Department of Clinical Psychology and Psychotherapy

Babes-Bolyai University

CT/CBT Depression Manual/Protocol

 

Cognitive Therapy (CT) 

 

To be Used Free for Research, Educational, and Training Purposes

 

Acknowledgements:

This CT manual/protocol for depression is based on the rational-emotive & cognitive-behavioral therapy (REBT/CBT) manuals, elaborated at Mount Sinai School of Medicine, USA, by a team of psychologists (Dr. Daniel David, Dr. Maria Kangas, Dr. Julie Schnur), together and under the supervision of Dr. Guy Montgomery (principal investigator, American Cancer Society grant #RSGPBCPPB-108036). The external consultant for the CT depression manual/protocol was Dr. Arthur Freeman, Academy of Cognitive Therapy, USA.

To cite this CT depression manual/protocol:

·         David, D., Kangas, M., Schnur, J.B., & Montgomery, G.H. (2004). CT depression manual; Managing depression using cognitive therapy. Babes-Bolyai University (BBU), Romania.

 

      The preliminary and final Romanian versions of the CT manual/protocol for depression were used in a randomized clinical trial in Romania:

·         David, D., Szentagotai, A., Lupu, V., & Cosman, D. (2008). Rational emotive behavior therapy, cognitive therapy, and medication in the treatment of major depressive disorder: A randomized clinical trial, post-treatment outcomes, and six-month follow-up. Journal of Clinical Psychology, 64, 728-746.

      To cite the Romanian CT manual/protocol for depression (used in Romania):

·          David, D. (ed.) (2006).  Rational Treatment. Tritonic Press. Bucharest.

·         David, D. (ed.) (2007). Clinical protocol of cognitive therapy for depression: The treatment of depression by cognitive therapy. Synapsis Publisher. Cluj-Napoca.

 

The major handbooks and general CT manuals that are the background of this CT depression manual/protocol are:

Ÿ      Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Ÿ      Beck, J. (1995). Cognitive Therapy: Basic and beyond. New York: The Guilford Press.

 

Foreword:

This CT depression manual/protocol is an evidence-based one, tested in a randomized clinical trial investigating the relative efficacy of rational-emotive behavior therapy (REBT), cognitive therapy (CT), and pharmacotherapy (fluoxetine) in the treatment of 170 outpatients with non-psychotic major depressive disorder (David et al., 2008). Patients were randomly assigned to one of the following: 14 weeks of REBT, 14 weeks of CT, or 14 weeks of pharmacotherapy. The continuous outcome measures used were the Hamilton Rating Scale for Depression (HRSD) and the Beck Depression Inventory (BDI); the categorical measure was SCID. In the CT condition, at 14 weeks, the response rates (HRSD<12) were 63% and the recovery rates (HRSD<7) were 50%. At six-month follow-up, the response rates (HRSD<12) were 67% and the recovery rates (HRSD<7) were 51%. No differences among treatment conditions at posttest were observed. A larger effect of REBT (significant) and CT (nonsignificant) over pharmacotherapy at 6 months follow-up was noted on the HRSD only.

 

 

 

CT DEPRESSION MANUAL

 

 

 

I. Therapist’s Research Guide

 

II. Therapist- Patient Interaction Guide

 

1. Aim of the CT Depression Manual

 

2. Definitions

(a)  Depression Basics

(b)  What is Cognitive Therapy?

1) What are Cognitive Techniques?

2) What are Behavioral Techniques?

 

3. Managing Depression with Cognitive Techniques: The Power of Our Thoughts

(a)   Relearning our A-B-Cs

(b)  How to Think in a More Positive and More Adaptive Way – The Alphabet Approach (A-B-C-D-E-F)

 

4. Managing Depression with Behavioral Techniques

     (a) Activity Scheduling/Planning

     (b) Distraction Techniques

             

6. Beyond CT Treatment

 

*APPENDIX

(1)   Study Instructions

(2)   Spare Copies of the “Depression A-B-C-D-E-F Self Help Form”

(3)   Example of Scheduling Form

(4)   Spare Copies of the “Scheduling Form”

(5)   Spare copies of the “Daily Practice Monitoring Form”

 

 

 

 


I. THERAPIST RESEARCH GUIDE:

1. Patients:

The present REBT manual/protocol should be used with depressed patients (e.g., who meet criteria for Major Depressive Disorder, according to the DSM-IV). In the clinical trial run based on this manual (David et al., 2008), we had some additional inclusion and exclusion criteria. Inclusion criteria included a score of at least 20 on the Beck Depression Inventory, and a score of 14 or higher on the 17-item Hamilton Rating Scale for Depression. Exclusion criteria included a number of psychiatric disorders (i.e., bipolar or psychotic subtypes of depression, panic disorder, current substance abuse, past or present schizophrenia or schizophreniform disorder, organic brain syndrome, and mental retardation). Patients who were in some concurrent form of psychotherapy, who were receiving psychotropic medication, or who needed to be hospitalized because of the imminent suicide potential or psychosis were also excluded (based on the clinical protocol of Jacobson et al., 1996).

 

2. CT Intervention (20 sessions):

The treatment is based on the techniques and descriptions in the Beck et al. (1979) and Beck (1995) CT manuals. The CT treatment includes behavioral activation and dysfunctional thought modification, and also incorporates the identification and structural modification of generalized intermediate and core beliefs that are presumed to be the major causes of dysfunctional thinking and depressive reactions. Treatment will be conducted in a progressive manner with the therapist focusing on overt behavior change, then on the automatic thoughts and finally on the identification and modification of intermediate and core beliefs (e.g., schemas) (Beck et al., 1979). DEM (i.e., the irrational belief of demandigness) will be identified and disputed only if it can be revealed by using standard CT techniques. According to Beck et al. (1979) DEM is readily recognizable in the cognitions collected as homework, as well as verbalizations in the therapy sessions. No additional effort is made in CT to infer the presence of DEM if it is not directly transparent by current CT techniques.

 

 

 

The CT intervention consists of a 14 weeks clinical trial [12 weeks of full treatment and 2 weeks of follow-up meetings (one meeting each week) focused on therapy termination], involving a maximum of 20 individual 50-minute therapy sessions:

Weeks 1-4 (initial phase: 2 sessions each week)

Ÿ      Session 1 (introduction)

o       Clinical diagnosis/assessment and General clinical conceptualization

o       Building a therapeutical relationship (i.e., empathy, collaboration, congruence, unconditional acceptance of patient as person)

o       CT education and Treatment expectations

o       Problems list

Ÿ      Sessions 2-8

o       Each problem from the list is approached based on the ABC(DEF) model of CT

o       The focus is on behavioral activation and automatic thoughts identification and changing

Weeks  5-8 (middle phase: 2 sessions each week)

Ÿ      Sessions 9-16

o       working toward strengthening the patients’ adaptive beliefs and weakening the maladaptive beliefs

o       encourage the patients to see the links between problems, particularly those which are characterized by common intermediate and core beliefs

Weeks 9-12 (final phase: 1 session each week)

Ÿ      Sessions 17-20.

o       prepare patients for the task of becoming his/her own future therapist

o       discuss dependency problems and relapse prevention

Structure of the first session (see also Beck, 1995):

Ÿ      Starting to build an emphatic and collaborative therapeutic relationship

Ÿ      Setting the agenda (and providing a rationale for doing so)

Ÿ      Doing a mood check, including objective scores

Ÿ      Briefly reviewing the presenting problems and obtaining an update (since evaluation)

Ÿ      Identifying problems and setting goals

Ÿ      Educating the patient about the CT model

Ÿ      Eliciting the patients’ expectations for therapy

Ÿ      Educating the patient about her/his disorder and psychotherapy process

Ÿ      Setting the homework

Ÿ      Providing a summary and eliciting feedback

Structure of session two and beyond (see also, Beck, 1995):

Ÿ      Checking and maintaining the therapeutical relationship

Ÿ      Brief update and check on mood (and medication, alcohol and/or drug use, if applicable)

Ÿ      Bridge from previous session

Ÿ      Setting the agenda

Ÿ      Review of homework

Ÿ      Discussion of issue on the agenda, setting new homework, and periodic summaries

Ÿ      Final summary and feedback

Fundamental aspects to follow during CT intervention:

Ÿ      The cognitive conceptualization of the problem, based on the ABC model

Ÿ      The use of a large repertoire of cognitive and behavioral techniques to change the unhelpful thoughts into helpful thoughts

Ÿ      The steps of CT interventions: (1) behavioral activation; (2) focus on changing automatic thoughts; and (3) focus on changing intermediate and core beliefs

Ÿ      The use of homework

 

3. CT Manuals for Detailed Intervention Strategies:

Ÿ      Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: The Guilford Press.

Ÿ      Beck, J. (1995). Cognitive Therapy: Basic and beyond. New York: The Guilford Press.

Ÿ      Jacobson, N.S., Dobson, K.S., Truax, P.A., Addis, M.E., Kowener, A.K., Gollan, J.K., et al. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295–304.

 

 II. THERAPIST-PATIENT INTERACTION GUIDE

 

1. Aim of the CT Depression Manual:

The aim of this manual is to teach you a variety of skills to help you manage any depressive symptoms or depression-related problems you might experience. More specifically, we are going to teach you how to use Cognitive Therapy (CT).

Research has found that approximately 75% of patients who undergo CT will experience an improvement in their depression symptoms. This manual will teach you how to help yourself feel less depressed and more energetic, and to cope as best as you can with any symptoms you may experience. Research has shown that the skills we’ll teach you are helpful in managing emotional distress.  

 

 

2. Definitions:

 

(a) Depression Basics

[This brief presentation is based on the free/public educational texts from http://www.depresion.com (© 1997-2008 GlaxoSmithKline: paragraphs 1, 3, and 4) and http://www.nimh.nih.gov/health/publications/depression-a-treatable-illness.shtml (paragraph 2)]

“Some people say that depression feels like a black curtain of despair coming down over their lives. Many of them feel like they have no energy and can’t concentrate. Others feel irritable all the time for no apparent reason. The symptoms vary from person to person, but if you feel “down” for more than two weeks, and these feelings are interfering with your daily life, you may be clinically depressed.” (GlaxoSmithKline).

“A depressive disorder is a problem that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.” (NIH).

“Most people who have gone through one episode of depression will, sooner or later, have another one. You may begin to feel some of the symptoms of depression several weeks before you develop a full-blown episode. Learning to recognize these early triggers or symptoms and working with your therapist will help to keep the depression from worsening.” (GlaxoSmithKline).

“Most people with depression never seek help, even though most of them will respond to treatment. Treating depression is especially important because it affects you, your family, and your work. Some people with depression try to harm themselves in the mistaken belief that the way they feel will never change. Depression is a treatable disorder.” (GlaxoSmithKline).

(b)   What is Cognitive Therapy (CT)?

Cognitive Therapy (CT) is a form of cognitive behavior therapy (CBT) and was created by Dr. Aaron Beck in the ‘60s. According to the CT model, people experience undesirable activating events, about which they have adaptive (e.g., functional, rational, helpful, healthy) or maladaptive (e.g., dysfunctional, irrational, unhelpful, unhealthy) beliefs (e.g., thoughts). These beliefs then lead to emotional, behavioral, and cognitive consequences. Adaptive beliefs lead to functional consequences, while maladaptive beliefs lead to dysfunctional consequences. Clients who engage in CT are encouraged to actively change their maladaptive beliefs and to assimilate more efficient, adaptive and rational beliefs, which should have a positive impact on their emotional, cognitive, and behavioral responses. Thus, CT is a psychological theory and a treatment consisting of a combination of three different types of techniques (e.g., cognitive and behavioral) you can use to help yourself feel better physically and emotionally, and to engage in healthier behaviors.

 

(1) What are Cognitive Techniques?

·        Cognitive techniques are specific strategies to change or modify unhelpful and/or negative thoughts concerning a particular event. (For example, learning to change one’s thoughts to cope better with one’s depression)

 

(2) What are Behavioral Techniques?

·        Behavior techniques involve learning practical techniques that help you to cope in demanding or stressful situations, such as depression and/or loss. Examples of behavioral strategies include learning how to plan and manage your daily schedule, and learning how to distract yourself from negative thoughts.  

 

 

3. Managing Depression with Cognitive Techniques: The Power of Our Thoughts:

·              Although we may not always be aware of our thoughts, they nevertheless can have a strong effect on how we feel and behave in response to a particular situation or event.

 

(a)   Re-learning our A-B-Cs:

·              According to the cognitive theory, the effect that our thoughts can have on our physical, behavioral and emotional responses to a particular situation can be illustrated using the following diagram:

 

A = Activating event or situation that we experience

                             ê

B= Beliefs or thoughts regarding the situation

                             ê

C = Consequence: How we feel or act based on these beliefs 

 

·              Let’s illustrate this model using an example:

Example 1:

Person 1:    A (Activating Situation) = A friend does not return your phone call

 

B (Beliefs/Thoughts) = “I must have done something to upset them. I am such a horrible person.”

 

                   C (Consequence/Effect) = Anxious, upset, depressed 

 

Person 2:    A (Activating Situation) = A friend does not return your phone call

 

B (Beliefs/Thoughts) = “They’re probably just really busy, and haven’t had time to get back to me yet.”

                            

C (Consequence/ Effect) = Content, neutral

 

·                    The above example shows how two people may experience the same situation (e.g., having a friend not return one’s telephone call), but have very different reactions to the event based on how they interpret and evaluate the situation according to their thoughts and beliefs.

 

(b)   How to think in a more positive and more rational way – The alphabet approach (A-B-C-D-E-F):

  • In this section, we’ll describe how to use the Depression A-B-C-D-E-F Self Help forms we have included at the end of this manual.
  • It might be helpful if you look at the form we filled out together while you read through this section, in order to review our approach.
  • Recommendation: Learning to observe and change one’s thoughts takes practice. Like any new skill we learn (e.g., riding a bike, or learning to program our VCR), the more we practice, the better we get. Therefore, we recommend that you complete at least one of these forms per day. Blank copies of this form are located at the end of this booklet. One of our research staff will collect these forms from you during the course of your treatment.
  • If you need extra forms at any point, just ask our research staff.
  • Ok, now let’s begin!

 

Let’s start at the very beginning – A’s (Activating Events)

  • On the top of the form, on the left hand side, you will see a box labeled “A (Activating Events).”
  • In this box, we would like you to write about an upsetting event that happened to you today. We have provided some examples of upsetting events below the box, but you should fill in examples that are personal to you.
  • We would like to particularly encourage you to focus on monitoring those times when you feel particularly sad or when you are tired/fatigued. 
  • If there is a day where nothing particularly upsetting happens, we would like you to fill in this “A” box with either (a) an upsetting event that happened to you in the past, or (b) an upsetting event you’ve made up.

EXAMPLE:  “I feel depressed because of my unsuccessful life, and wonder how I am going to get through the rest of the day.

Before we move on to B’s, let’s first focus on C’s.

 

C’s – Consequences following the events
  • On the top of the form, on the right hand side, you will see a box labeled “C (Consequences)”
  • In this box, we would like you to write the consequences of the event.
  • There can be three types of consequences. You may experience one, two, or all three of them:
    • Unhealthy negative feelings. Below the box, we have included a few examples of unhealthy negative feelings (e.g., depressed mood, fear, rage). However, we encourage you to write in whatever words best describe your experience.

 

  •  
    • Unhelpful behaviors. Below the box, we have included some examples of unhelpful behaviors. These are things you do that are unproductive or harmful in some way.

 

  •  
    • Negative Physical Consequences of Distress. When people experience an upsetting event, they may experience some physical symptoms. For example, if you argue with a friend, you may find yourself flushed, hot, or shaking. We have listed some examples of physical consequences below the box, but again, please write any physical reactions you experience.
      • Note: Although many physical symptoms can be caused or worsened by stress, while you are in treatment, all physical symptoms should be taken seriously and discussed with your treatment team.

 

EXAMPLE:   “I feel hopeless and sad, I have stopped trying to exercise, and I feel even more fatigued.”

 

 

 

OK, now we’ll get back to B.

 
The Keys to Change – B’s (Negative or Unhelpful Beliefs)
  • As we have shown earlier, even though it may seem like an upsetting event (A) leads you to feel upset (C), this is not 100% true.
  • In reality, it is not the event itself that upsets you, it is your negative or unhelpful beliefs (B’s) about the event that upset you.
  • So how do you identify your negative or unhelpful beliefs?
    • Typically your unhelpful beliefs fall into three categories (Beck, 1995):
      • automatic thoughts – stream of thinking that coexists with a more manifest stream of thought -; interpretation of a situation often expressed in automatic thoughts influences your subsequent emotion, behavior, and physiological response;
      • intermediate beliefs – deeper, often unarticulated ideas or understandings that patients have about themselves, others, and their personal world, which give rise to specific automatic thoughts;
      • core beliefs (i.e., schemas) – one’s most central ideas about the self.
    • First, we should focus on identifying and modifying automatic thoughts, and later on the intermediate and core beliefs
  • See if your automatic thoughts fall into any of the following categories of common thinking errors we are prone to making when we are not feeling comfortable in a particular situation or when we are experiencing unpleasant or negative feelings and sensations. These errors include (Beck et al., 1979; Beck, 1995):

 

1. All-or nothing thinking / Black-and-white thinking:

This involves seeing things in black and white (in extreme terms). That is, situations or circumstances are interpreted as being good or bad, positive or negative. There is no middle/common ground.

 

Example: “My life was great before I was diagnosed with depression, but now I have nothing to look forward to.”

 

 

 

 

2. Overgeneralizing:

This type of thinking involves placing a lot of importance on one single negative experience, to the point where you see one negative experience as being a sign for a never-ending pattern of negative events that you forecast (expect) to face in the near future.

 

Example: “If I felt very tired yesterday, surely I am always going to feel very tired throughout the course of my treatment and probably forever more.”

 

3. Mental Filter:

This type of thinking involves picking out a single negative detail from an unpleasant experience you may have had, and then dwelling exclusively on this negative detail. That is, you ignore the bigger picture and ‘filter out’ any positive aspects of the event.

 

Example: “I dread having to go to the hospital. Although I thoroughly enjoy the social chit-chats I have with other depressive patients and the nursing staff are so helpful and friendly, I dislike having to be at the hospital for my treatment.”

 

4. Mind-Reading:

This error involves thinking that you know what other people are thinking and feeling and why they act (or behave) the way they do, even without asking them. 

 

Example: “I know my family and friends think I am useless now that I have depression.”

 

     5. Catastrophizing –  Magnifying events out of proportion:

This thinking error involves exaggerating the importance of things, especially negative situations. You make a big issue out of one negative experience. 

 

Example: “I felt lousy after yesterday’s session. This surely is a sign that I am getting worse. I will never recover from this disorder.”

 

 

 

 

6. Minimizing (down-playing) the Positive:

This thinking error involves downplaying, ignoring or ‘minimizing’ your own, or other people’s strengths and assets, or a positive event or situation that you have experienced. 

 

Example: “So what if I managed to cook my family dinner last night which they enjoyed. After all, it is my responsibility to make sure that my family eats well and that they enjoy their mealtimes no matter how bad I am feeling.”

 

7. Personalization:

This thinking error involves taking responsibility or inappropriately blaming yourself for the cause of a negative experience which often may be beyond your own control.  

 

Example: “My son failed his math exam because I didn’t have enough time to help him study as I was too depressed.”

 

8. Jumping to Conclusions:

This thinking error involves reaching a decision or interpreting a situation in a negative manner based on no definitive (certain) facts, or where the evidence actually supports the contrary (opposite) conclusion. 

 

Example: “My sister has not contacted me in over a week. I must have said something which upset her and now she is avoiding me.”

 

9. Emotional Reasoning:

This error involves thinking that what you are feeling (about yourself, others or life circumstances) reflects the way things really are.  That is, you are thinking/reasoning based upon your emotions.

 

Example: “Now that I am undergoing treatment for my depression, I feel I am a huge burden to my family. If I am feeling this way, surely my partner and children must also feel the same way. I am definitely a burden to them.”

 

 

10. Demandigness: “Should”, “Must” and “Ought” Statements:

This thinking error involves holding strong views about how you and others should/must or ought to behave. When you direct these statements towards other people, you tend to feel strong negative emotions such as anger, resentment, frustration and annoyance. When you direct these statements towards yourself, you tend to feel guilt and despair.  

 

Example: “I ‘should’ not let my depression interfere with my family life. I ‘must’ therefore make sure that my family’s lifestyle is not disrupted whilst I am undergoing treatment.”

 

11. Labeling/ Mislabeling:

This thinking error involves an extreme form of overgeneralization. You tend to attach a negative label to yourself or others on the basis of one negative experience.  

 

Example (1): “I have depression, I am a ‘misfit’ to society.”

 

Example (2): “My neighbor was rude to me the other day, he is a ‘nasty’ person.”

 

12. Blaming:

This thinking error involves blaming yourself for other people’s troubles. Alternatively, you hold other people responsible for your troubles and misadventures.  

 

Example (1): “I would not feel so tired during my treatment if my family were more considerate of my needs.”

 

Example (2): “My son would have done better at school if it weren’t for my depression.”

 

  • Learning to monitor one’s automatic thoughts takes practice. Like any new skill we learn (e.g., riding a bike, or learning to program our VCR) we get better at learning a new skill by practicing it on a regular basis. Therefore, we recommend that you practice identifying your automatic thoughts by using the “Daily Practice Monitoring Form for Automatic Thoughts” on a daily basis for at least the first week during your CT treatment. Blank copies of this form are located at the end of this booklet. One of our research staff will collect these forms from you during the course of your treatment.

 

  •  
    • Although this task may appear cumbersome, we suggest that you only focus on monitoring those situations which make you feel strong emotions, sensations or cause you to behave in a strong reactive manner (e.g., feeling very sad, tired, angry, or even happy). Moreover, we encourage you to focus on monitoring those times, which you feel particularly depressed or tired / fatigued.

 

  • Once you have kept a diary of your daily automatic thoughts for at least 3 consecutive days (preferably one-week), you will notice that you may have certain times during the day in which you are more prone to experiencing strong emotive and/or physical reactions, such as feeling depressed, worn-out, tired/fatigued, moody, and irritable.

 

  •  
    • You may notice that during these times you may be thinking in a more “negative” (unhelpful) way than you do at other times during the day, when you are feeling less depressed, tired, or irritable.

 

  • Keep in mind that when we feel an unpleasant emotion (e.g., depressed, frustrated, or lousy) or physical (body) sensation (e.g., muscle weakness), we are more likely to think in a negative or unhelpful way. That is, our thoughts, expectations or attitudes may make us more sensitive to experiencing unpleasant, negative feelings (emotions) and bodily sensations. These unhelpful thinking patterns may also cause us to behave (react) to a situation in a manner that is not helpful to us or which we may later regret. For instance, when feeling tired and irritable one may be more prone to being short-tempered with one’s family and saying things they may later regret.

 

 

 


 

DAILY PRACTICE MONITORING FORM FOR AUTOMATIC THOUGHTS

A =

Activating event/situation

B =

Beliefs, thoughts, expectations

C =

Consequences – Feelings and Behavior

Example 1:

Feeling exhausted mid-way through the day and concerned with how to manage the remainder of the day.

 

 

I will get through the day if I stay calm. I will attend to the tasks I really need to get done today and leave the other chores for another day when I am feeling better

 

Feelings: optimistic, in-control, confident

Behavior: re-planning schedule for day to accomplish essential tasks only.

Example 2:

Ran out of time to prepare evening meal for the family.

 

I’m useless! Why I am not coping?  

 

Feelings: upset, frustrated

Behavior: disorganized

 

 

 

 

 

 

Feelings:

 

 

Behavior:

 

 

 

 

 

 

 

Feelings:

 

 

Behavior:

 

 

 

 

 

 

 

Feelings:

 

 

Behavior:

 

 

 


 

·        Remember, negative thoughts are those thoughts that make us feel and/or behave in a negative, hurtful, or unpleasant manner (e.g., feeling depressed, or angry and being short-tempered).

·        Once you recognize the negative belief you have about the situation, please write it in the “B” box.

 

D’s – Debating your Negative Beliefs

 

·        After you recognize your negative or unhelpful thoughts, the next step is to DEBATE or challenge them in a collaborative, Socratic, and active way. There are lots of different ways you can do this.

·        First, you can ask yourself, “Where is holding this belief getting me? Is it helpful, or is it getting me into trouble?”

o       For example, if your belief leads you to feel upset (e.g., to cry, to feel depressed), to do things that are unhelpful or harmful to you (e.g., stop socializing with friends, not following through on treatment recommendations), or to physically feel worse (e.g., to feel more tired), then you might decide that your belief is unhelpful.

·        Second, you can ask yourself, “Where is the evidence to support my negative belief? Is it logical?”

o       For example, I may catastrophically think, “I CAN’T STAND feeling so tired.” But if I stop, and really consider this, I realize I can stand it. I’m still waking up every morning; I’m still taking care of my medical appointments, etc. So even though I may not like feeling so tired, I can stand it.

·        Please write in box D what you said to yourself to debate and dispute your negative thoughts.

 

 

 

 

E’s – Effective/Helpful Beliefs

·        Once you have successfully debated against your negative beliefs (in an active way), you are ready to replace them with new more helpful and or logically and empirically supported beliefs.

·        Healthier beliefs may sound like one of the following:

o       Anti all or nothing thinking: You see the situation on a continuum instead of only two categories

o       Anti-Catastrophizing: This is a healthier, more rational alternative to catastrophizing. This is when you can recognize that a situation is very bad, without thinking it is 100% catastrophic. For example, you might think, “Being too tired to go to work 5 days a week is really bad, but at least I know this won’t last forever, and staying at home does give me more time to catch up with my friends,” instead of thinking “Feeling this tired is catastrophic!”

 

·        Please write in Box E your new, more helpful beliefs.

 

·        Note: We are NOT asking you to replace your negative unhelpful thoughts with unrealistically positive thoughts. We do not expect you to write in fantasies, or positive thoughts that are not grounded in reality. In order for this technique (called cognitive restructuring) to work, you need to really believe the new, healthier thoughts you come up with.

 

F’s – New More Functional Emotions and Behaviors

·              Now you’re ready to see the results of all your hard work!

·              By changing your negative beliefs into more helpful ones, you should now:

o       Feel better emotionally!

§         For example, you may feel more positive (happier, calmer, more relaxed), or less strongly negative (e.g., disappointed/sad vs. depressed, annoyed vs. furious)

o       Behave in a more helpful way!

§         For example, you may exercise, or socialize with friends, or pursue a hobby.

o       Feel better physically!

§         For example, you might feel more energetic or have less muscle tension.

 

Now use the ABCDEF model to identify and change your Intermediate Beliefs:

Ÿ      Rigid rules: “I must be a perfect partner”

Ÿ      Exaggerated attitudes: “It is awful if they consider me stupid”

Ÿ      Unrealistic assumptions (if/then):

o       Positive: “Only if I do everything right he/she will consider me a good partner”

o       Negative: “If I make a small mistake he/she will consider me stupid”

 

Now let us use the ABCDEF model to identify and change your Core Beliefs:

Ÿ      Core beliefs essentially fall into two broad categories:

o       Helplessness: “I am a failure, stupid, weak etc.”

o       Unlovability: “I am unlovable, unworthy, unlikable etc.”

 

Summary

·        Remember, although we cannot always change a particular situation or event (“A”) (e.g., loosing a close relative), we CAN manage and take control of our own thoughts. As a result, we can feel better or less distressed about situations we may have to confront.

  • We recommend that you complete at least one Depression A-B-C-D-E-F Self-Help form per day during your treatment, and one Daily Monitoring Form of Automatic Thoughts per day during your first week of treatment. Doing this will give you practice in catching your unhelpful thoughts, in recognizing how they are related to negative consequences, and most importantly, in changing those thoughts so you can have fewer depression symptoms, and a more positive treatment experience.
  • We want to emphasize that learning this skill can be challenging, and it takes practice. The more you practice, the easier it will become to change your thoughts and feelings, and the better you will feel.
  • Blank copies of this form are located at the end of this booklet. Our research staff will collect your completed forms during the course of your CT treatment. If you need more forms at any point, our research staff will provide you with extra copies.


4. Managing Depression with Behavioral Techniques

 

(a) Behavioral Techniques

 

  • Sometimes when we have to deal with a stressful or challenging life situation, or when we are having a particularly hectic day, we may not have enough time or energy to focus on using the cognitive techniques we have just reviewed (i.e., A-B-C-D-E-F model) in order to manage our negative thoughts.   

 

  • On those days, the simple and brief strategies outlined below are alternative techniques you can use to help you manage any feelings of distress, negative thinking, fatigue, or other symptoms.

 

  (1) Activity Scheduling/Planning

  • Some people may begin to feel overwhelmed by negative thoughts when undergoing their CT treatment as they try to fit in all their usual day-to-day activities. The aim of this section is to help you plan your daily and weekly schedule during the course of your CT treatment. Planning your daily and weekly schedules in advance will help you manage your daily activities, decrease your negative thoughts, control your level of fatigue, and overall, help you feel less depressed and more in control of your life.

 

  • At the end of this manual, a sample copy of a weekly diary schedule for a woman undergoing depression treatment is provided.  This sample copy is intended as a guide to help you complete your weekly schedules. Blank copies of the weekly diary are also located at the end of this booklet for you to use during the course of your CT treatment.

 

  • Here are the steps we recommend for planning a manageable schedule:

 

(1)        First, we recommend that you write down your weekly depression treatment sessions. When you start your depression treatment you will find that the therapy team will try to keep your weekly appointments at a regular time each week (e.g., at 10am). You will also find that your visit to the therapist’s office will take on average 50 minutes. Keep in mind when planning your day to allow extra time for traveling to and from the office.

 

(2)        Second, we suggest that you plan to give yourself 3 daily meal breaks, for breakfast, lunch and dinner. You may also want to include several short (about 10-15 minutes) snack breaks during the day.

 

(3)        Third, we recommend that you also slot in at least one 30-minute daily physical/recreational activity. Pick an activity that you enjoy doing, such as walking, gardening, or attending yoga classes. Previous studies have shown that it is helpful to continue to engage in at least low to moderate levels of physical/recreational activities (such as working out, walking, or even gardening) during the course of your depression treatment. This will ensure that your fitness level does not considerably decrease during the course of your treatment.

 

(4)        Fourth, we suggest that you write down on a blank sheet of paper all the activities you would like to complete during the course of the day. Make sure to list your work activities (if you are employed or self-employed), or your regular home activities if you work from home, as well as your regular daily chores such as preparing dinner, laundry, ironing, picking up kids from school, etc.

 

  •  
    • Once you have made your list of daily activities, number each activity in terms of how important it is to you. That is, if you have to go to work that day, number your work activities as #1, followed by the next essential task you would like to accomplish. Example 1= work, 2 = picking up child from school, 3 = preparing dinner, etc.
    • Once you have numbered your daily activities, write down each activity into your weekly planner, making sure you allow yourself enough time to accomplish each task.

 

  •  
    • You may find that you cannot fit in all the activities you would like to accomplish in one day. If so, we suggest that you put off the activities that are less important to you (that is, those activities that were further down on your list, like those you rated a 5 or a 6), and move them to another day during the week when your schedule is less hectic. 

 

  •  
    • You may feel tempted to bypass your daily rest (Step 3) or physical/recreational activity (Step 4) on a particular day so that you can fit in another activity. We suggest you refrain from doing this, given that making time for both exercise/recreational activities and relaxation is important to maintaining a balanced lifestyle. Remember, we all need to be realistic about what we can and cannot accomplish in one day. Sometimes it is impossible to try to complete the amount of tasks we would like to do in a single day. Therefore, set realistic goals for yourself. This way you make sure that you do not set yourself up for disappointments.

 

(b)   Distraction Techniques

  • Distraction techniques help take your mind off of your negative thoughts. Some distraction techniques are as follows:

 

(1) Imagining a Pleasant Image/Scene

  •  
    • A type of distraction technique you can use to take your mind off of your negative thoughts and feelings (including fatigue) is to imagine a pleasant scene. Some examples include:
      • Planning a ‘dream’ holiday. Try to visualize where you would like to go, who you would like to go with, how you would like to get there, what you would like to do there, and how much time you would like to spend in your ‘dream’ place.
      • Remembering an enjoyable vacation you have had. Imagine the fond memories you have of this vacation. Try to recall the details of the place, where you stayed, the fun activities you pursued.
      • Visualizing a relaxing scene. Try to imagine a peaceful, serene place (e.g., lying on a beach somewhere, or meditating in a tranquil garden setting).

(2) Listening to relaxing or enjoyable music tapes, CDs, videos

o       You may want to listen to some of your favorite music or watch one of your favorite movies to relax you, distract you, or lift your mood.

(3) Take a short walk

o       Another strategy you could use to distract yourself from unpleasant thoughts and feelings you may have is to take a stroll. If you are at work, take a brief walk around your workplace, focusing on the sights and sounds around you (e.g., pictures, music, etc.). If you are at home, take a stroll around your neighborhood, or garden. Pay close attention to the characteristics of things in your neighborhood (such as the color, shape and size of neighboring buildings; what’s on display in shop windows, etc).

(4) Visualizing a “STOP” Sign  

  •  
    • Try to imagine a traffic stop sign or even a ‘red light’ signal in your mind when you are feeing overwhelmed or upset by your negative thoughts and feelings, including fatigue. Follow the instructions of the stop signal by saying to yourself “stop thinking these negative unhelpful thoughts” or “stop dwelling on the negative”.

 

 

 

 

 

5. Beyond CT Treatment

  • The CT techniques that have been covered in this manual will help you to manage your depression symptoms. Moreover, these techniques can be applied to any situation in the future when you may feel overwhelmed and/or distressed.

 

  • It is important to note that following the completion of your CT treatment, you may occasionally experience days when you feel fatigued or distressed. During such periods, we suggest that you review the contents of this manual, and continue to use the CT skills that you have learned.

 

  • Over time and with practice, these CT skills will become natural for you, like riding a bike or driving a car.

 

  • We hope that you will find these techniques valuable, and we wish you every success in the future.

 

 

 

 

 

 

 

 

APPENDIX (availabe upon request)

 

1. Study Instructions

 

2. Spare Copies of the Depression A-B-C-D-E-F Self-Help Form

 

          3. Example of the Scheduling Form

 

   4. Spare Copies of the Scheduling Form

    

5. Spare Copies of the Daily Practice Monitoring

    Form for Automatic Thoughts

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