CBT

Edward Thorndike (1911)

• law of effect

• “behavior modification” 

• cat in a box with a pulley system

John Watson (1920)

• Little Albert

  • baby with no fear of white rabbits/rats

  • conditions to be scared of it — struck a steel bar with a bate every time rat was there

  • ethical issue: unknown if he ever was deprogrammed and died at 6

  • generalized to other objects similar — rabbit, dog, mask

BF Skinner

• operant conditioning — rewards and punishments 

• term behavior therapy 

• Skinner box — rat in a box

Joseph Wolpe (1940s/1950s)

• beginnings of modern behavior therapy 

• reciprocal inhibition (theory) 

  • Systematic desensitization rests on this

• can’t feel 2 things at once

  • relaxation and can’t feel anxious when scared

  • Replace anxiety fear response with relaxed response

1st generation of CBT

• basic learning research backgrounds

• results were positive but it stalled

• problems — people didn’t use the same theories and language

• psychoanalysis dominated

• research people not talking to clinical people 

• psychologists in different fields looked down on others in different fields 

Second Gen of CBT

• emphasis on cognition

• behavior and cognition connected

• Aaron Beck (founder of CBT)

• widespread support — gradual replacement of psychoanalysis model 

Third Generation of CBT

• acceptance based mindfulness therapies

• CBT didn’t make enough progress — missing some people

  • efficacy stalled — why haven’t we solved anxiety and depression

  • still need research why things work

Present Centeredness

• what maintains the problem NOW 

• why are you here today 

Empiricism

focus on what works empirically (in real test of it) to modify behavior, regardless of what should work theoretically

• here to learn with you 

Measurement

• Strong focus on measurement of behavior before, during, and after treatment

  • homework, worksheets, tells us what works in real time

• Session only 1 hour — CBT goes on after the session

  • even if someone doesn’t do work it gives us data 

Dimensionality 

Behaviors exist along different dimensions: intensity, frequency and duration

is it impairing functioning?

Lawfulness

• behavior is not random, it can be predicted once you understand the cognitive, affective, and situational triggers

Functional Analysis

• “often one part of a larger case conceptualization”

• To change a behavior you need to carefully analyze and change the context of a behavior (what happens/exists before and after a behavior)

• have to do more than just ask why?  looking at triggers/big picture

• way to understand certain behaviors, more narrow (case conceptualization: all behaviors, functional analysis: 1 behavior)

3 tenets of FA

• Human affect, cognition, and behavior are idiosyncratic (aka “behaviors”)

• Behaviors best understood in the “context” in which they occur

• Behavior and context are an inseparable whole

“What happens when”

Process of detecting patterns or consistencies between behaviors and contexts

Detect patterns (aka “functional relations”) within ”behaviors” and “context”

Maintain Behaviors

• all behavior is learned the same way whether helpful or unhelpful

• no behavior is bad or good per se. it depends on CONTEXT

Individualized Approach

• behavior is individually determined. 

• What creates, maintains, a particular behavior in one person may not create or maintain the same behavior in another 

Chunking

• break down problems into subparts and then target areas for intervention

• ex: fear hierarchies: start small work up

Treatment Packages

• Multiple behavior therapy techniques together to achieve treatment goals 

• see what works best 

Operant Conditioning

• rewards and punishments to modify behavior

• voluntary responses vs. classical (involuntary responses) 

• rewarded behavior repeated

• punished behavior less likely to occur 

Stimulus and Consequences in Operant Conditioning

• Stimulus Role

  • Positive: Application of Stimulus. Stiulus is presented or added

  • Negative: Removal or withdrawal of stimulus. Stiulus is taken away

• Consequences

  • Reinforcement: behavior increases

  • Punishment: behavior decreases 

Positive Reinforcement

• add something the person likes — behavior increases 

ex. money for getting an A makes it more likely student will keep getting As

Negative Reinforcement

Takes away something you do NOT like — behavior increases

ex. taking advil to relieve headach makes it more likely you will take it again

Positive Punishment

Add something you do NOT like — behavior decreases

ex. being yelled at

Negative Punishment

take away something you DO like — behavior decreases

being put in time out

Secondary Reinforcement

• Something a person has learned

• acquired its value only through repeated association with primary reinforcers

• developed in our world: money, grades, gold stars

Primary Reinforcement

• inherently desirable

• item is reinforcing itself

• need food, warmth, water

Schedules of Reinforcement

behavior modification technique which involves selectively reinforcing behaviors you want and withholding what you don’t want

continuously — every time

intermittent — not every time 

4 types of intermittent schedules

Ratio (responses) Schedules vs Interval (time) schedules

fixed ratio — Reinforcement is delivered after a set, predictable number of responses.

variable ratio — Reinforcement is delivered after an unpredictable, variable number of responses. most resistant to extinction because you don’t know when reward will come. ex. gambling. consistent, persistent 

Fixed interval —  Reinforcement is delivered for the first response that occurs after a specific, predictable amount of time has passed. Good before because you know reward is gonna happen, behavior decreases after reward. Ex. trying a lot harder because you know youre going to get a raise 

Variable interval - Reinforcement is delivered for the first response that occurs after an unpredictable, variable amount of time. constantly doing it because you don’t know when reward will happen

Extinction

• loss of conditioned behavior

• reinforcement is withheld from a preivously reinforced behavior — behavior decreases/elimanted 

Extinction Burst

when a behavior is no longer followed by a reward, the individual may exhibit an increase in the frequency, duration, or intensity of that behavior. This increase in behavior is known as an extinction burst.

Case Conceptualization in CBT

working hypothesis on what’s happening with patient, how disorder is developped maintained, triggered. contextual. Often CBT therapists share canse conceptualizaztion

• Understanding of patient’s presenting problem

• identify variables related to difficulties

• identify treatment targets, goals, and objectives

• broad hypothesis of a person (all behaviors)

• A method and clinical strategy to obtain and organize info about the patient

• incorporates ares such as learning history, maintaining factors, and presenting problem

• can work as a map or blueprint of treatment based on personalized factors

• should continually be updated throughout treatment

• Process: descriptive emphasis (derived from assessment), treatment recommendations, review and update

“The formulation is a hypothesis about the mechanisms causing and maintaining the patient’s problems. The therapist uses the formulation (and other information) to develop a treatment plan and obtain the patient’s informed consent to it.

Comorbidity

when conditions present together. the simultaneous presence of two or more diseases or medical conditions in a patient.

Idiographic

individualized/unique features of someone

Nomothetic

how they look like everyone else, ex base rates

Why use Case Conceptualization?

To better understand behavior

To increase empathy

To identify ways to engage clients

To identify targets for intervention

To create a shared understanding of a child or adolescent

Efficacy

how well it works in controlled environment, internal validity

Effectiveness

does it work in real world, external validity

5 Ps

• Presenting problem: what the pt and clinician identify as difficulties.

• Predisposing factors: biological, genetic, environmental, psychological, or personality risk factors

• Precipitating factors: significant events preceding onset of disorder

• Perpetuating factors: repeating behavioral, cognitive, or biological patterns that maintain dysfunction

  • most important in CBT case conceptualization 

• Protective factors: strengths and supports

broad biopsychosocial formulation of overall case

big-picture understanding of person’s history, context, and strengths

SORC Model for case formulation

S — Stimuli (triggers, procedes it)

O — Organism factors (everything that happens in brain (thoughts, feelings, emotions)

R — Response (observable behavior (avoiding eyecontact, shaking, not speaking)

C — Consequence (short term, long term)

functional analysis of a specific behavior/problem 

practical for IDying and changing specific behaviors 

Cognitive Behavioral Triangle

thoughts, emotions, behaviors all linked 

if we can make thoughts more truthful, we can help your behaviors and feelings

General Principles of CBT

•Cognitive behavioral therapy is:

•Semi‐structured, time‐sensitive, active;

•Based on a case conceptualization;

•Focused on skill development; and

•Oriented toward a hypothesis‐testing approach.

•Clinician and client work collaboratively with a focus on a strong relationship.

•All interventions aim at cognitive change.

Stages of Traditional Exposure therapy 

• Psychoeducation

• Joint Formulation

• Creation of the fear hierarchy

• Systematic Enaction of hierarchy

  • Can be ordered, random, top-down… depends on the client

• Process/integrate new learning (can include some cognitive work)

• Relapse prevention

Why is psychoeducation important

• Necessary for understanding anxiety disorders in a way that leads to a clear rational for using exposure therapy

• Providing and ensuring buy in of treatment rationale/psychoeducation increases compliance

• Leads to a shared road map for functional assessment/treatment planning

• Allows therapist and patient to understand how to optimize learning during exposure

• Effective in Preventing relapse by teaching patient how to be their own therapist

• Facilitates troubleshooting (e.g., non-adherence, therapist discomfort)

Fear/Panic vs Anxiety/Worry

Fear/Panic – Present-Oriented Mood State

• Immediate fight or flight response to danger or threat

• Abrupt activation of the sympathetic nervous system

• Strong avoidance/ escapist tendencies

Anxiety/Worry – Future-Oriented Mood State

• Apprehension about future danger or misfortune (“anticipatory fear”)

• Physical symptoms of tension/apprehension (e.g., muscle tension, etc.)

• Characterized as negative affect (manifests with physiological, behavioral, and cognitive components)

Both anxiety & fear are “normal,” helpful emotional states - in normal doses

Common themes: anxiety

• triggers —> thought/interpretations —> elevated anxiety —> behaviors (avoid, safety behavior, distract, ruminate) —> short term reduced anxiety but prolonged and worsened anxiety in long term 

Anxiety is maintained by safety behaviors/avoidance

Safety Behavior

don’t allow you to fully experience the anxiety you should be feeling

coping mechanisms people use to reduce anxiety 

• Avoidance ex. eye contact, parties, places associated with panic

• Impression management ex. rehearsing sentences or monitoring ones’s behavior

• Checking ex. locks, symptoms

• Neutralizing rituals ex. rituals to feel safe (pacing, squeezing hands, checking)

Exposures

Type of psychological treatment that helps people face their fears by gradually exposing them to situations that cause distress.

• imaginal exposure

• in vivo exposure (go out and do it)

• interoceptive exposure (feel physical sensations: running/ breathing fast)

• virtual reality 

Pacing of Exposures

• gradual —> steps, work way up

• flooding —> do it all at once

• systematic desensitization —> engage in behavior while simultaneously engaging in relaxation (Dr. Foster has mixed feelings, don’t really learn to face anxiety)

How does exposure help

Old thinking —> habituation (get used to sensation) and extinction (fear goes away)

New thinking —> inhibitory learning

• create new learning pathways that are ideally stronger than old ones

• old one doesn’t go away that’s why there’s a risk of relapse

• more you practice, stronger new learned response becomes over old response (Old response not gone just not as prominent as learned response from exposure)

Self-efficacy 

emotional processing — process in a safe enviornement first

General Rules for exposure

• allow sufficient time 

• if you do it for 35 mins here, you can do it at home by yourself

• with in sessioni anxiety reduction is good but not neccesary 

  • what Is necessary is homework (more you do it more anxiety decreases)

• Don’t do anything to reduce anxiety in middle of exposure 

• keep an eye out for safety behaviors 

  • need to learn they aren’t feeling better because of the safety behavior but because fully feeling anxiety can create and develop new learning behaviors (that the event isn’t that bad)

  • engaing in behaviors they think help but worsen anxiety long term

• even if a ‘bad’ response happens you got through it! you handled it

• don’t give patient anything you wouldn’t do 

CBT for panic disorder

• Barlow’s Panic Control Therapy (PCT)

  • 3 components:

  • Physical, Cognitive, Behavioral

• Psychoeducation, particularly re fight-or-flight response

• Normalizes physiological sensations

• “Scanning”/”detecting” cognitive biases

• Cognitive treatment

• Psychoeducation

• Interoceptive exposure

• Build in exposure for agoraphobia throughout.

CBT for PTSD

Prolong Exposure for PTSD

• manualized versions from 8-15 sessions, 90-120 mins per sess

• individualized

• psychoeducation 

• trauma assessment 

• breathing 

• imaginal exposure —> go back to the trauma, keep eyes close, tell your story and sit with it

• invivo exposure 

Cognitive Processing Therapy 

EMDR (eye movement desensitzation and restructuring) 

• looking at light back and forth  to be engaged in exposure

SUDS

subjective units of distress scale

Creating a Fear Hierarchy

• teach SUDS scale — anchor points

• use info from intake and knowledge of typical triggers

• stay cognizant of what they can do at home (include imaginal, invivo, simulated, and interoceptive as needed)

• target primary fears 

• if needed, reorder list so highest scenario is at top

• rate anxiety for scharios when engaging and NO avoidance behaviors 

• Start at something a little hard but want them to succeed to increase feelings of self-efficacy and willingness to do future exposures

• overcorrect — if you can do this you can do easier things (if you lick a toilet bowl you can eat at a restauarnt)

CBT for OCD

EXRP — exposure response prevention 

• strong evidence that this is better than relaxation and anxiety management 

• more effective than other CBT

involves gradually exposing individuals to their feared stimuli (exposures) while preventing them from engaging in their compulsive rituals (response prevention). 

Blood Injection Injury Phobia

• unique because it’s assoicated with fainting

  • vasovagal response (sudden drop in heart rate and BP)

  • bradicardia — heart rate slower rate than normal 

  • bradys and BD drop associated with phobia and then fainting 

• blood pressure drop in bradicardia

• can’t do run of the mil exposure — be in contact with medical provider (or client should be)

• applied tension paired with exposure 

  • prior to exposure — tense body parts to elevate heart rate and BP so when it drops shouldn’t drop to fainting 

Generalized Anxiety Disorder

• Worry = a chain of catastrophising thoughts that are predominantly verbal

• Maladaptive worry generates a repetitive range of negative outcomes in which the individual attempts to generate coping solutions until some internal goal is achieved (e.g., “a sense of control”)

• People with severe anxiety want to control things — treatment can be learning to live with not knowing things. 

• Worry exposure is a specific variant of imaginal exposure

• Threatening mental images and their corresponding unpleasant emotional arousal are avoided by worrying in words and sentences

• Exposure = sustained imaginal exposures of actual worse case scenarios ripe with imagery and emotional content.

  • worry diary as a type of exposure

    • what are you most scared of happening? what would happen if it did? could you work through it

Non-compliance

• exposure can have a high drop out

• need to have a buy in

• meet someone where they are, hear them and their concerns (UNDERSTAND THEM), make sure they understand it

• enlist at home support, ID real barriers to complience, psychoedu, prep clients ahead oftime for difficulty of tx, if needed reduce difficulty of exposures 

CBT for Depression

• behavior activation and cognitive restructuring 

• antidepressants are helpful but CBT can help relapse because you’re learning skills 

  • best is a combo for severe depression

• cycle of depression (BA targets actions that tie into feelings b/c in CBT all related)

Behavior Activation 

identifying things they enjoyed doing before and giving them ways to reaccess it 

Based on premise that limited rewarding experiences and reduced ability to experience positive reward from the environment maintain depression

Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problems that allow them to lead a more rewarding life

• strong efficacy, can be used as stand alone treatment for cognitive restructuring

Key elements:

• Behavioral case conceptualization

• Activity monitoring and scheduling

• Identification and elimination of avoidance patterns

• Establishment of healthy routines

• Behavioral strategies for targeting worry or rumination

• Goals are specific to the individual

Activity Chart

• Central tool in BA

• baseline assessment of activity and relationship with mood

• ongoing monitoring of activity and mood

• evaluate progress 

Routine Regulation

• tool in BA

• work with patient to develop regular routine for basic life activities: sleeping, eating, exercise, Basic self-care, work/school, chores

Rumination

• can function as avoidance, can maintain depression

• just can’t stop thinking, circles, argue with self

• Focus on context and consequences of rumination ,not content

Cognitive Triad and Depression Aaron Beck

• 3 types of negative thoughts lead to depression 

  • negative views about the world: no one values me, everyone ignores me

  • negative views about oneself: I’m worthless, I wish I was different

  • negative views about the future: things will never change, only gets worse

Clinical Implementation of CT

• protocols typically 12-25 weekly sessions (2x weekly initially for severe depressives) 

• model: cognitive triad (self, environment, & future)

• importance of nonspecifics (warmth, genuineness, accurate empathy) 

• rational, linear thinking

• highly directive 

• collaborative relationship

buy in, can’t just tell them how to think

• Intro to cognitive model

• Eliciting and recording automatic thoughts

• Testing and/or questioning automatic thoughts

• Use of Socratic questioning very important in cognitive therapy!

• Identifying and adopting alternative/adaptive thoughts

• “Act as if”

• “Try on for size”

• Core belief work (sometimes)

CT: Focus on content of thinking

“I was depressed all day yesterday because I was thinking about how my sister really doesn't’t love me.”

• What is the evidence that this thought is accurate?

• What would it mean if it were true?

• Can you think of another way to interpret what your sister said?

• Why must everyone love you?

CT: Focus on context and consequences of thinking

“I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.”

• When did you start thinking that?

• How long did it last?

• What were you doing while you were thinking that?

• How engaged were you with the activity, context, etc.?

• What were consequences of thinking about that?

Cognitive Model

In CBT, the model behind it is that there is a situation that leads to a thought, leading to an emotion, leading you to engage in specific behaviors

The thought aspect is why people feel and react differently to different situation

We’re trying to change the thought

Not just for depression

Linear process

First step is to become aware of the thought → thought record

• if we can restructure someone’s thought, we can restructure emotional experience, is true for a lot of experiences (even if not all)

Thought Record

part of CT

• thought record —- go in the real world and come back, tell me about situation, and what was emotion, and if you need to work backwards to figure out what were your thoughts (usually start with first three then as treatment progresses implant second)

• used to see what thoughts were happening after a situation that led to emotion and behavior

Automatic Thoughts

• can be a picture, often in short hand, running underlying thoughts not necessarily in full sentences (like news running footer) 

  • lonely... getting sick... can't stand it... cancer... no good.”

• Sometimes automatic thought is a brief reconstruction of some event in the past

• Specific messages 

  • A young man who fears rejection tells himself, "She doesn't want you. You look silly." 

• Different than unconscious —- we have at our grasp / we have access to it we’re just not paying attention to it

• almost always believed

• reflexive and plausible

  • plausible because they are hardly noticed, let alone questioned or challenged

    • therapists want to notice them AND challenge them 

• often couched in terms of "should," "ought," “can’t” or "must." 

  • People torture themselves with "shoulds" 

• Automatic thoughts tend to “awfulize” 

  • predict catastrophe, see danger in everything, and always expect the worst

  • Awfulizers are the major source of anxiety.

• hard to turn off

• Weaving through the fabric of your internal dialogue.  

• come and go with a “will of their own”

• They tend to act as cues for each other. 

  •  Everyone has had the experience of one depressing thought triggering a long chain of associated depressing thoughts.

• Learned

  • Since childhood people have been telling you what to think

  • You have been conditioned by family, friends, and the media to interpret events a certain way

  • good case conceptualization helps us figure out where they are learned 

  • even if they are true (to an extent) — how helpful is it to focus on it?

  • have to go deeper sometimes and find out what’s driving automatic thoughts 

How do we start noticing automatic thoughts

• many patients are unaware of their thinking patterns

• they will often be more aware of their emotions than of what precipitated emotions

• how do we help notice? 

  • work backward from affect — what was the emotional experience? work backwards 

  • take a reasonable guess 

    • what might someone else think in this situation that could lead to the emotion I’m experiencing  

“shoulds"— commonly come up, trigger for therapist to notice that it’s usually inaccurate and unhelpful

common cognitive distortions that will lead to automatic thoughts 

All-or-nothing thinking

• Self Centered (thinking in extremes): Umbrella way of thinking (not a cognitive distortion — the bold and italics are cog distortions)

  • All-or-nothing thinking (also called black-and-white, polarized, or dichotomous thinking): You view a situation in only two categories instead of on a continuum

    • Example: “If I’m not a total success, I’m a failure.”

Mind Reading

• Self Centered (thinking in extremes): Umbrella way of thinking (not a cognitive distortion — the bold and italics are cog distortions)

• Mind reading: You believe you know what others are thinking, failing to consider other, more likely possibilities.

  • you actually don’t know what other people are thinking

  • Example: 

    • “He thinks that I don’t know the first thing about this project.” 

    • “Everyone hates me” 

    • “I know when I go to school, the people there do not like me”: went to school and smiled, people smiled back, changed her entire thinking and realized her belief wasn’t true

“Should” and “must” statements

• Self Centered (thinking in extremes): Umbrella way of thinking (not a cognitive distortion — the bold and italics are cog distortions)

• “Should” and “must” statements (also called imperatives): You have a precise, fixed idea of how you or others should behave, and you overestimate how bad it is that these expectations are not met.

• Example: 

  • “It’s terrible that I made a mistake. I should always do my best.”

  • “I should’ve known better”

  • “Should’ve done better on that test”

Magnification/minimization

• Minimizing and mislabelling: These distortions involve giving less weight to positive things and more weight to negative things.

  • Magnification/minimization: When you evaluate yourself, another person, or a situation, you unreasonably magnify the negative and/or minimize the positive.

    • Example: 

      • “Getting a mediocre evaluation proves how inadequate I am. Getting high marks doesn’t mean I’m smart.”

Labeling/mislabeliing

• Minimizing and mislabelling: These distortions involve giving less weight to positive things and more weight to negative things.

  • Labeling/mislableing: You put a fixed, global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion.

    • Example:

      •  “I’m a loser. He’s no good.”

      • “I suck”

Overgeneralization

• Assuming the worst: assuming the worst can lead to depression 

  • Overgeneralization: You make a sweeping negative conclusion that goes far beyond the current situation.

    • Example: 

      • “[Because I felt uncomfortable at the meeting] I don’t have what it takes to make friends.”

Emotional Reasoning

• Assuming the worst: assuming the worst can lead to depression 

• Emotional reasoning: You think something must be true because you “feel” (actually believe) it so strongly, ignoring or discounting evidence to the contrary.

  • Example: “I know I do a lot of things okay at work, but I still feel like I’m a failure.”

  • I feel like I am a failure = I am a failure

Mental Filter

• Assuming the worst: assuming the worst can lead to depression 

• Mental filter (also called selective abstraction): You pay undue attention to one negative detail instead of seeing the whole picture.

  • Example: 

    • “Because I got one low rating on my evaluation [which also contained several high ratings] it means I’m doing a lousy job.”

Disqualifying or Discounting the Positive

• Assuming the worst: assuming the worst can lead to depression 

• Disqualifying or discounting the positive: You unreasonably tell yourself that positive experiences, deeds, or qualities do not count.

  • Example: 

    • “I did that project well, but that doesn’t mean I’m competent; I just got lucky.”

    • Yeah I got a good review, but this is why it was still bad

    • negating — that doesn’t count 

Personalization

• Assuming the worst: assuming the worst can lead to depression 

• Personalization: You believe others are behaving negatively because of you, without considering more plausible explanations for their behavior.

  • Example: 

    • “The repairman was curt to me because I did something wrong.”

    • he was hurt because of me, I know I did something wrong (even if you have no evidence to support)

Catastrophizing

• Assuming the worst: assuming the worst can lead to depression 

• Catastrophizing: :This prompts people to jump to the worst possible conclusions

  • Example

    • “I’ll be so upset, I won’t be able to function at all.”

    • Making a mountain out of a moll hill 

    • If I fail this test, I’m gonna fail the program, never have a job

Cognitive Distoritions

Type of automatic thoughts.

Automatic thoughts happen so fast, people not paying attention to them, the reason why they’re called Common Cognitive Distortions suggests that the thinking isn’t based in reality — distorted, a sign we should question it 

in the model, this thinking comes first and then the emotion

• how these thoughts if believed can lead to really negative emotions, if you keep having them, serious potential pathology 

Elicit automatic thoughts 

1. Ask them how they are/were feeling and where in their body they experienced the emotion.

2. Elicit a detailed description of the problematic situation.

3. Request that the patient visualize the distressing situation.

4. Suggest that the patient role-play the specific interaction with you (if the distressing situation was interpersonal).

5. Elicit an image.

6. Supply thoughts similar or opposite to the ones you hypothesize actually went through their minds.

7. Ask for the meaning of the situation.

8. Phrase the question differently.

Evaluating Thoughts

• treat it a little like an experiment 

• Examine the validity of the automatic thought.

  • How true is it? 

• Explore the possibility of other interpretations or viewpoints.

• De-catastrophize the problematic situations

  • what does it mean if they don’t like you? Could you live like that?

  • what does it mean if your thought is right

  • acceptance 

• Recognize the impact of believing the automatic thought.

  • how much is it impacting your life that you believe it

  • your spending a lot of energy on it, and your life is so much bigger than this (even if it is true, and what would it mean if it was)

• Gain distance from the thought.

  • time helps

  • more distance you have allows you to evaluate it more fairly 

• Take steps to solve the problem.

  • experiment, try to solve

  • what would happen if you smiled when you went to work 

1. What is the evidence that supports this idea

• What is the evidence against this idea?

2. Is there an alternative explanation or viewpoint?

3. What is the worst that could happen (if I’m not already thinking the worst)? If it happened, how could I cope?

• What is the best / worst that could happen?

• What is the most realistic outcome?

4. What is the effect of my believing the automatic thought?

• What could be the effect of changing my thinking?

5. What would I tell____________[a specific friend or family member] if he or she were in the same situation?

6. What should I do?