Week 4

Question 1

Why do we want to elicit positive emotions?

Answer 1

-Promote Well-being & resilience
-Increase scope of attention, cognitions, and lower arousal
-Improve coping

Question 2

How to elicit positive emotions?

Answer 2

-Discuss Interests
-Positive Memories
-Encourage pleasant actions
-Help client draw adaptive conclusions about their experiences

Question 3

If the client is having trouble identifying positive emotions, you can:

Answer 3

-Provide multiple choice options
-Imaginal exposure
-Listing emotions

Question 4

When might you want to increase negative emotions?

Answer 4

-Increase intensity of ATs
-Exposure
-Change cognitions on an emotional level
-Evaluate maladaptive behaviour

Question 5

List activities for regulating negative emotions

Answer 5

-Problem Solving
-Evaluating and responding to negative thoughts
-Engaging in (and being fully mindful of) social, pleasurable, or productive activities)
-Exercising
-Accepting negative emotion nonjudgmentally
-Mindfulness (for detaching from thoughts)
-Relaxation
-Engaging in self-soothing
-Focusing on positive qualities of oneself

Question 6

What are the different kinds of ATs in CBT?

Answer 6

Inaccurate thoughts that lead to distress and/or maladaptive behavior

Accurate but unhelpful thoughts

Thoughts that are part of a dysfunctional thought process (rumination, obsession, self-criticism)

Question 7

How do you address a client’s unhelpful, yet accurate, thoughts?

Answer 7

-Problem-solve,
-Evaluate inaccurate conclusion,
-Work towards acceptance,
-Change focus of attention

Question 8

How do you address a client’s distressing and inaccurate ATs?

Answer 8

-Behavioural Experiments
-Verbal evaluation

Question 9

How do you address thoughts that are part of a dysfunction thought process (rumination, obsession, self-criticism)?

Answer 9

-Evaluate beliefs about thought process
-Use mindfulness,
-Emphasize valued action

Question 10

How do you select key ATs?

Answer 10

-Is it currently causing significant distress? Or is it unhelpful and likely to reoccur?
-Does it pose itself as an obstacle to the client’s goals?
-Is it likely to cause the client distress again?

Question 11

Do you directly challenge ATs and why?

Answer 11

-No. As therapist, we do not know the validity of the AT.
-It can invalidate the client’s feelings and perspective.
-Non-collaborative

Instead, apply gentle Socratic questioning.

Question 12

How do you use Socratic questioning? (List out of 6)

Answer 12

1. Evidence questions
   * Help to identify evidence to the contrary (which they often fail to identify)
2. Alternative explanation questions
   * “Is there another way to look at this/an alternative explanation?”
3. “Decatastrophizing” questions
   * Ask them how they could cope if the worst does happen
   * Help to think of more realistic outcomes and ask for the best outcome
4. “Impact of the automatic thought” question
   * “What is the effect of you thinking…?”
   * “And what could happen if you changed your thinking?”
5. “distancing” questions
   * “What would be good to do now?”
   * Ask how likely Abe is to text him and respond to obstacles that could get in the way
   * Ask if he wants to text him right then in my office
6. Problem-Solving Questions
   -“What would you like to DO about this situation?”

Assess the outcome of the evaluation process by asking how much they still believe their thought (in %)

Question 13

Reasons for cognitive restructuring being ineffective: (list 6)

Answer 13

1. There more central automatic thoughts not yet identified
2. Evaluation of automatic thoughts is implausible, superficial or inadequate
3. Client hasn’t sufficiently expressed the evidence that support automatic thought
4. Automatic thought is broad, overgeneralized cognition (=core belief)
5. Client understands intellectually that automatic thought is distorted but not on an emotional level
6. Automatic thought is part of a dysfunctional thought pattern

Question 14

How can you identify when cognitive restructuring is ineffective?

Answer 14

Ask client to rate how much they believe in their adaptive response & how they feel

Question 15

Alternative ways to address ATs (list 5)

Answer 15

1. Using alternative questions
   * “What makes you think you should/not …?”
   * “Is it reasonable to …?”
2. Identifying cognitive distortions (see appendix)
   * Give them a list
   * Can help to gain distance from their thoughts
   * Explain how to use it and then label it as part of action plan
3. Designing behavioral experiments
   * If possible, suggest to do the experiment right in the session (otherwise outside of session)
   * Help client draw adaptive conclusion after having done successful
   ® “What did you learn/conclude?”
   ® “What does this experience mean for the future?”
4. Using self-disclosure
   * To demonstrate how you were able to change similar automatic thoughts of your own
5. Asking clients for a helpful response
   * Ask how clients would like to respond to an automatic thought
   * “Can you think of a more helpful way to view this?”

Question 16

What can you do when the ATs are true? (List 3)

Answer 16

1. Focus on problem solving
   * Investigate whether the problem can be solved at least to some degree
2. Investigate invalid conclusions
   * Examine underlying belief or conclusion
   * “What does it mean about you?” or “What are you afraid will happen?”
3. Work toward acceptance & valued action
   * Help them learning to focus on core values, pursue valued action, emphasize the more rewarding parts of live & enrich experience in new ways

Question 17

After helping a client respond to an AT, you should…

Answer 17

encourage the client to record their responses.

Question 18

Having evaluated an automatic thought with clients ask them to summarize:

Answer 18

• “What do you think would be important for you to remember this week?”
• “If the situation comes up again, what do you want to tell yourself?”
• “Would you like to write it down? I want to make sure you remember it this week?”

–Read therapy notes every morning & every time needed throughout the day

Question 19

Clients can respond to ATs with:

Answer 19

-“Testing Your Thoughts” worksheet
-Thought Records
-Evaluative questioning

Question 20

What should you do if a worksheet isn’t helpful enough?

Answer 20

Check for obstacles/ limiting thoughts before giving it as homework

Emphasize that it’s a skill they build over time, that it’s okay to make mistakes

You can also skip many steps in the worksheets and just do two columns: “automatic thought” and “response/ what I can remind myself of”

Question 21

How can mindfulness be helpful in CBT?

Answer 21

-Focus on the present, internal and external

-Change relationship to thoughts

-Improve acceptance of internal experience

Question 22

TECHNIQUE FOR INRTODUCING A MINDFULNESS INTERVENTION FOR RUMINATION (6 steps)

Answer 22

1. Educate about cognitive model
2. Apply Socratic questioning
3. Do pros and cons of rumination vs. focusing on present moment
4. Educate how mindfulness can be helpful
5. Have them start the thought process right in the session
6. Ask them to rate intensity

Question 23

Two reasons why we want clients to engage in unhelpful thought process before starting an exercise:

Answer 23

1. Can serve as behavioral experiment to test dysfunctional beliefs: “Rumination is uncontrollable”
2. Important to replicate the conditions clients will experience when using this strategy outside of session

Question 24

What is the AWARE technique? What are the 6 steps?

Answer 24

Mindfulness technique designed to be used when clients worry excessively or experience excessive anxiety

1. Accept anxiety (or other emotion)
2. Watch it
3. Act constructively with it
4. Repeat the steps
5. Expect the best

Question 25

How is CBTp different from CBT?

Answer 25

A lot of experiential learning Patient's view is respected and stimulated Reduce distress and enhance freedom Do NOT discuss what is real and what is not, don't be judgmental and try to convince them their wrong

Question 26

What types of goals does CBTp serve?

Answer 26

Reducing current distress Being free, Having to avoid less, Being less alert all the time

Question 27

What types of goals does CBTp not serve?

Answer 27

Improving illness insight Taking away voices (we can't) Treating a former psychosis that is not present now

Question 28

What is & when do you use a historical test and how to you do it?

Answer 28

Discussing how and when a negative core belief originated and became maintained and why it made sense for the client to believe it at the time 1. Ask client to remember time when they had belief x (e.g. aged 6-11) 2. Ask for relevant memories when they were an adolescent 3. Use Socratic questioning to reframe the meaning they put to each of these experiences 4. Ask them to record a summary of their new understanding of themselves from the most salient time – ask them to read it everyday

Question 29

When do you use a probability (chance) calculation?

Answer 29

It is used when patients overestimate the probability for negative events and/or have limited awareness of the many prerequisites that need to be fulfilled for the event to actually happen. Often concerns beliefs with a ‘if .... then’ structure

Question 30

How do you use a probability (chance) calculation? (7 steps)

Answer 30

1. Explain rational: multiple things need to happen before x can happen 2. Formulate negative expectancy and probability 3. Write down all necessary previous steps and rate probability 4. Explain that even if one step doesn’t happen, the feared event will not happen  all probabilities need to be cumulated 5. Calculate cumulated probability for each step – multiply cumulated probability of step 1 with that of step 2 and so on 6. Discuss results, check with initial probability rating, write down conclusion 7. Rate belief again and see if it has changed

Question 31

When do you use the pie chart technique?

Answer 31

When patients tend to jump to conclusions and have difficulty formulating alternative explanations for events. Patients tend to stick to only one explanation and this technique addresses that.

Question 32

When and how do you use a cost-benefit analysis?

Answer 32

To examine the effects of behavior, beliefs about a behavior or other beliefs; behavior/ belief emerged because of a reason, but now it probably has a very high cost; determine if it’s worth it and find alternative Steps: 1. Take a form + describe behavior/ belief 2. Ask patient how useful behavior is 3. Write down all pros and cons 4. Discuss results (2 options): More cons: talk about where this behavior comes from, what its function is but also how it relates to safety behaviors, coping and avoidance More pros: emphasize that behavior has a lot of benefits; try to find other behavior that have the same benefits but less costs 5. Review the usefulness of behavior 6. Formulate alternative behaviors/ beliefs

Question 33

When do you use the cognitive continuum?

Answer 33

-Patients that think black/ white or that have very high standards, -Perfectionism, -Core beliefs and automatic thinking -To help illustrate a middle ground between success and failure

Question 34

How do you use the cognitive continuum? (7 steps)

Answer 34

1. make a scale, define 0 and 100, ask client to rate themselves on the scale 2. ask for real life examples: does anyone come to mind when you think of a really good/ bad x?  ask them to rate themselves again now 3. start defining each extreme of the scale: what are the characteristics of being a really bad x or a really great x? * really go into detail - what does x mean to you? can you describe that more? (write it down, use client's words) 5. ask client to rate themselves on each of the named qualities/ characteristics on the scale 6. add up all the points and divide by number of items/ characteristics 7. new score on scale -> look at difference between initial and final rating; how does it feel? What did they learn?

Question 35

7 ways to strengthen adaptive beliefs:

Answer 35

1. Eliciting positive data and drawing conclusions 2. Examining advantages of adaptive belief 3. Pointing out the meaning of positive data 4. Referencing other people 5. Use a chart to collect evidence 6. Inducing images of current & historical experiences 7. Acting "as if"

Question 36

When might you use intellectual-emotional role plays?

Answer 36

When clients get it intellectually but not emotionally

Question 37

The video for socratic questioning identifies 4 types of questions:

Answer 37

1. Questions for clarification 2. Questions that probe reasons & evidence 3. Questions about viewpoints and perspectives 4. Questions that probe consequences

Question 38

Describe the evidence technique (4 types of evidence)

Answer 38

“things will never change” Evidence for: assign % on how much this evidence proofs that things will never change 1. statistics that prove it -e.g. unemployment rate (%) 2. tensional objects -something physical that you can look at (e.g. journal) (%) 3. testimony -things that people said to him 4. social consensus -e.g. experts making negative predictions about economy in future Evidence against: go through all steps again

Question 39

When do you use the 'Pie Chart'?

Answer 39

-When patients tend to jump to conclusions and have difficulty formulating alternative explanations for events e.g., Responsibility in a tragic event, Hypochondria

Question 40

What is 'personalization'?

Answer 40

A thought distortion Believing that others are behaving negatively because of you, without considering more plausible explanations for their behaviour.

Question 41

What is 'tunnel vision'?

Answer 41

A thought distortion Only seeing the negative aspects of a situation