COGNITIVE BEHAVIOR THERAPY
A: You will try to specify the problem and establish its meaning to the patient, then intervene or mark the problem for intervention
Q: What if . . . patients have a negative reaction to the session?
A: You will try to specify the problem and establish its meaning to
Structure of the First Therapy Session 79 TherapisT: Okay, should I write “optional” or cross it off?
paTienT: Maybe cross it off.
TherapisT: Okay. (Does so.) Now, was there anything else that bothered you about today’s session?
Here the therapist recognizes the necessity for strengthening the therapeutic alliance. The therapist had either missed signs of the patient’s dissatisfaction during the session or the patient was adept at concealing it. Had the therapist failed to ask for feedback about the session or been less adept at dealing with the negative feedback, it is possible that the patient would not have returned for another session. The therapist’s flexibility about the homework assignment helps the patient reexamine his misgivings about the appropriateness of cognitive behavior therapy. By responding to feedback and making reasonable adjustments, the therapist demonstrates understanding of and empathy toward the patient, which facilitates collaboration and trust.
The therapist will make sure to express at the beginning of the next session how important it is that they work as a team to tailor the treatment and the homework so the patient finds them helpful. The therapist also uses this difficulty as an opportunity to refine the conceptualization of the patient. In the future, the therapist ensures that homework is set more collaboratively with the patient and that he does not feel overwhelmed.
The initial therapy session has several important goals: establish- ing rapport; refining the conceptualization; socializing patients to the process and structure of cognitive behavior therapy; educating patients about the cognitive model and about their disorder(s); and providing hope and some symptom relief. Developing a solid therapeutic alliance and encouraging patients to join with you to accomplish therapeutic goals are of primary importance in this session. Chapter 7 describes the structure of subsequent therapy sessions and Chapter 8 deals with difficulties in structuring sessions.
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BEHAVIORAl ACTIVATION
O
ne of the most important initial goals for depressed patients is scheduling activities. Most have withdrawn from at least some activities that had previously given them a sense of achievement or pleasure and lifted their mood. And they frequently have increased certain behaviors (staying in bed, watching television, sitting around) that maintain or increase their current dysphoria. They often believe that they cannot change how they feel emotionally. Helping them to become more active and to give themselves credit for their efforts are essential parts of treatment, not only to improve their mood, but also to strengthen their sense of self-effi cacy by demonstrating to themselves that they can take more control of their mood than they had previously believed.CONCEPTUAlIzATION Of INACTIVITY
When considering engaging in activities, patients’ depressed automatic thoughts frequently get in their way.
Situation: Thinking about initiating an activity
[Common] Automatic thoughts: “I’m too tired. I won’t enjoy it. My friends won’t want to spend time with me. I won’t be able to do it.
Nothing can help me feel better.”
Behavioral Activation 81
[Common] Emotional reactions: Sadness, anxiety, hopelessness
[Common] Behavior: Remain inactive.
Patients’ relative inactivity then contributes to their low mood, as they have a paucity of opportunities to gain a sense of mastery or plea- sure, which leads to more negative thinking, which leads to increased dysphoria and inactivity, in a vicious cycle.
CONCEPTUAlIzATION Of lACk Of mASTERY OR PlEASURE
Even when patients do engage in various activities, they often derive low levels of satisfaction and pleasure because of their self-critical auto- matic thoughts.
Situation: Engaging in an activity
[Common] Automatic thoughts: “I’m doing a terrible job. I should have done this long ago. There’s still so much left to do. I can’t do this as well as I used to. This used to be more fun. I don’t deserve
to be doing this.”
[Common] Emotional reactions: Sadness, guilt, anger at self
[Common] Behaviors: Stop the activity. Push self beyond a reasonable point. Fail to repeat this activity in the future.
Self-critical thoughts may arise as patients engage in activities or afterward, as they reflect on the results. When scheduling activities, it is important to anticipate automatic thoughts that could interfere with patients’ initiation of activities, as well as thoughts that could diminish patients’ sense of pleasure or achievement during or after an activity.
When you are treating relatively “easy” patients like Sally, you will facilitate the identification of activities that could potentially help them feel better, address interfering thoughts, and assist them in putting pleasurable or productive activities in their schedule. You may need to help more severely depressed patients develop an hourly schedule of
activities for the week to counteract their extensive passivity and inactiv- ity. It may also be useful for some patients to rate their sense of pleasure and achievement following their activities, to examine whether becom- ing more active and responding to their dysfunctional thinking does improve their mood.
Perhaps the easiest and quickest way to get patients behaviorally activated is to review their typical daily schedule (pages 50–52). The following questions can guide your discussion.
Which activities are patients doing too little of, thus depriving
•
themselves of obtaining a sense of achievement (mastery), a sense of pleasure, or both? These might be activities related to work or school, family, friends, their neighborhood, volunteering, sports, hobbies, physical exercise, their household, nature, spirituality, or sensual, intellectual, or cultural pursuits.
Do patients have a good balance of mastery and pleasure
•
experiences? for example, are patients driving themselves too hard, and so have a dearth of pleasure? Are they avoiding activities they predict will be challenging, and so have little opportunity to obtain a sense of mastery?
Which activities are lowest in mastery and/or pleasure? Are these
•
activities inherently dysphoric, such as ruminating in bed, and so should their frequency be reduced? Or are patients feeling dysphoric during potentially rewarding activities because of their depressed thinking?
In the following transcripts, I review Sally’s schedule with her, reinforce her conclusions about how she might better plan her time, encourage her to commit to specific changes, elicit the thoughts that might impede instituting the changes, label her thoughts as predictions that can be tested, give her the choice of a follow-up homework assign- ment, and teach her to give herself credit.
TherapisT: Thinking about your schedule, what do you notice? How are your activities different from say, a year ago, when you weren’t depressed?
paTienT: Well, I’m spending a lot of time in bed.
TherapisT: Does staying in bed make you feel much better? Do you get out of bed feeling refreshed and energetic?
paTienT: (Thinks.) No . . . I guess not. I usually feel groggy and down when I get up.
Behavioral Activation 83 TherapisT: Well, that’s valuable information. [providing psychoedu- cation] It seems most people who are depressed think they’ll feel better if they stay in bed. But they usually find that doing almost anything else is better . . . What else is different?
paTienT: Last semester, I used to go out more with friends or just hang around with them. Now I just go from my dorm room, to class, to the library, to the cafeteria, and back to my room.
TherapisT: Does that give you an idea of what you might like to change this coming week?
paTienT: Yes, well, I’d like to spend more time with other people, but I just don’t seem to have any energy.
TherapisT: So you end up staying in bed?
paTienT: Yes.
TherapisT: Well, that’s an interesting idea you have: “I don’t have the energy to spend time with people.” Let’s write that down. [inquir- ing about setting up a behavioral experiment] Now, how could we test this idea to see if it’s true?
paTienT: I guess I could plan to spend some time with my friends and see if I could do it.
TherapisT: [trying to motivate Sally to do so] Would there be an advantage to doing that?
paTienT: I guess I might feel better.
I infer from Sally’s tone of voice that she might be reluctant to do the experiment. I conceptualize that automatic thoughts might be interfering.
Situation: Discussing spending time with friends
Automatic thought: ??
Emotional reaction: Unspecified negative emotion
To discover Sally’s automatic thought, I ask her directly:
TherapisT: What’s going through your mind right now?
paTienT: I don’t know.
TherapisT: [providing Sally with the opposite of what I actually believed she was thinking] Were you thinking what a good time you’d have with your friends?
paTienT: No, I guess I’m worried that my friends won’t want to hang out with me.
TherapisT: Okay. [reinforcing the cognitive model] Can you see how that thought might stop you from approaching them?
I mentally hypothesize the following scenario:
Situation: Thinking of hanging out with friends
Automatic thought: “They won’t want to hang out with me.”
Emotional reaction: Sadness?
likely behavioral reaction (if she doesn’t respond to the automatic thought): Stay in her room.
Next, I determine whether Sally can devise her own response.
When she cannot, I help her evaluate the validity of her thought and devise a behavioral experiment.
TherapisT: How can you answer that thought?
paTienT: . . . I don’t know.
TherapisT: Do you have any evidence that they won’t want to hang out with you?
paTienT: No, not really, not unless they’re busy . . . Except I’m not much fun these days.
TherapisT: Have they said something?
paTienT: No . . .
TherapisT: Do you have any evidence on the other side—that maybe they would want to spend time with you?
paTienT: (Thinks.) Well, Emily asked me to go to lunch with her today, but I couldn’t.
TherapisT: Okay, that sounds pretty good. So how could you find out for sure whether Emily or others would want to hang out?
paTienT: I guess I could ask them if they want to have dinner or some- thing.
Next I ask a series of questions to set up the behavioral experiment in a way that maximizes the chance of a positive outcome.
Behavioral Activation 85 TherapisT: Who would be easiest for you to ask? Emily?
paTienT: No, Allison and Joe, I guess.
TherapisT: Good. Then you can test two of your predictions. One, that your friends won’t want to hang out, and two, that you’re too tired to spend time with them. Does that sound right?
paTienT: Yes.
TherapisT: [trying to increase the likelihood that Sally will follow through] How likely are you to approach Allison and Joe or some- one else?
paTienT: (in an affirmative tone of voice) I’ll do it.
TherapisT: [recognizing that Sally is more likely to do it if she does it immediately] Do you think you could do it today?
paTienT: I guess I could. I could text them after the session.
TherapisT: [giving positive reinforcement] That’s great. Then if it turns out okay, could you keep trying to get together for friends for the rest of the week? What do you think?
paTienT: Yeah, okay.
TherapisT: [hypothesizing that Sally might turn her friends off if she is too down] Do you want to talk about what to say to your friends about your depression? Or how to balance talking about it with some more upbeat things?
paTienT: No, I don’t need to. They already know I’ve been down.
They’re pretty supportive.
TherapisT: Good . . . [predicting that Sally could feel worse if she’s turned down] Now, if it turns out that friends say no, do you think it will be important to remember that it might be because they’re busy, not because they don’t want to spend time with you?
paTienT: Yeah.
TherapisT: Should I write that down?
paTienT: (Nods.)
TherapisT: (writing) “If they say no, it’s likely that they’d like to hang out with me but they’re too busy.” (pause) Good. Now, can we go back to your schedule? Anything you think you need to change?
paTienT: I guess I’m watching too much TV.
TherapisT: Anything you’d like to try to replace it with this week?
paTienT: I really don’t know.
TherapisT: I notice you don’t seem to be spending much time doing physical activities—is that right?
paTienT: Yeah. I used to run most mornings or swim.
TherapisT: What’s gotten in the way of your doing these things lately?
paTienT: Same thing as before, I guess. I’ve felt really tired. And I didn’t think I’d enjoy it.
Situation: Thinking about getting exercise
Automatic thoughts: “I’m too tired. I won’t enjoy it.”
Emotional reaction: Dysphoria
Behavioral reaction: Stays in bed.
TherapisT: Would you like to plan more exercise, say, going for a short run or swim a few times this week?
paTienT: Okay.
TherapisT: How likely is it that you’ll make plans to see friends and swim or run—maybe at least three times?
paTienT: Oh, I will.
TherapisT: Should we write these things on an activity chart [see Fig- ure 6.1] so you’ll be more likely to commit to them?
paTienT: No, I don’t need to. I’ll do them.
TherapisT: One more thing. Do you think you could give yourself credit every time you do one of these things? You could just say,
“Good. I did it.”
paTienT: (Looking quizzical.) You mean you want me to give myself credit for making plans with my friends?
TherapisT: Absolutely. [providing psychoeducation] When people are depressed, it’s often difficult for them to do things that they used to do easily. Doing things like calling a friend or going for just a short run are really important in starting to get yourself over the depression. And they do take more energy than lying in bed. So of course you deserve credit.
paTienT: But those things used to be easy.
TherapisT: When you’re over the depression, you don’t have to give yourself credit. But if they’re even a little bit difficult to do now, you do deserve credit. And reminding yourself of that will help you recognize that you’re doing something productive to get better.
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Reprinted by permission in Cognitive Behavior Therapy: Basics and Beyond, Second Edition, by Judith S. Beck (Guilford Press, 2011). Permission to photocopy this material is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may download a larger version of this material from www.guilford.com/p/beck4.
mON.TUE.WED.THU.fRI.SAT.SUN.
morn
6–7 7–8 8–9 ing 9–10 10–11 11–12
Afte rno
12–1 on 1–2 2–3 (cont.) FIGURE 6.1. Activity Chart. From J. S. Beck (2011). Copyright 2011 by Judith S. Beck. Adapted by permission.
88
mON.TUE.WED.THU.fRI.SAT.SU
Afte rno
3–4 on 4–5 5–6
Even
6–7 7–8 8–9 ing 9–10 10–11 11–12 12–1 FIGURE 6.1. (cont.)
Behavioral Activation 89 paTienT: Okay.
TherapisT: In fact, I’d like you to give yourself credit whenever you do something active—that is, whenever you’re not napping or watching TV or surfing the Web. [See pages 274–276 for a further description of giving oneself credit.]
In this segment, I lead Sally to draw conclusions from a review of her typical day. Some patients need more guidance than others to do this (e.g., “Do you notice how much time you spend in bed? What is your mood like when you get up—do you feel much better? What changes do you think you might like to try this week?”). I guide Sally to commit to implementing specific changes and identify automatic thoughts that might interfere, proposing behavioral experiments to test the validity of her negative predictions. I also ask her to give herself credit when- ever she is active.
Q: What if . . . patients believe they are incapable of becoming more active, or that becoming more active will not improve their mood?
A: You will provide education, set up behavioral experiments to help