to patients becoming overwhelmed and disappointed, which
strengthens depressive symptoms rather than reducing them.
3. CBT addresses current problems and focuses on very specific issues, it does not address the
possible underlying causes of mental health conditions, such as an unhappy childhood
4. CBT focuses on the individual’s capacity to change themselves and does not address wider
problems in systems or families that often have a significant impact on an individual’s health
and wellbeing.
5. CBT is not a quick fix. A therapist is like a personal trainer that advises and encourages but
cannot ‘do’ it for a patient.

Relapse Prevention

• What have I learned?

• What was most useful?
• What can I continue to do?
• When will I be at risk of this happening again?
• What are the signs?
 • What could I do to avoid losing control?
• What could I do if I did lose control?

STEPS IN CBT

Step 1: Ask for a problem.

Ask the client for a problem at the very beginning of the session. The question Can be like:
“What problem would you like to work on today?” It is suggested that you establish the problem-
solving orientation of CBT immediately by asking your client what problem she would like to
discuss first. Establishing the target problem communicates a number of messages to the client.

1. You are both there to get a job done.

2. CBT is efficient and focused approach to problem-solving.

3. As a therapist, you are going to be active and the client has to work on their problems.

Step 2: Set the agenda, get an agreement on the agenda.

Arriving at a common understanding of the problem and agreeing to work on it is an important

therapeutic step in CBT in that it strengthens the therapeutic alliance. A therapeutic alliance is more
important than rapport. When your client discusses his target problem in vague or confusing terms, it is
important that you help him operationalize the problem. When clients say they want to change someone
else’s reactions, explain to them how it is unrealistic, and how it makes sense to work on their own
dysfunctional reactions.

Once a goal has been selected, ensure that your client has a realistic chance of achieving it and
that it will not reinforce her existing problems. Ask yourself, if the client works on this agenda,
how will it benefit him?

• What would you like to achieve from discussing this problem with me today?
• How would it help you to work on this agenda? What would you like the outcome of therapy to
be?
• What feelings or behaviours would you like to increase or decrease?
• How would you like to react differently to the situation?

Step 3: Ask for a specific example of the target problem.

Que. “Can you give me concrete example of this problem, or once incident when this happened?”
Help the client to understand that being specific about the problem will help her deal more
constructively with it in the situations about which she is disturbed. Interrupt when the clients
give vague answers, or excessive irrelevant details.

Step 4: Assess the Antecedent event.

While you are assessing A, help your client assess the most relevant part of A Clients may give you
unnecessary details about the situation, discourage this and interrupt tactfully. Avoid asking “how did
the event make you feel?”

“What exactly happened just before you got upset?” “What in the entire Situation was most upsetting
for you?”.

Step 5: Assess Consequences

In assessing C, remember that your client’s emotional problem will be an unhealthy (disturbed)
negative emotion, not a healthy (disturbed) negative emotion. If the client has a healthy C, no
therapeutic work needs to be done. Also assess the intensity of the emotion on a 0-100 scale. Assess
behavioural reaction and physiological reactions.

• How did you feel when…?” (State the situation).

• How intense was the emotion?
• What did you experience in the body at that time?
• What did you do when you felt _____?
• What did you not do when you felt____?

Step 6: Refine agenda if required

The one you have assessed the A & C elements of your clients presenting problem, you will discover
that the problem as assessed may be different from the one you and your client have defined

For e.g., Say your client defines her problem as Anxiety and states that her goal is to learn to manage
worry. However, when her Anxiety is assessed, it is discovered that she gets depressed over being
judged negatively, hence worries that people will judge her negatively. At this point, we need to work
om her feelings of depression rather than Anxiety.

Step 7: Help your client to see the connection between initial goal, assessed emotions
Because there have been two goal setting stages your client may become confused as to how different
goals emerged. Help her to understand that the problem as assessed goal is based on a more detailed
understanding of her problems than was attempted previously. Summarise frequently

Step 8: Make Thinking-Feeling connection

If there were 20 neutral observers/camera on the wall, would they/it say that A was true? When you
feel this, did you notice that you act in this way?

If your client doesn’t understand the connection, you can use the following method known as the “100
people technique:”

Que: "Would 100 people of your age and gender all feel… (State “C”) about… (State “A”)?”

Step 9. Assess ANTS

Find out the Cognitive distortions

• What was going through your mind when it happened?

• What were you telling yourself that made you_____?
• What were you thinking at that time?

Step 10: Connect Thoughts and feelings.

How does thinking like that make you feel?

Step 11: Cognitive restructuring

The major goal of questioning at this stage of the CBT treatment process is to encourage your client to
understand that her thoughts are distorted, unproductive, illogical, unrealistic and that the alternative to
these thoughts is productive, logical, and realistic.

The therapist will help the client ask QUESTIONS TO SELF. It is recommended that the therapist
doesn’t question the client’s distorted thoughts himself.

• . E.g., Can you stop, and ask yourself, what is the evidence that my thought Is true?
• What’s the evidence that my thought is NOT true?
• What can be done now to cope with it better?
 • How does believing my thought help me?
• What will be a more realistic/helpful thought?
• How else could you have viewed this situation?
• How likely is it that my inference is true?
• If there were 20 neutral observers/camera on the wall, would they/it say that A was true?

Step 12: Generate a helpful, realistic thought and ask to write down.

Prepare your client to deepen conviction in realistic thoughts. This requires your client to
question his distorted thoughts repeatedly and to practice thinking realistically and functionally
in relevant life context. This process will involve undertaking a variety of homework
assignments.

Step 13: New modified reactions.

Once a new helpful and realistic thought is generated, ask them again,

1. How does thinking like this make you feel?

2. How intensely do you feel the negative emotion now?
3. What will you do when you feel like this?

If the client still adheres to her distortions at Automatic thought level, work at a deeper level, question
and modify the Intermediate beliefs, and then the core beliefs.

Step 14: Negotiate a H.W assignment.

H.W is assigned in order to deepen the conviction of your client in their helpful and realistic thoughts.
Make sure that the H.W assignment are relevant to the client's problem, if the client carries out these
assignments, doing so will help him deepen his conviction in the realistic and helpful thoughts.

Help your client to choose from among a wide variety of homework assignment advocated in CBT:

1. Cognitive assignments.

2. Imagery assignments.

3. Emotive- evocative assignments.

4. Behavioural assignments.

Negotiate homework

Step 16: Check homework assignments.

In the beginning of the next session, check what she has learned from the experience. If you fail
to you show your client that you do not consider homework assignments to be important. Make
sure that the client has worked on to change distorted thoguhts rather than avoiding A. If the
client fails to do the homework, work on the beliefs that interfered with working on the
homework in that session.

Que. How much of homework have you done?

Step 17: Facilitate the working-through process.

The purpose of this working- through process is of your client to integrate a more helpful and
realistic thought process into his emotional and behavioural repertoire. The therapist need to
explain to the client that change is nonlinear and that he will probably experience some
difficulties in sustaining his success at questioning the ANTS in a wide range of contexts.
Identify possible setbacks and help your client develop ways of handling these setbacks

Socratic Questions:

The overall purpose of Socratic questioning, is to challenge accuracy and completeness of thinking in a
way that acts to move people towards their ultimate goal..

Conceptual clarification questions: Get them to think more about what exactly they are asking or
thinking about. Prove the concepts behind their argument. Use basic ‘tell me more’ questions that get
them to go deeper.

• Why are you saying that? What exactly does this mean?
• How does this relate to what we have been talking about?
• What is the nature of…?
• What do we already know about this? Can you give me an example?
• Are you saying … or…? Can you rephrase that, please?

Probing assumptions: Probing their assumptions makes them think about the presuppositions and
unquestioned beliefs on which they are founding their argument. This is shaking the bedrock and should
get them really going!

• What else could we assume? You seem to be assuming…?

• How did you choose those assumptions?
• Please explain why/how…?
 • How can you verify or disprove that assumption?
• What would happen if …?
• Do you agree or disagree with …?

Probing rationale, reasons and evidence: When they give a rationale for their arguments, dig into that
reasoning rather than assuming it is a given. People often use un-thought-through or weakly-understood
supports for their arguments.

• Why is that happening?

• How do you know this?
• Show me…?
• Can you give me an example of that?
• What do you think causes…?
• What is the nature of this? Are these reasons good enough?
• Would it stand up in court? • How might it be refuted?
• How can I be sure of what you are saying?
• Why is… happening?

Core Beliefs and Schemas

We all develop beliefs about ourselves, other people, and the world we live in, beginning in early
childhood. Some of these beliefs are so fundamental to how we view…everything…that we see them as
absolute truths. We call these “core beliefs.” Core beliefs are your basic assumptions about your value
in the world. Core beliefs determine to what degree you see yourself as worthy, safe, competent,
powerful, independent, and loved. They also establish your sense of belonging and basic picture of how
you are treated by others.

We may not be consciously aware of our core beliefs – they are kind of like the water fish swim in.
However, they have a significant impact (like water does for fish): situations can activate core beliefs,
which then shape our perception and interpretation of the situation. In fact, we tend to filter incoming
information to accept information that fits the core belief, while discounting anything that contradicts
our belief.

The way that core beliefs influence our perception, interpretation, and response to a situation is through
what is called “intermediate beliefs.” This category includes our attitudes, assumptions, and rules.
Attitudes are evaluative statements (“It would be terrible if…”), assumptions tend to be “if…then…”
statements, and rules are “shoulds” (or musts, or oughts). These intermediate beliefs arise from core
beliefs, either as logical extensions thereof, or as attempts to cope with a painful core belief (often that
one is inadequate and/or unlovable): I am inadequate so I need to work harder than everyone else. I am
unlovable, so I should expect rejection. Etc. Both kinds of beliefs shape the content of your thoughts
from moment to moment – your internal monologue, or “automatic thoughts.” Automatic thoughts, in
turn, strengthen and reinforce your beliefs. For example, when you tell yourself constantly that you’re
stupid, you convince yourself that this is true. By the same token, if your self-statements reflect a basic
faith in your intelligence, this core belief will be confirmed and solidified.

As you can see, core beliefs are the very foundation of your self-image: they largely dictate what you
may and may not do (your rules), how you present yourself (your attitude) and how you interpret events
in your world (your assumptions and automatic thoughts). Therefore, holding negative beliefs takes a
significant toll on your mood, relationships, and overall functioning. Changing your core beliefs
requires time and effort; and yet changing them will fundamentally alter your view of yourself and your
environment.

Schemas

Core beliefs are also combined in patterns that are referred to as schemas. Schemas include beliefs
about yourself, the future, other people and the world, along with associated intermediate beliefs (now
called schema processes), which produce emotions, body sensations, and behaviours. Schemas form
templates for processing and interpreting life experiences.

Dr.Young and his colleagues have identified 18 “early maladaptive schemas:” schemas that develop
very early in life and can produce distress and difficulties throughout one’s life. Read through their list
of schemas and rate how strongly you think each one applies to you, from 0 -100%.

Emotional Deprivation

This schema refers to the belief that one’s primary emotional needs will never be met by others. These needs can
be described in three categories: Nurturance – needs for affection, closeness and love: Empathy-needs to be
listened to and understood; and Protection – needs for advice, guidance and direction. Generally parents were
cold or removed and didn’t consistently care for the child in ways that would adequately meet the above needs.
Abandonment/Instability

This schema refers to the expectation that one will soon lose anyone with whom an emotional attachment
is formed. The person believes that, one way or another, close relationships will end imminently. As
children, they may have experienced the divorce or death of parents. This schema can also arise when
parents have been inconsistent in attending to the child’s needs; for instance, there may have been
frequent occasions on which the child was left alone or unattended to for extended periods.

Mistrust/Abuse

This schema refers to the expectation that others will intentionally take advantage in some way. People with this
schema expect others to hurt, cheat, or put them down. They often think in terms Of attacking first or getting
revenge afterwards. In childhood, these people were often abused or treated unfairly by parents, siblings, or peers.

Defectiveness/Shame

This schema refers to the belief that one is internally flawed, and that, if others get close, they will realize this and
withdraw from the relationship. This feeling of being flawed and inadequate Often leads to a strong sense of
shame. Generally, parents were very critical and made them feel as if they were not worthy of being loved.

Social Isolation/Alienation

This schema refers to the belief that one is isolated from the world, different from other people, and/or not part of
any community. This belief is usually caused by early experiences in which children see that either they, or their
families, are different from other people...

Dependence/Incompetence

This schema refers to the belief that one is not capable of handling day-to-day responsibilities
competently and independently. People with this schema often rely on others excessively for belp in areas
such as decision-making and initiating new tasks. Generally, parents did not encourage children to act
independently and develop confidence in their ability to take care of themselves.

Vulnerability to Harm and Illness

This schema refers to the belief that one is always on the verge of experiencing a major catastrophe (financial,
natural, medical, criminal, etc.). It may lead to taking excessive Precautions to protect oneself. Usually there was
an extremely fearful parent who passed on the idea that the world is a dangerous place.

Enmeshment/Undeveloped Self

This schema refers to a pattern in which a person experiences too much emotional involvement with others-
usually parents or romantic partners. It may also include the sense that one has too little individual identity or
inner direction, causing a feeling of emptiness or of floundering. This schema is often brought on by parents who
are so controlling, abusive, or overprotective that the child is discouraged from developing a separate sense of
self.

Failure

This schema refers to the belief that one is incapable of performing as well as one’s peers in areas such as career,
school or sports. These clients may feel stupid, inept or untalented. People with this schema often do not try to
achieve because they believe that they will fail. This schema may develop if children are put down and treated as
if they are a failure in school and other spheres of accomplishment. Usually, the parents did not give enough
support, discipline, and encouragement for the child to persist and succeed in areas of achievement, such as
schoolwork or sport.

Subjugation

This schema refers to the belief that one must submit to the control of others in order to avoid negative
consequences. Often these people fear that, unless they submit, others will get angry or reject them. They
therefore ignore their own desires and feelings. In childhood there was generally a very controlling parent

Self-Sacrifice

This schema refers to the excessive sacrifice of one’s own needs in order to help others. When these
people pay attention to their own needs, they often feel guilty. To avoid this guilt, they put others’ needs
ahead of their own. Often people who self-sacrifice gain a feeling of increased self esteem or a sense of
meaning from helping others. In childhood the person may have been made to feel overly responsible for
the wellbeing of one or both parents

Emotional Inhibition

This schema refers to the belief that one must suppress spontaneous emotions and impulses. Especially anger,
because any expression of feelings would harm others or lead to loss of self esteem, embarrassment, retaliation or
abandonment. These people may lack spontaneity, or be viewed as uptight. This schema is often brought on by
parents who discourage the expression of feelings.

Approval-Seeking/Recognition-Seeking

This schema refers to the placing of too much emphasis on gaining the approval and recognition of others at the
expense of one’s genuine needs and sense of self. It can also include excessive emphasis on status and appearance
as a means of gaining recognition and approval. People with this schema are generally extremely sensitive to
rejections by others and try hard to fit in. Usually they did not have their needs for unconditional love and
acceptance met by their parents in their early years.
Unrelenting Standards/Hyper-criticalness

This schema refers to the belief that whatever you do is not good enough, that you must always strive
harder. The motivation for this belief is the desire to meet extremely high internal demands for
competence, usually to avoid internal criticism. People with this schema show impairments in important
life areas, such as health, pleasure or self-esteem. Usually, these clients’ parents were never satisfied and
gave their children love that was conditional on outstanding achievement.

Entitlement/Grandiosity

This schema refers to the belief that one should be able to do, say, or have whatever one wants immediately,
regardless of whether that hurts other or seems reasonable to them. These people are not interested in what other
people need, nor are they aware of the long-term costs of alienating others. Parents who overindulge their
children and who do not set limits about what is socially appropriate may foster the development of this schema.
Alternatively, some children develop this schema to compensate for feelings of emotional deprivation or
defectiveness.

Insufficient Self-Control/Self-Discipline

This schema refers to the inability to tolerate any frustration in reaching one’s goals, as well as an
inability to restrain expression of one’s impulses or feelings. When lack of self-control is extreme, it may
lead to criminal or addictive behaviours. Parents who did not model self-control, Or who did not
adequately discipline their children, may predispose them to this schema as adults.

Negativity/Pessimism

This schema refers to a pervasive pattern of focusing on the negative aspects of life while minimizing the
positive aspects. Clients with this schema are unable to enjoy things that are going well in their lives because they
are so concerned with negative details or potential future problems. They worry about possible failures no matter
how well things going for them. Usually, these people had a parent who worried excessively.

Punitiveness

This schema refers to the belief that people deserve to be harshly punished for making mistakes. People with this
schema are critical and unforgiving of both themselves and others. They tend to be angry about imperfect
behaviours much of the time. In childhood these clients usually had at least one parent who put too much
emphasis on performance and had a punitive style of controlling behaviour.

QUESTIONING AUTOMATIC THOUGHTS

1.What’s the evidence- pro and con?

A. What is the evidence that supports this idea?

B. What is the evidence against this idea?

2.Is there an alternative explanation?

3.What’s the worst that could happen? Could I live through it?

What’s the best that could happen?

What’s the most realistic outcome?

4.what should I do about it?

5.What’s the effect of my believing the automatic thought?

What could be the effect of changing my thinking?

II. If________ Was in this situation and had this

thought, what would I tell him/her? (friend’s name)
III. What’s a more reasonable way to view this
situation?

DYSFUNCTIONAL THOUGHT RECORD

Directions: When you notice your mood getting worse, ask yourself, “What’s going through my mind
right now?” and as soon as possible jot down the thought or mental image in the Automatic Thought
column
Date Situation Automatic Emotions Alternative Outcome
/Time 1.what actually event thought(s) 1.What response 1.How
stream of thoughts or 1.what emotion(s) 1.(optional) much do
daydreams or thoughts(s) and (Sad, what cognitive you now
recollection led to or images(s) anxious, distortion did believe
unpleasant emotion went through angry etc.) you make? each
2 what (if any) your mind did you Example all or automatic
distressing physical 2.How much feel at the nothing thought
sensation did you did you believe time? thinking mind 2.To
have each one at the 2.How reading what
time intense (0- catastrophizing emotions
100%) 2.Use do you
was the questions at feel now
emotion? bottom to how
compose a intense
response to the (0-
automatic 100%) is
thought(s) the
3.How much emotion
do you believe 3.what
each response will you
do? Or
did you
do?

Questions to help compose an alternative response:

1. What is the evidence that the automatic thought is true? Not true?
 2. Is there an alternative explanation?
3. What’s the worst that could happen? If it did happen, how could I cope? What’s the best that
could happen? What’s the most realistic outcome?
4. What’s the effect of my believing the automatic thought? What could be the effect of changing
my thinking?
5. What should I do about it?
6. If (friend’s name) were in this situation and had this thought, what would I tell him/her?

Testing your thoughts

This worksheet is an easier version of the Dysfunctional Thought Record and should be used in place of. Not in
addition to, the DTR, for certain clients, such as adolescents.

What is the situation? _________

What am I thinking or imagining? __________

How does that thought make me feel? Mad, Sad, Nervous, Other__________

What makes me think the thought is true? ________

What makes me think the thought is not true or not completely true? __________

What’s another way to look at this? _________

What’s the worst that could happen? What could I do then? ____________

What’s the best that could happen? __________

What will probably happen? _____________

What could happen if I changed my thinking? ________

What would I tell my friend [think of a specific person] __________ If this happened to him or her? ________

What should I do now? _________

Unhelpful Thinking Styles

All or nothing thinking

• Sometimes called black and white thinking

• If I’m not perfect have failed
• Either do right or not all
Over generalizing

• Everything Is always rubbish

• Nothing good ever happens
• Seeing a pattern based upon single event, or being overly broad in the conclusion we draw

Mental filter

• Only paying attention to certain types of evidence

• Noticing our failures but not seeing our success

Disqualifying the positive

• Discounting the good things that have happened or that you have done for some reason or another
• That doesn’t count

Jumping to conclusion

There are two key types of jumping to conclusions

• Mind reading (imagining we know what are thinking)

• Fortune telling (predicting the future)

Magnification (catastrophising) & minimization

• Blowing things out if proportion

• (Catastrophizing) or inappropriately shrinking something to make it seem less important

Emotional reasoning

• Assuming that because we feel a certain way what we must be true

• I feel embarrassed so I must be an idiot

Should must

• Using critical words like “should, must, or ought” can make us feel guilty, or like we have already failed
• If we apply should to other people the results Is often frustration

Labelling

• Assigning labels to ourselves or other people

 • I am a loser
• I am completely useless
• They’re such an idiot

Personalization “this is my fault”

• Blaming yourself or taking responsibility for something that wasn’t completely your fault
• Conversely, blaming other people for something that was your fault

Adaptation Healthy vs. Unhealthy Emotion

Working to improve your mental health one of the most important things to identify is the difference between
healthy and unhealthy emotional response. This is important because you do very different things with healthy vs.
healthy emotions. If an emotion is healthy, you have several good options:

• You can simply accept the feeling

• . You can express it in a respectful way.
• You can act on the feeling in a constructive way.

An emotional response is unhealthy, you can work to alter the emotion by re-examining thoughts and beliefs you
have about yourself, others, or the situation. However, if you have difficulty expressing emotion it is important to
be very careful about trying to suppress healthy feelings because they are uncomfortable or you feel that it is
wrong to press them. On the other hand, if you have a tendency to act impulsively, it is important to be careful
about acting it on unhealthy feelings. How can you tell the difference? Below is a list of some common names
and characteristics for healthy vs. unhealthy emotions.

Positive emotions Negative emotions

Healthy Unhealthy Healthy Unhealthy

Self esteem Arrogance Sadness Depression

Love Codependence Hurt

Disappointment
 Happiness Mania Annoyed Anger

Interest Obsession Regret/ Shame/Guilt

remorse

Desire Addiction Alertness/ Paranoia/fear

concern

Serenity Passivity Concerned Anxiety/worry

Characteristics of Healthy Feelings

• He feelings go away after a period of time.

• Your negative thoughts are realistic and not filled with distortions.
• You continue to be productively involved with your ife and solving problems.
• You do not incur a loss of worth or self-esteem.
• Your feelings allow you to have a healthy enjoyment of our life. Your feelings are in reasonable
proportion to the event had triggered them.
• You do not feel discouraged about the future.
• You can express your feeling in a respectful way.
• You believe that both you and the other person have valid ideas and feelings that deserve to be
understood. Your emotions help you to learn from the situation so you can be wiser in the future.
• Your emotions help you to build positive relationships with other people.
• You look for a solution in which neither you nor anyone else has to lose.
• There are no hidden motives that are driving the emotion such as wanting to avoid a problem or feeling
that you do not like.
Characteristics of Unhealthy Feelings
• The feeling may go on endlessly with no limits.
• Your negative thoughts are exaggerated and distorted, even though emotionally they feel true.
• You lose interest in important areas of your life or stop trying to solve problems. You lose self-esteem or
feel worthless.
• Your feelings cause you to participate in behaviours that are self-destructive and harmful to you.
• Your feelings are far out of proportion to the event that triggered them.
• You feel demoralized and convinced that things will never get better.
 • You cannot express your feeling in a way that is respectful of others.
• You feel that your way of seeing things is the only right way.
• Your emotions cause you to become overwhelmed and avoid all similar situations even when the new
situation isn’t actually dangerous.
• Your emotions make it difficult to have healthy relationships with other people
• You feel like you are in a battle or a competition where you or someone else has to lose.
• Your emotion is serving to help you avoid emotions or Problems that you do not want to confront.

RESPONSIBILITY PIE

We often blame ourselves some feared future event that might happen. However, we usually give ourselves more
than our fair share of that blame and responsibility

This “Responsibility Pie” one way of challenging that distorted thinking

Write down how responsible you would feel if the feared situation happened, using percentage scale with 0%
being not at all responsible, and totally responsible.

Now think about and write down all the other factors that may have contributed to this event, share some
responsibility
Now draw lines out to the circle from the centre and mark off sections for each factor, according to how
responsible that factor would be

The part you are left with (if any) is how responsible you really might be

The Responsibility pie can also be used when we blame ourselves totally for a bad event that did happen

CORE BELIEF WORKSHEET

Old CORE BELIEF: __________

How much do you believe the old core belief right now? (0-100) __________

What’s the most you’ve believed it this week? (0-100) __________

What’s the least you believed it this week? (0-100%) __________

New belief I’m competent, though with both strengths and weaknesses.

How much do you believe the new belief right now? (0-100%) ______________
 Evidence that contradicts Evidence that seems to
old core belief and support old core belief with
supports new belief reframe

Should situations related to an increase or decrease in the strength of the belief be topics for the agenda?

Core Beliefs Worksheet

Core belief to be challenged

Experience that shows this belief is not completely true all the time

1.______________________________________

2_______________________________________

3._______________________________________

4._______________________________________

5._______________________________________
 6._______________________________________

7._______________________________________

8._______________________________________

9._______________________________________

10._______________________________________

Balanced core beliefs:

Core belief to be tested

Tasks prediction what actually

happened
 Conclusion

Balanced core beliefs

Modifying rules and assumptions:

What is the rule (or assumption) I live by that I would like to modify?

I’m not the best or I’m a failure (assumption)

How does this rule (or assumption) affect me in my day to day life?

It means I try really hard at whatever I do. set myself incredibly high standards

Which are tough to live up to I’m always worried up slipping up and making mistakes.

What are the origins of this rule (or assumption)?

Where did I learn it? What was going on my earlier life that meant this may have been a helpful le at the
time?

My parents were very driven. Dad’s motto was “second is just a fancy word for losing

As a child I got lots of praise for succeeding.

What are the advantages of this rule (or What are the disadvantages of this rule (or
assumptions) assumption)

I am exhausted

It means that I try hard and I have achieved I am always checking to make sure I am not
Is there an alternative to my rule (or assumption) that would be more flexible?

This may take more words to express than the original rule is there a new rule (or assumption that
would allow you to get most of the advantages with fewer of the disadvantages? How can you put this
new rule or assumptions in to practice?

Doing a good job is good enough in this life. Not being the best doesn’t make me a failure.

Real life isn’t a competition there’s no medal for being the best. It’s more important for me to have a
balance in life and try to enjoy it than to beat myself about achieving all the time.

Cognitive Conceptualization Diagram

 Relevant Childhood Data
(Include information gathered in additional sessions)

CORE BELIEFS
(I need to be in control, I am
unlovable)

Intermediate Beliefs(S)
(If my doesn’t obey me, I am not in control/she doesn’t love me
If my husband doesn’t do what I want him to do, I am not in control/he does love me)

Compensatory Strategy(ies)
(Anger outbursts, place blame on others, and avoid immediate expression of feeling to
husband)

SITUATION 1
SITUATION 3
SITUATION 2
Daughter hides in
Husband spends
closet, which Daughter refuses to
night playing model
causes them to be go to school
trains
late at school

AUTOMATIC AUTOMATIC AUTOMATIC

THOUGHT THOUGHT THOUGHT
She is a self- She’s becoming a I might as well not
centered brat, she tyrant; she doesn’t be married, he
doesn’t care about care about what I doesn’t
me need

MEANING OF
MEANING OF MEANING OF THOUGHT
THOUGHT THOUGHT
“I am not in control
“I am not in control, “I am not in control I am unlovable”
I am unlovable" I am unlovable”
 EMOTIONS(s)
EMOTION(s) EMOTION(s)
Anger, feeling on
Anger, worried Anger, Resentful
edge

BEHAVIOUR(s) BEHAVIOUR(S) BEHAVIOUR(s)

Yelled at daughter Yelled at daughter Yelled at husband

ADVANTAGE/DISADVANTAGE ANALYSIS (Instructions)

Parents may find it helpful to learn the skill of analysing the advantages and disadvantages in a variety Contexts:

1.In decision making

A. Weighing attributes (Should I take job A or job B2)

B. Deciding whether to take a certain step. (Should I leave my partner? Go back to school? Take
medication?)

C. Determining whether this is a reasonable time to take a certain step. (Given that I’ll eventually have to
change jobs, should I do so now or later?)

1. In changing certain beliefs

A) What are the advantages and disadvantages of continuing to hold this belief?

B) What might be the advantages and disadvantages of changing the belief?

2. In motivating the patient.

A) What are the advantages and disadvantages [of engaging in this behaviour]?
 B) What are the advantages disadvantages [of not engaging in this behaviour]?

Advantage/Disadvantage Analysis

Advantages of ___________________ Disadvantages of ________________

Advantages of ____________________ Disadvantages of ___________________

THOUGHT DIARY

Instructions:

Keep a note of when you feel any of the following: anxiety, fear, hurt, anger, shame, guilt, depression in the
FEELINGS column. Rate how strongly you experience the feeling on a scale of 0% (low) to 10% (high).

1. Note what you were doing at the time in the SITUATION column.
2. Think about what you were saying to yourself about the situation and identify any
unhelpful thoughts. Write these into the THOUGHTS column.
 4.Try to generate more helpful, realistic and supportive thoughts in the ALTERNATIVE
THOUGHTS column. Helpful thoughts tend to a) promote acceptance of self, others and the
world. B) state preferences, wishes or wants rather than making absolute demands like ‘should,
ought or must.”
5.Practise thinking these new ALTERNATIVE THOUGHTS next time you are in, or entering a
similar situation.
6. MONITOR what NEW FEELINGS you experience and rate these on a scale of 0% - 10%.
More helpful feelings can include: annoyance, concern, regret, sadness, remorse etc..
Day Situati Thought Feelin Alternati New
on s gs ve feelin
What Anxious, 0( Thoughts gs
were Negative low) - . Helpful O
you , 10 (low)
doing? pessimist (high) -10
ic (high)
Monday
Tuesday
Wednesd
ay
Thursday
Friday
Saturday
Sunday

The IF/THEN quiz

Try the IF/THEN Quiz. What do you think will happen?

IF I am good THEN

IF I get into trouble THEN

IF I get things wrong THEN

IF I work hard THEN

IF I have no friends THEN

IF People like me THEN

IF I make people happy THEN

IF I let my parents down THEN

IF I am not kind THEN

IF I am successful THEN

The negative trap

Think about one of your most difficult situations and Write/draw:

• What HAPPENS
• How you FEEL
• What you think about when you are in that situation.

What I think :

What I do How I feel:

What are they thinking? Fill in the thought bubbles by writing or drawing what these people might be
thinking.

What happens when I feel sad?

Think about something that made you feel really sad and unhappy. How would someone else know that you felt
like this?
What does your face look like when you are sad?

How does your body show that you are unhappy?

How do you behave when you are unhappy?

How much of the time do you feel unhappy?

Never All the time

1 2 3 4 5 6 7 8 9 10

What happens when I feel happy?

Think about something that made you feel really happy. How would someone else know that you felt like this?

What does your face look like when you are happy?

How does your body show that you are happy?

How do you behave when you are happy?

How much of the time do you feel happy?

Never: All the time

1 2 3 4 5 6 7 8 9 10

What happens when I feel angry?

Think about something that made feel really cross and angry. How would someone else know that you felt like
this?

What does your face look like when you are angry?

Does your body show that you angry?

Do you behave when you are angry?

Much of time do you feel angry?

Never All the time

1 2 3 4 5 6 7 8 9 10

Behaviour Activation Theory

The behavioural activation model suggests that negative life events such as grief, trauma, daily stressors,
or a genetic predisposition to depression can lead to a person having too little positive reinforcement.
Additionally, a person might turn to unhealthy behaviours-drug use, sleeping late into the afternoon,
social withdrawal, etc.-in an attempt to avoid the negative feelings. These behaviors provide temporary
relief, but ultimately result in more negative outcomes, and worsening depression.

When using behavioural activation, a clinician intervenes in two primary ways: They increase the amount of
positive reinforcement a person experiences, and they end negative behaviour patterns that cause depression to
worsen. Replacing negative avoidant behaviours with new rewarding behaviours increases a person’s positive
reinforcement and reduces negative reinforcement

No Treatment

Negative Avoidant Depression worsens

Behaviour

Behavioural Activation

Positive Replacement Depression subsides

Behaviour

Using Behavioural Activation

The goal of behavioural activation might seem simple (just replace negative behaviors with positive
alternatives), but its implementation in real life comes with challenges. Imagine being in immense pain
and having a tool that allows you to immediately relieve that pain. Now, imagine you have a tool that you
hear will help more in the long run, but it isn’t going to relieve the pain you’re experiencing right now.
Behavioural activation is the tool that will help in the long-run, but there won’t be any instant relief.
Unhealthy avoidant behaviours are the tools that provides instant relief, but ultimately do more harm than
good. Because the goals of behavioural activation can be unclear to a client, education is an important
first step.
Who do not understand the reasoning behind behavioural activation are unlikely to be ated to follow
through. How is going out with friends or going for a walk going to help the long-run when they still feel
miserable doing these things? Why shouldn’t they stay home in bed when that’s the one thing that makes
them feel better? It’s the clinician’s job to ep a client recognizes how their avoidant behaviour (in this
example, staying at home in bed) causing their depression to worsen. This requires a clinician to listen,
pinpoint negative behaviour patterns, and collaborate with a client to figure out how they can be
damaging. It can be helpful to draw a quick diagram, as shown below.

NEGATIVE BEHAVIOR

Sleep until noon nearly every day to avoid stress and negative feelings.

IMMEDIATE CONSEQUENCES Miss breakfast .No time to

exercise. No time for daily responsibilities.

RESPONSE

Increased stress due to unaddressed responsibilities. Guilt about worsening health due to little activity. Reduced
energy due to inadequate diet.

Developing Positive Replacement Behaviours

After educating a client about behavioural activation and identifying some negative behavior patterns, the
next step is to come up with some positive replacement behaviours. This can’t be emphasized enough:
The positive replacements should be both easy and rewarding. Someone who is depressed might have a
hard time getting out of bed by noon and brushing their teeth, let alone waking up at 6 AM, creating a
résumé, or running a 10K. It can be helpful to create a list of positive rewarding behaviours, and rank
them from 1 to 10 in the areas of ease and reward.

Emotion Regulation Handout

1. Meditating
2. making plans for the future
3. finishing something
4. talking with a friend
5. browsing in a catalogue
6. watching TV
7. sitting/lying in the sun
8. listening to others
9. drawing
10. playing an instrument
11. looking outside
12. watching people
13. watching a movie
14. meeting a friend
15. repairing something
16. memories of the words of loving people wearing nice clothes
17. taking care of plants
18. going to a party
19. thinking about buying things
20. praying
21. thinking I am a good person
22. writing a letter
23. cooking
24. sleeping
25. fixing your hair and makeup daydreaming
26. making a list of task/goals
27. watching sports
28. thinking about pleasant events
29. writing in a diary
30. reading a book
31. discussing books
32. having lunch with a friend
33. solving riddles/puzzles
34. looking at showing photos
35. learning to play a new card game reflecting on how I have improved thinking I’m a person who
can cope taking a warm bath
36. paying bills
37. playing a game
38. remembering good times
 39. relaxing
40. reading a book
41. laughing out loud
42. painting
43. singing
44. remembering beautiful scenery watching the birds
45. eating
46. gardening
47. thinking about retirement
48. doodling
49. exercising
50. having a quiet evening
51. arranging flowers
52. drinking a favourite beverage
53. going on a picnic
54. losing weight
55. a day with nothing to do
56. buying clothes
57. going to the beauty parlour
58. making a gift for someone
59. having your picture taken
60. listening to music
61. taking a walk
62. playing sports
63. acting
64. dancing
65. cleaning
66. being alone
67. playing cards
68. having a political discussion
69. shooting pool
70. learning to play a game
71. talking on a phone
72. helping a friend cope

Beck's Depression Inventory

This depression inventory can be self-scored. The scoring scale is at the end of the questionnaire.
1.

0 I do not feel sad.

1 I feel sad

2 I am sad all the time and I can't snap out of it.

3 I am so sad and unhappy that I can't stand it.

2.

0 I am not particularly discouraged about the future.

1 I feel discouraged about the future.

2 I feel I have nothing to look forward to.

3 I feel the future is hopeless and that things cannot improve.

3.

0 I do not feel like a failure.

1 I feel I have failed more than the average person.

2 As I look back on my life, all I can see is a lot of failures.

3 I feel I am a complete failure as a person.

4.

0 I get as much satisfaction out of things as I used to.

1 I don't enjoy things the way I used to.

2 I don't get real satisfaction out of anything anymore.

3 I am dissatisfied or bored with everything.

5.

0 I don't feel particularly guilty

1 I feel guilty a good part of the time.

2 I feel quite guilty most of the time.

3 I feel guilty all of the time.

6.
0 I don't feel I am being punished.

1 I feel I may be punished.

2 I expect to be punished.

3 I feel I am being punished.

7.

0 I don't feel disappointed in myself.

1 I am disappointed in myself.

2 I am disgusted with myself.

3 I hate myself.

8.

0 I don't feel I am any worse than anybody else.

1 I am critical of myself for my weaknesses or mistakes.

2 I blame myself all the time for my faults.

3 I blame myself for everything bad that happens.

9.

0 I don't have any thoughts of killing myself.

1 I have thoughts of killing myself, but I would not carry them out.

2 I would like to kill myself.

3 I would kill myself if I had the chance.

10.

0 I don't cry any more than usual.

1 I cry more now than I used to.

2 I cry all the time now.

2 I used to be able to cry, but now I can't cry even though I want to .

11.
0 I am no more irritated by things than I ever was.

1 I am slightly more irritated now than usual.

2 I am quite annoyed or irritated a good deal of the time.

3 I feel irritated all the time.

12.

0 I have not lost interest in other people.

1 I am less interested in other people than I used to be.

2 I have lost most of my interest in other people.

3 I have lost all of my interest in other people.

13.

0 I make decisions about as well as I ever could.

1 I put off making decisions more than I used to.

2 I have greater difficulty in making decisions more than I used to.

3 I can't make decisions at all anymore.

14.

0 I don't feel that I look any worse than I used to.

1 I am worried that I am looking old or unattractive.

2 I feel there are permanent changes in my appearance that make me look

unattractive

3 I believe that I look ugly.

15.

0 I can work about as well as before.

1 It takes an extra effort to get started at doing something.

2 I have to push myself very hard to do anything.

3 I can't do any work at all.

16.
0 I can sleep as well as usual.

1 I don't sleep as well as I used to.

2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.

3 I wake up several hours earlier than I used to and cannot get back to sleep.

17.

0 I don't get more tired than usual.

1 I get tired more easily than I used to.

2 I get tired from doing almost anything.

3 I am too tired to do anything.

18.

0 My appetite is no worse than usual.

1 My appetite is not as good as it used to be.

2 My appetite is much worse now.

3 I have no appetite at all anymore.

19.

0 I haven't lost much weight, if any, lately.

1 I have lost more than five pounds.

2 I have lost more than ten pounds.

3 I have lost more than fifteen pounds.

20.

0 I am no more worried about my health than usual.

1 I am worried about physical problems like aches, pains, upset stomach, or

constipation.

2 I am very worried about physical problems and it's hard to think of much else.

3 I am so worried about my physical problems that I cannot think of anything else.

21.
0 I have not noticed any recent change in my interest in sex.

1 I am less interested in sex than I used to be.

2 I have almost no interest in sex.

3 I have lost interest in sex completely.

INTERPRETING THE BECK DEPRESSION INVENTORY

Now that you have completed the questionnaire, add up the score for each of the twenty-one questions by
counting the number to the right of each question you marked. The highest possible total for the whole
test would be sixty-three. This would mean you circled number three on all twenty-one questions. Since
the lowest possible score for each question is zero, the lowest possible score for the test would be zero.
This would mean you circles zero on each question. You can evaluate your depression according to the
Table below.

Total Score ____________________Levels of Depression

1-10____________________These ups and downs are considered normal

11-16___________________ Mild mood disturbance

17-20___________________Borderline clinical depression

21-30___________________Moderate depression

31-40___________________Severe depression

over 40__________________Extreme depression

IPDE – ICD-10 Screening questionnaire

Directions:

The purpose of this questionnaire is to learn what type of person you have been during the past five years. Please
do not skip any items. If you are not sure of an answer, select the one TRUE or FALSE- Which is more likely to
be correct. There is no time limit but do not spend too much time thinking about the answer to any is no single
statement. When the answer is True circle the letter T. When the answer is false circle the letter f

1. I usually get True False

fun enjoyment
out of life
2. I don’t react True False
well when
someone
offends me
3. I’m not fussy True False
about little
details
4. I cannot True False
decide what
kind of person
I want to be
5. I show my True False
feelings for
everyone to
see
6. I let others True False
make my big
decisions for
me
7. I usually feel True False
tense or
nervous
8. i almost never True False
get angry
about
anything
9. I go to True False
extremes to
try to keep
people from
leaving me
10. I am a very True False
cautious
person
11. I have never True False
been arrested
12. People think True False
I’m cold and
detached
13. I get into very True False
intense
relationship
that don't last
14. Most people True False
are fair and he
honest with
me
15. I find it hard True False
to disagree
with people if
I depend on
them a lot
16. I feel True False
awkward or
out of place in
social
situations
17. I am too True False
easily
influenced by
what goes on
around me
18. I usually feel True False
bad when I
hurt or
mistreat
someone
19. I argue or True False
fight when
people trying
to stop me
 from doing
what I want
20. at times i have True False
refused to
hold a job
even when i
was expected
to
21. When I am True False
priced or
criticized I
don’t show
others my
reaction
22. I have held True False
grudges
against people
for years
23. I spent too True False
much time
trying to do
things
perfectly
24. people often True False
make fun of
me behind my
back
25. I have never True False
threatened
suicide or
injured myself
on purpose
26. My feelings True False
are like the
weather they
 are always
changing
27. I fight for my True False
rights even
when it
annoys people
28. I like to dress True False
so I stand out
in the crowd
29. I will lie or True False
con someone
if it serves my
purpose
30. I don’t stick True False
with a plan if
I don’t get
results right
away
31. I have little or True False
no desire to
have sex with
anyone
32. People think True False
I’m too strict
about rules
and
regulations
33. I usually feel True False
uncomfortable
or helpless
when I am
alone
34. I won’t get True False
involved with
people until I
 am certain
they like me
35. I would rather True False
not to be the
centre of
attention
36. I think my True False
spouse or
lover maybe
unfaithful to
me
37. Sometimes I True False
get so angry I
break or
smash things
38. I have had True False
close
friendship that
lasted a long
time
39. I worry a lot True False
that people
may not like
me
40. I often feel True False
empty inside
41. I work so hard True False
that I don’t
have time left
for anything
else
42. I worry about True False
being left
alone and
having to care
for myself
43. lot of things True False
seems
dangerous to
me that don't
bother most
people
44. I have True False
reputation for
being a flirt
45. I do not ask True False
favours from
people I
depend a lot
46. I prefer True False
activities that
I can do by
myself
47. I lose my True False
temper and
get into
physical
fights
48. People think True False
I’m too stiff
or formal
49. I often seek True False
advice or
reassurance
about
everyday
decisions
50. I keep to True False
myself even
when there
are other
people around
51. It’s hard for True False
me to stay out
of trouble
52. I’m convinced True False
there is a
conspiracy
behind many
things in the
world
53. I’m very True False
Moody
54. it's hard for True False
me to get used
to a new way
of doing
things
55. Most people True False
think I’m a
strange person
56. I take chances True False
and do
reckless
things
57. Everyone True False
needs a friend
or two to be
happy
58. I’m more True False
interested in
my own
thoughts then
what goes on
around me
59. I usually try True False
to get people
 to do things
my way

Beck Anxiety Inventory

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much
you’ve been bothered by the symptoms during the past month including today by circling the number in the
corresponding space in the column next to each symptom

Numbness 0 Moderately Severely

or tingling Mildly- - it was not - it
but it pleasant at bothered
did not times me a lot
bother
me
much
Feeling hot 0 1 2 3
0 1 2 3
Wobbliness
in legs
Unable to 0 1 2 3
relax
Fear of 0 1 2 3
worst
happening
Dizzy or 0 1 2 3
light
headed
Heart/ 0 1 2 3
pounding
racing
unsteady 0 1 2 3
Terrified 0 1 2 3
or afraid
Nervous 0 1 2 3
 Feeling of 0 1 2 3
choking
Hands 0 1 2 3
trembling
Shaky 0 1 2 3
unsteady
Fear of 0 1 2 3
losing
control
Difficulty 0 1 2 3
in
breathing
Fear of 0 1 2 3
dying
Scared 0 1 2 3
Indigestion 0 1 2 3
Faint/light 0 1 2 3
headed
Face 0 1 2 3
flushed
Hot/cold 0 1 2 3
sweats
Column
sum
Scoring – sum each column. Then sum the column totals to achieve a grand score. Write that score
here __________

Interpretation

A grand sum between 0-21 indicates very low anxiety. That is usually a good thing. However, it is possible that
you might be unrealistic in either your assessment which would be denial or that you have learned to “mask” the
symptoms commonly associated with anxiety. Too little “anxiety” could indicate that you are detached from
yourself, others, or your environment.

A grand sum between 22-35 indicates moderate anxiety. Your body is trying to tell you something. Look for
patterns as to when and why you experience the symptoms described above. For example, if it occurs prior to
public speaking and your job requires a lot of presentations you may want to find ways to calm yourself before
speaking or let others do some of the presentations. You may have some conflict issues that need to be resolved.
Clearly, it is not “panic” time but you want to find ways to manage the stress you feel.

A grand sum that exceeds 36 is a potential cause for concern. Again, look for patterns or times when you tend to
feel the symptoms you have circled. Persistent and high anxiety is not a sign of personal weakness or failure. It is,
however, something that needs to be proactively treated or there could be significant impacts to you mentally and
physically. You may want to consult a counsellor if the feelings persist.

Cognitive Behaviour Therapy, Basics and Beyond

What is cognitive behaviour therapy

Aaron Beck developed a form of psychotherapy in the early 1960s that he originally termed “cognitive therapy.”
Beck devised a structured, short-term, present-oriented psychotherapy For depression, directed toward solving
current problems and modifying dysfunctional (inaccurate and/or unhelpful) thinking and behaviour

. In all forms of cognitive behaviour therapy that are derived from Beck’s model, treatment is based on
cognitive formulation, the beliefs and behavioural strategies that characterize a specific disorder (Alford
& Beck, 1997).

The therapist seeks in a variety of ways to produce cognitive change modification in the patient’s thinking
and belief system—to bring about enduring emotional and behavioural change.

There are a number of forms of cognitive behaviour therapy that share characteristics of Beck’s therapy,
but whose conceptualizations and emphases in treatment vary to some degree. These include rational
Emotional behaviour therapy (Ellis, 1962), dialectical behaviour therapy (Linehan, 1993), problem-
solving therapy (D’Zurilla & Nezu, 2006), Acceptance and commitment therapy (Hayes, Follette, &
Linehan, 2004), exposure therapy (Foa & Rothbaum, 1998), cognitive processing therapy (Resick &
Schnicke, 1993), cognitive behavioral analysis System of psychotherapy (McCullough, 1999), behavioral
activation (Lewinsohn, Sullivan, & Grosscup, 1980; Martell, Addis, & Jacobson, 2001), cognitive
behavior modification (Meichenbaum, 1977), and others.

What Is the Theory Underlying Cognitive Behaviour Therapy?

In a nutshell, the cognitive model proposes that dysfunctional thinking (which influences the patient’s mood and
behaviour) is common to all psychological disturbances

For example, if you were quite depressed and bounced some checks, you might have an automatic
thought, an idea that just seemed to pop up in your mind: “I can’t do anything right.”

For lasting improvement in patients’ mood and behaviour, cognitive therapists work at a deeper level of
cognition: patients’ basic beliefs about themselves, their world, and other people. Modification of their
underlying dysfunctional beliefs produces more enduring change. For example, if you continually
underestimate your abilities, you might have an underlying belief of incompetence.

How Was Beck’s Cognitive Behaviour Therapy Developed?

In the late 1950s and early 1960s, Dr. Beck decided to test the psychoanalytic concept that depression is the
result of hostility turned inward toward the self. He investigated the dreams of depressed patients, which, he
predicted, would manifest greater themes of hostility than the dreams of normal controls. To his surprise, he
ultimately found that the dreams of depressed patients contained fewer themes of hostility and far greater themes
of defectiveness, deprivation, and loss.

Important components of cognitive behaviour therapy for depression include a focus on helping patients
solve problems; become behaviourally activated; and identify, evaluate, and respond to their depressed
thinking, especially to negative thoughts about themselves, their worlds, and their future.

The basic principles of cognitive behaviour therapy are as follows:

• Current thinking
• Problematic behaviours
• Precipitating Factors
• Developmental events
• Patterns of Interpreting

Principle No. 2. Cognitive behaviour therapy requires a sound therapeutic alliance.

All the basic ingredients necessary in a counselling situation: warmth, empathy, caring, genuine regard,
and competence. I show my regard for Sally by making empathic statements, listening closely and
carefully, and accurately summarizing her thoughts and feelings. I point out her small and larger
successes and maintain a realistically optimistic and upbeat outlook. I also ask Sally for feedback at the
end of each session to ensure that she feels understood and positive about the session.

Principle No. 3. Cognitive behaviour therapy emphasizes collaboration and active participation

Together we decide what to work on each session, how often we should meet, and what Sally can do
between sessions for therapy homework.

Principle No. 4. Cognitive behaviour therapy is goal oriented and problem Focused.

Enumerate her problems and set specific goals so both she and I have a shared understanding of what she
is working toward.

Principle No. 5. Cognitive behaviour therapy initially emphasizes the present.

The treatment of most patients involves a strong focus on current problems and on specific situations that
are distressing to them

Therapy starts with an examination of here-and-now problems, regardless of diagnosis. Attention shifts to
the past in two circumstances. One, when patients express a strong preference to do so, and a failure to do
so could endanger the therapeutic alliance. Two, when patients get “stuck” in their dysfunctional thinking,
and an understanding of the childhood roots of their beliefs can potentially help them modify their rigid
ideas.

Principle No. 6. Cognitive behaviour therapy is educative, aims to teach the patient to be her own
therapist, and emphasizes relapse prevention

In our first session I educate Sally about the nature and course of her dis- Order, about the process of
cognitive behaviour therapy, and about the cognitive model (i.e., how her thoughts influence her emotions
and behaviour)

Principle No. 7. Cognitive behaviour therapy aims to be time limited.

Many straightforward patients with depression and anxiety disorders are treated for six to 14 sessions.
Therapists’ goals are to provide symptom relief, facilitate a remission of the disorder, help patients resolve their
most pressing problems, and teach them skills to avoid relapse.

Not all patients make enough progress in just a few months, however. Some patients require 1 or 2 years of
therapy (or possibly longer) to modify very rigid dysfunctional beliefs and patterns of behaviour that contribute to
their chronic distress.

Principle No. 8. Cognitive behaviour therapy sessions are structured.

No matter what the diagnosis or stage of treatment, following a certain structure in each session
maximizes efficiency and effectiveness. This structure includes an introductory part, a middle part and a
final part.

Principle No. 9. Cognitive behaviour therapy teaches patients to identify, evaluate, and respond to
their dysfunctional thoughts and beliefs.

Patients can have many dozens or even hundreds of automatic thoughts a day had affect their mood,
behaviour, and/or physiology (the last is especially pertinent to anxiety). Therapists help patients identify
key cognitions and adopt more realistic, adaptive perspectives, which leads patients to feel better
emotionally, behave more functionally, and/or decrease their physiological arousal. They do so through
the process of guided discovery, using questioning (often labelled or mislabelled as “Socratic
questioning”) to evaluate their thinking (rather than persuasion, debate, or lecturing). Therapists also
create experiences, called behavioural experiments, for patients to directly test their thinking (e.g., “If I
even look at a picture of a spider, I’ll get so anxious I won’t be able to think”). In these ways, therapists
engage in collaborative empiricism.

Principle No. 10. Cognitive behaviour therapy uses a variety of techniques to change thinking, mood, and
behaviour

Although cognitive strategies such as Socratic questioning and guided discovery are central to cognitive
behaviour therapy, behavioural and problem-solving techniques are essential although automatic thoughts
seem to pop up spontaneously, they become fairly predictable once the patient’s underlying beliefs are
identified.
 CBT WORKSHEETS

Situation that triggered anger

What I did Consequences

Next time, I will

 Situation that triggered anger

What I did Consequences

 Next time, I will

Trigger
 My Response

Consequences
Next Time, I
Can…

Trigger
 My Response

Consequences
Next Time, I
Can…
Cognitive Distortions

THOUGHT

EXAMPLE: I am a failure

THOUGHTS

THOUGHTS

THOUGHTS
 Right now, I feel…

We usually refer to our emotions as either

“good” or “bad”. Let’s refer to them as
“comfortable” or “uncomfortable” instead!
Why? Because emotions can’t be bad- it’s
okay to feel how you feel.

Look at the emotion you wrote down above. Is

that a comfortable or uncomfortable emotion
for you? Why do you think that is?
 Right now, I feel…

We usually refer to our emotions as either

“good” or “bad”. Let’s refer to them as
“comfortable” or “uncomfortable” instead!
Why? Because emotions can’t be bad- it’s
okay to feel how you feel.

Look at the emotion you wrote down above. Is

that a comfortable or uncomfortable emotion
for you? Why do you think that is?
 Right now, I feel…

We usually refer to our emotions as either

“good” or “bad”. Let’s refer to them as
“comfortable” or “uncomfortable” instead!
Why? Because emotions can’t be bad- it’s
okay to feel how you feel.

Look at the emotion you wrote down above. Is

that a comfortable or uncomfortable emotion
for you? Why do you think that is?
 Right now, I feel…

We usually refer to our emotions as either

“good” or “bad”. Let’s refer to them as
“comfortable” or “uncomfortable” instead!
Why? Because emotions can’t be bad- it’s
okay to feel how you feel.

Look at the emotion you wrote down above. Is

that a comfortable or uncomfortable emotion
for you? Why do you think that is?