Treating Late Life Depression: A Cognitive-Behavioral Therapy Approach, Therapist Guide 9780199724901, 9780195383690

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Treating Late-Life Depression

EDITOR-IN-CHIEF

David H. Barlow, PhD

SCIENTIFIC ADVISORY BOARD

Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

Treating Late-Life Depression A COGNITIVE-BEHAVIORAL THERAPY APPROACH

W o r k b o o k Larry W. Thompson • Leah Dick-Siskin • David W. Coon • David V. Powers • Dolores Gallagher-Thompson

1 2010

1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2010 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. ISBN 978-0-19-538370-6

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Printed in the United States of America on acid-free paper

About TreatmentsThatWork TM

One of the most difficult problems confronting patients with various disorders and diseases is finding the best help available. Everyone is aware of friends or family who have sought treatment from a seemingly reputable practitioner, only to find out later from another doctor that the original diagnosis was wrong or the treatments recommended were inappropriate or perhaps even harmful. Most patients, or family members, address this problem by reading everything they can about their symptoms, seeking out information on the Internet, or aggressively “asking around” to tap knowledge from friends and acquaintances. Governments and healthcare policymakers are also aware that people in need don’t always get the best treatments—something they refer to as “variability in healthcare practices.” Now healthcare systems around the world are attempting to correct this variability by introducing “evidence-based practice.” This simply means that it is in everyone’s interest that patients get the most up-to-date and effective care for a particular problem. Healthcare policymakers have also recognized that it is very useful to give consumers of healthcare as much information as possible, so that they can make intelligent decisions in a collaborative effort to improve health and mental health. This series, TreatmentsThat Work™, is designed to accomplish just that. Only the latest and most effective interventions for particular problems are described in user-friendly language. To be included in this series, each treatment program must pass the highest standards of evidence available, as determined by a scientific advisory board. Thus, when individuals suffering from these problems or their family members seek out an expert clinician who is familiar with these interventions and decides that they are appropriate, they will have confidence that they are receiving the best care available. Of course, only your health care professional can decide on the right mix of treatments for you. This workbook is designed for your use as you work together with a therapist to overcome your depression. It contains information on cognitive-behavioral therapy and how it can help to reduce the symptoms of depression. Each chapter corresponds to a treatment module so it is recommended that you do not skip

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ahead. Case examples are presented throughout and provide excellent illustrations of the main points. Answer the summary questions at the end of each section to review the information presented to you in sessions. Complete home assignments and in-session exercises, and use the worksheets and forms provided to put the techniques that you’ve learned into practice. Learn how your thoughts, emotions, and behaviors work to maintain your depression and also learn how to challenge and modify them in order to improve your mood and quality of life. David H. Barlow, Editor-in-Chief, TreatmentsThatWork™ Boston, MA

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Acknowledgments

We wish to extend our heartfelt appreciation to the numerous colleagues, students, and patients with whom we have worked and collaborated in our professional lives over the past 20 years. Their input has enabled us to develop, refine, revise, and update the materials and strategies included in both the therapist guide and the client workbook. We particularly wish to thank Dr. Aaron T. Beck and colleagues associated with the Academy of Cognitive Therapy for their support and encouragement—when no one else believed that CBT could be done with older adults, this group was there for us (and they still are!). This research received major funding from several grants from the National Institute of Mental Health, and grants continue to be written to further study the efficacy of CBT with a variety of older adult patient populations. In addition, considerable support was provided by the Veterans Administration Health Care System located at Palo Alto, CA, and by the Department of Psychiatry and Behavioral Sciences of Stanford University School of Medicine. Finally, we wish to thank our co-authors, Drs. David Coon, Leah Dick-Siskin, and David Powers, whose creativity and high levels of energy and commitment kept this project going during both challenging times and good times. They never gave up believing in the viability of CBT for depressed older adults, and never stopped maintaining effective collaborative relationships with us. For this we will always be grateful. Dolores Gallagher-Thompson, Ph.D. Larry W. Thompson, Ph.D. Los Altos, CA, April, 2009

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Contents

Part I

Early Phase of Therapy 1

Chapter 1 Module 1: Introduction to Cognitive-Behavioral Therapy

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Chapter 2 Module 2: Identifying Target Complaints and Setting Goals 13 Part II

Middle Phase of Therapy 29

Chapter 3 Module 3: Doing Tools 31 Chapter 4 Module 4: Thinking Tools 59 Chapter 5 Module 5: Feeling Tools 101 Chapter 6 Module 6: Communication Tools 129 Part III

Late Phase of Therapy 151

Chapter 7 Module 7: Ending Therapy 153 The California Older Person’s Pleasant Events Schedule (COPPES) 169 Appendix of Forms 173 National Resources for Older Adults 225

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Early Phase of Therapy

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Chapter 1

Module 1: Introduction to Cognitive-Behavioral Therapy

Goals ■

To begin using the workbook

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To learn about the cognitive-behavioral therapy (CBT) approach to treatment of depression

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To learn about the A-B-C model

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To understand the downward spiral of negative changes

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To learn what to expect from CBT

About This Workbook This workbook will help you put into practice the new skills you will be learning in therapy. It is designed to follow the same pace as your face-to-face meetings with your therapist, so we do not recommend reading ahead or completing exercises before you and your therapist cover the new material together. Bringing this workbook to each session and referring to it for each new exercise will really help you. If something seems too difficult or frustrating, circle that part, continue with the rest if you can, and ask your therapist for clarification during the next session. Your therapist may also skip to sections that fit you best, leaving some parts to be covered later. Get in the habit of asking yourself after each section, “Do I understand this well enough to explain it to somebody else?” The answer to this question will let you know if you need to review the material again. Please work at your own pace; everyone progresses differently in mastering new skills to deal with difficult situations. Remember, if something in this workbook is confusing, ask your therapist!

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A Summary of the Cognitive-Behavioral Approach By now, you may be asking, “What exactly is this treatment that I am starting?” Before getting to the “nuts and bolts” of how this program can help you, it will be useful to learn about the four important components of the cognitive-behavioral approach and how they interact with one another. These four components reflect on your current health status, your thoughts, your behaviors, and your emotions. This explanation might seem abstract, and it may be difficult to see how it might apply to your problems, so here is an example to show how the CBT approach works:

Example of the Cognitive-Behavioral Model

John is a 66-year-old retired, married man who has weekend plans to finish painting his wife’s bookcases (behavior). Unfortunately, he wakes up feeling ill on Saturday morning (health status) and is unable to complete the project (behavior). As a result, he feels angry and anxious about not getting to his work (emotions), believing that he is disappointing his wife (thought). He thinks, “My wife will think that I do not care about helping her decorate the study.” This belief raises his anxiety (emotion) as well as his frustration about not feeling up to par. This makes it even harder for John to figure out how to face the day, and consequently he stays in bed (behavior), which in turn only serves to raise his anxiety and strengthens his negative thoughts about his wife’s reaction. Figure 1.1 shows how John’s behaviors, health, thoughts, and mood affect each other. Note that each connection has an arrowhead in two directions. For example, John’s negative beliefs about his wife’s disappointment may have worsened his physical health status, as well as his mood, which in turn, reinforces his behavior of staying in bed. Although you will be concentrating on how to change your negative emotions, note that the relationships within this model also work for positive emotions. Also note that the word “environment” surrounds the CBT model. Environment refers to the events and the people around you that affect what you do and think, as well as how you feel physically and emotionally. In this example, John’s environment could be his plans to paint the bookcases and also his commitment to his wife to complete this project. Additional elements of the environment could be a friend moving away or the death of a family member. As you can imagine,

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Environment

Environment Physical Health Status (John’s illness)

Thoughts

Behaviors

(My wife will be

(stayed in bed)

disappointed in me.)

Emotions (anxiety, frustration, or anger)

Environment Environment

Figure 1.1 Example of Interaction of Cognitive, Behavioral, Emotional, and Physical Factors.

any number of different situations might occur that could affect these components in either positive or negative directions. In the course of therapy, you are going to be looking at many different situations in your environment to see how they affect these four components. Exercise: Cognitive-Behavioral Model

Now, choose an example of your own and fill in the blank CBT Model Worksheet using the following questions: Behavior: Recall the last time you had a successful outcome from a good job you did or a task that you just completed. Thoughts: What kinds of thoughts did you have about yourself? Emotional consequences from thoughts and behavior: What kind of mood were you in as a result? Health: What was your health status that day?

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Blank CBT Model Worksheet

Environment

Environment Physical Health

Thoughts

Behaviors

Emotions

Environment Environment

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How Does Cognitive-Behavioral Therapy Work?

People usually come to therapy because they do not feel good emotionally for one reason or another. Unfortunately, it is not possible for your therapist to “reach in” and change how you feel. This program also does not try to change your physiology directly through drugs or other means. That leaves us with two factors, thoughts and behavior. CBT can help you change what you think and what you do. You can learn how to change your thinking so that you are not as upset or depressed or nervous about things. You can also make changes in your behavior by learning to build in more pleasant activities into your schedule, express yourself more clearly, and solve problems systematically.

A-B-C Model The A-B-C model shows how CBT can help improve thinking. A-B-C signifies: Antecedent (or event), Belief, and Consequences (emotional). See Figure 1.2. For example, assume that you are going up on an elevator when suddenly you receive a sharp poke in the ribs. What goes through your mind? You might think to yourself, “This person is going to rob me,” and you feel scared. Or you might think “what an inconsiderate person,” and feel irritated. Now assume that you turn around and you notice the person who poked you is blind. How do you feel now? By gaining this new information about the situation, you probably would have a more positive reaction. This is a small example of how CBT works. You will learn various ways to “turn around” your thoughts, assumptions, and perceptions in order to gain new insights and more helpful beliefs that will lead to more positive emotions.

Antecedent: What Happened? Sharp poke in the ribs

Beliefs or Thoughts

Consequences: How Did This Make You Feel?

This person is going to rob me.

Scared

What an person.

Irritated

inconsiderate

Figure 1.2 The A-B-C Model.

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Now try doing an A-B-C chain with your own example.

Antecedent: What Happened?

Beliefs or Thoughts

Consequences: How Did This Make You Feel?

Downward Spiral Keep in mind that an important idea in CBT is that the four dimensions— thoughts, feelings, behaviors, and health status—have a notable influence on one another. This influence is also reciprocal in nature—it goes in both directions. Thus, a negative thought stemming from an unpleasant event can affect behaviors or emotions, which in turn can affect thoughts, and so on. Often, these components can start a downward spiral of negative changes that can throw a person into a tailspin, leading to depression or an anxiety disorder (see Figure 1.3). This illustration shows that “giving in” to the “slowed down” feeling that often comes with depression leads to a downward spiral (do less → feel worse → do even less, and so on). Note that the figure on the right shows how a person can “pull out” of a tailspin. The goal of therapy will be to stop a tailspin before it gets started by changing your behaviors and thoughts that could lead to a downward spiral. You will also learn techniques to reverse the tailspin and move yourself in an upward spiral. Feel Down

THE Do Less

Feel Worse

Do Even Less

T A I L S P I N

Figure 1.3 Tailspin of Thoughts, Activities, and Emotions.

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Feel

Even

Better

Do More

Feel a Little Better

Do Something

About Cognitive-Behavioral Therapy Who Does Cognitive-Behavioral Therapy Help?

A common response to the beginning of cognitive-behavioral therapy is, “It sounds good, but can this help me?” or “This is too simple (or too hard) to solve the problems I have.” Don’t dismay! Many research studies have shown that people with serious, complicated problems have found the cognitive-behavioral approach helpful. No matter whether you’re “a little blue” or seriously depressed, or whether you feel a little nervous about something or have extreme panic, this approach might be the thing to help you feel better and function more effectively. You may also have the belief that you are “too old to change,” or that your beliefs have been around for so long, “it seems hopeless.” However, it has been discovered that older people have success in this therapy equivalent to younger adults. You can successfully change your thoughts and behaviors as you learn and practice these skills.

What Can I Expect From Cognitive-Behavioral Therapy?

Following are some things to expect from CBT: therapist role, client role, a collaborative relationship, goals for therapy, and home practice.

Therapist Role

You can expect that your therapist ■

is an expert on the latest techniques in CBT with older adults,

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is quite experienced in working with the unique concerns of older people,

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will work very hard to understand your problems,

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will help you learn the skills you need to reach your therapy goals,

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will maintain continuity of work accomplished from session to session,

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will make every effort to reschedule appointments if one is missed or cancelled,

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will expect you to be an active participant in this therapy and will encourage your collaboration in completing practice assignments.

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Client Role

As a client of CBT, you are expected ■

to be open with your therapist about your concerns and any difficulties you are having with the material,

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to arrive on time for sessions and to call in advance if you need to cancel or reschedule,

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and to be an active member of the relationship, which involves practicing skills in between sessions and being open to discussing the difficulties in completing home practice.

The Collaborative Relationship

The heart and soul of CBT is the formation of a collaborative relationship between the client and the therapist. A collaborative relationship means that both the client and the therapist take an active role in understanding the problems that brought the client to therapy, defining goals, and working to achieve goals through the end of therapy. Goals for Therapy

CBT includes setting goals and working toward them step by step. The outlining of specific goals for therapy makes tracking progress a measurable task. Importance of Home Practice

It is very important for you to practice new skills in between each session. Practice is one of the best ways to make the therapy skills a routine part of daily life. At the end of every session, you will be given an assignment for home practice. If you have trouble completing assignments, be sure to discuss this with your therapist.

Gift of Rewards Committing to actively change certain areas of your life is a major decision. This is hard work that will require a good deal of your attention. How you can treat yourself well as you work on these difficulties? Try to start thinking about nice

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things that you can do for (or say to) yourself as celebrations for even small steps of success. You may want to list these in the space provided:

It may be hard right now to consider that you deserve to treat yourself well, but at least consider the idea as you begin therapy. You can introduce rewards as you go along. If you can’t think about this now, don’t worry, your therapist will discuss with you ways to reward yourself as therapy progresses.

Summary Questions How many times have you suddenly had a brilliant idea or insight into a difficult problem, and you made a mental note that you should write it down as soon as it was convenient for you, only to discover several hours later that you had completely forgotten what this brilliant idea was? Had you taken the time to write the idea down or rehearse it in your mind several times, then in all likelihood you would have remembered it later. This is exactly what happens in therapy! When you come up with a good solution or insight about your problems and what you need to do about them, you’re much more likely to remember and apply it if you rehearsed it before it fades away. Summarizing what occurred during the therapy session is a good tool for rehearsing new ideas. Each chapter in this workbook will include questions to help you review what you have learned. Sometimes, people have difficulty completing these questions. If that happens to you, be sure to bring it up with the therapist, and review with him or her your thoughts on what were the main points of the session and the reading in this workbook that goes with the session. 1. What were the key points brought up in this chapter?

2. What skills did I learn?

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3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Remember that you and your therapist together will work out just exactly what the home practice assignments will be. Assignments for this section might include the following:

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✎

Complete CBT Model Worksheet.

✎

Complete A-B-C chain.

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Come up with some ideas for rewards.

✎

Answer summary questions.

Chapter 2

Module 2: Identifying Target Complaints and Setting Goals

Goals ■

To identify target complaints

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To set treatment goals

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To understand how progress is made

Identifying and Prioritizing Target Complaints Many times when we don’t feel well, it can be hard to quickly identify the problems or difficulties that contribute to our situation. Sometimes, the number of problems facing us seems endless. Other times, we can identify one particular problem that we would like help with, but that problem seems overwhelming. Therapy works best when you first identify some of the most important complaints bothering you and share them with your therapist. This section of the workbook is designed to help you identify these complaints in order to develop goals for you to work on with your therapist. This process involves three basic steps. 1. Identify the complaints. 2. Prioritize and target the complaints most important for you now. 3. Translate these problems into goal statements for you and your therapist to work on together. This process is illustrated with the case example of Mabel. Case Example: Mabel ■ Mabel is a 77-year-old woman who states that she has had bouts of depression all

her life. Mabel lives with her husband of 51 years and they have three grown children, who all live nearby with their families. Mabel reports that she has virtually no contact with her children, stating, “they blame me for everything and believe that

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I was a bad mother.” She also reports that she has a difficult relationship with her husband, especially when they disagree about their children’s decisions. Mabel explains that this time her depression began 3 months ago when she stopped volunteering at the local children’s hospital. Mabel states that it was her decision to end this activity when she discovered that her covolunteers did not have the same values that she held. Mabel was able to identify 3 areas that she would like to change: Problem #1: I would like to find more things to do with my day. Problem #2: I would like to be completely free from depression. Problem #3: I would like to communicate better with my husband and children. See Figure 2.1 for Mabel’s completed Target Complaint Worksheet. Note the additional information we learn about Mabel’s difficulties from these questions. In summary, we learn about how Mabel views her difficulty with finding time Problem #1 I no longer spend my days doing things that I like. a. In what situations does this occur? Daily. I am constantly doing things for the house, my husband, or my children. There’s no time left for me, and when there is, I don’t have the energy or the interest. b. Why do you think this problem occurs? My depression and the fact that I can’t stop taking care of them! c. Has this problem come up before? If yes, please continue with section d If no, please go to section e d. What have you tried in the past to help you manage this problem? Did these strategies help before? If they did help, why aren’t they helping now? I tried to volunteer to get me away from the house, but I wasn’t very happy with my coworkers. I feel out of options. e. Please circle the number that best describes how much this problem is bothering you now.

0% not at all

10

20

30 a little

Figure 2.1 Mabel’s Target Complaint Worksheet.

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40

50

60

70 very much

80 

90

100% couldn’t be worse

for herself and what strategies she has already tried to change her distress. We also learn that on a scale from 1 to 10, Mabel’s distress over not finding time for herself and doing things she likes falls in between “very much a problem” and “couldn’t be worse.” Let’s take each complaint you have identified one-at-a-time to see what additional information might help you prioritize. Now focus on your own life and complete the Target Complaint Worksheet on pages 16–18. What problems or difficulties do you want help with in treatment? Try to be specific about what thoughts, feelings, and behaviors seem to be most difficult for you in your current situation. Most of us can think of a number of things we want to change! But try to pick the “TOP 3.”

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Target Complaint Worksheet Problem #1

a. In what situations does this occur?

b. Why do you think this problem occurs?

c. Has this problem come up before? If yes, please continue with section d If no, please go to section e d. What have you tried in the past to help you manage this problem? Did these strategies help before? If they did help, why aren’t they helping now?

e. Please circle the number that best describes how much this problem is bothering you now.

0% not at all

16

10

20

30 a little

40

50

60

70 very much

80

90

100% couldn’t be worse

Problem #2

a. In what situations does this occur?

b. Why do you think this problem occurs?

c. Has this problem come up before? If yes, please continue with section d If no, please go to section e d. What have you tried in the past to help you manage this problem? Did these strategies help before? If they did help, why aren’t they helping now?

e. Please circle the number that best describes how much this problem is bothering you now.

0% not at all

10

20

30 a little

40

50

60

70 very much

80

90

100% couldn’t be worse

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Problem #3

a. In what situations does this occur?

b. Why do you think this problem occurs?

c. Has this problem come up before? If yes, please continue with section d If no, please go to section e d. What have you tried in the past to help you manage this problem? Did these strategies help before? If they did help, why aren’t they helping now?

e. Please circle the number that best describes how much this problem is bothering you now.

0% not at all

18

10

20

30 a little

40

50

60

70 very much

80

90

100% couldn’t be worse

Measuring Changes: Rating Scales

There will be many times throughout therapy that you will be asked to identify certain characteristics such as beliefs or feelings with a numerical rating. The importance of the rating scale is that it provides a basis of comparison between your initial impressions of the belief, goal, feeling state, or some other characteristic, and a later impression in order to judge whether these aspects have changed. On the Target Complaint Worksheet, you will be asked to rate how much each problem is bothering you. In this chapter you will also be asked to define and explain your goals; later, you and your therapist will revisit and re-rate these goals to determine whether the therapy is helpful. Consider the rating scale to be like a thermometer, where lower numbers mean less temperature, and higher numbers indicate greater temperature. Throughout this workbook, we will be using a rating scale, where low numbers will indicate that you do not have a strong connection to the characteristic, and a higher number will mean that you are strongly connected to the characteristic. Our rating scale will look like this:

0% not at all

10

20

30 40 a little

50

60

70 80 very much

90

100% couldn’t be worse

Translating Target Complaints into Goals How do we shape these target complaints into goals for therapy? Don’t try to do it on your own at first. Your therapist needs to be included in this process. Your therapist can provide effective feedback in helping shape your goals by (a) asking key questions that hadn’t occurred to you, (b) breaking down large target complaints into smaller separate ones, (c) helping break down goals into manageable steps, and (d) reminding you of limitations of time, money, material, or skills that may interfere with your goals.

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Language and Properties of Goals

The difference between a target complaint and a goal is that a goal is a well-defined plan of change (whether focusing on behaviors or beliefs) that is important, time-limited, specific, realistic, positive, and measurable. Each of these properties is defined next and illustrated through Mabel’s (see case example) desire to increase time for herself and the things she enjoys.

Important

A person’s goal must be a priority for him or else he will not have the motivation to work on it. Mabel’s goal was very important to her. She believed that unless she started treating herself better she would not be an active member of her family.

Time-Limited

Cognitive-behavioral therapy is a short-term treatment; therefore, the goals set must be manageable within the time allowed. The therapist explained to Mabel that brief, CBT has been shown to be quite effective in helping people organize their time and introduce pleasant activities.

Specific

If a goal is too complicated, or depends on too many components and regulations in order to be met, it is not a good recipe for success. It is always recommended that goals be straightforward and be targeted to a definite area of one’s life. Mabel’s desire to introduce new hobbies or pick up old ones is a very specific goal.

Realistic

A goal must be something that one can achieve independently. Mabel is the only one who will be ultimately responsible for making these changes. She will not be able (nor does she need) to rely on others to either give her time during the day or provide her with hobbies.

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Positive

Often, when people are depressed, they phrase their needs in terms of losses or negatives. Stating your goal with positive language will help you begin to understand how you can be in control of the changes that you want to make. Mabel originally presented a negative state of being such as “not having any time for myself.” She has restated the situation in terms of what she wants to gain and how she wants to take an active role in these changes. Measurable

In order to recognize changes in your goals, it is important that the stated goal can be assigned a value along the 10-point scale at the beginning of treatment. The same scale will then be used to rate the status of the complaint at different times throughout therapy. Aside from measuring change, the comparison of these values can initiate the discussion about which strategies have been helpful to making change, or if little change has been seen, what new strategies can be introduced to enhance improvement. Remember that Mabel rated the strength of her distress over this issue as “80%” which is quite high. This value will be compared to her perceptions of this issue at both the midpoint and the end of therapy. Mabel’s Goal-Setting Worksheet (Figure 2.2) illustrates the process of how a target complaint becomes a specifically stated goal. Now complete a blank Goal-Setting Worksheet for each of your target complaints. For larger target complaints, you may need to break them into smaller separate ones. You may photocopy the worksheet as needed. Additional copies are also provided in the appendix. Make sure that each goal is important, time-limited, specific, realistic, positive, and measurable.

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Goal: To increase pleasant activities in my day. 1. Is your goal:
Important to you? 


Time-limited?


Specific?


Positive?


Realistic?


Measurable?

2. How could you or someone else determine whether this goal has been met or not at the end of treatment? Please specify some concrete behaviors or concrete events that might be used as criteria to determine that the goal has been met. a. If treatment is a success in regard to this goal, I will probably: Have consistent, scheduled time for both my household responsibilities and fun activities. I will probably feel less depressed and less trapped in my home. b. If treatment is partially successful, I will probably: Have inconsistent (less planned) time for myself. I will probably still have strong moments of sadness about not being in control of my day. c. If the goal is not met at all, I will probably: Still be depressed and nothing will change.

Figure 2.2 Mabel’s Goal-Setting Worksheet.

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Goal-Setting Worksheet Goal:

1. Is your goal:
Important to you?


Specific?


Positive?


Time-limited?


Realistic?


Measurable?

2. How could you or someone else determine whether this goal has been met or not at the end of treatment? Please specify some concrete behaviors or concrete events that might be used as criteria that the goal has been met. a. If treatment is a success in regard to this goal, I will probably:

b. If treatment is partially successful, I will probably:

c. If the goal is not met at all, I will probably:

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Goal-Setting Worksheet Goal:

1. Is your goal:
Important to you?


Specific?


Positive?


Time-limited?


Realistic?


Measurable?

2. How could you or someone else determine whether this goal has been met or not at the end of treatment? Please specify some concrete behaviors or concrete events that might be used as criteria that the goal has been met. a. If treatment is a success in regard to this goal, I will probably:

b. If treatment is partially successful, I will probably:

c. If the goal is not met at all, I will probably:

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Goal-Setting Worksheet Goal:

1. Is your goal:
Important to you?


Specific?


Positive?


Time-limited?


Realistic?


Measurable?

2. How could you or someone else determine whether this goal has been met or not at the end of treatment? Please specify some concrete behaviors or concrete events that might be used as criteria that the goal has been met. a. If treatment is a success in regard to this goal, I will probably:

b. If treatment is partially successful, I will probably:

c. If the goal is not met at all, I will probably:

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Progress Toward Goals When considering progress on the goals you developed in therapy, remember to avoid thinking in extremes. If you haven’t accomplished everything that you wanted or reached your goals as quickly as you had hoped, it doesn’t mean that you accomplished “nothing.” Any step that takes you closer toward the change you want is a step of positive change and progress. So, remind yourself that change does not happen right away, by just taking the first step. If this was the case, you would have done it a long time ago. Most people expect change to happen immediately once the process of therapy begins. This expectation is illustrated in Figure 2.3. However, progress on set goals rarely occurs at a steady pace, or in a continuous direction, like climbing steps (see Figure 2.4). Remember that it is difficult to learn a new way of thinking and new behaviors that have seldom or never been tried out before. And making the effort and

GOAL

Figure 2.3 Expectation of Progress.

GOAL

Figure 2.4 Steady Progress.

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GOAL

Figure 2.5 Usual Progress.

showing progress is easier on some days than others. Most change happens with setbacks in between and looks more like a “sawtoothed” curve (see Figure 2.5). What does this all mean? Be prepared for “two steps forward and one step back” when looking at your progress. Try to evaluate progress on your goals in light of this principle. There will be times that you may begin to fall back on your old way of thinking or doing things, especially when you are experiencing a lot of stress. But, this doesn’t wipe out all the successes you have had up to that point, it doesn’t mean you haven’t made progress, and it certainly doesn’t mean you cannot change the thinking or behavior right then or the next time it happens! Often, we judge our progress by the direction we happen to be going rather than by what we have accomplished overall. For example, let’s say your goal is to lose 10 pounds. At the end of 6 weeks, you may have lost 6 pounds. How would you feel about that? You might rate yourself high on a scale from 1 to 10. Two weeks later, you lose 2 more pounds and continue to rate your mood highly. Yet, during week 9, you gain a pound. How would you feel then? So, when reviewing your progress toward goals, make sure you evaluate the overall process, not just compare the result of one week against the result of the previous week. And don’t forget to recognize and reward yourself for each step made toward achieving the goal!

Summary Questions 1. What were the key points brought up in this chapter?

27

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include one or more of the following:

28

✎

Complete Target Complaint Worksheet.

✎

Complete Goal-Setting Worksheet.

✎

Begin practicing relaxation exercises if covered and decided upon in session.

✎

Answer summary questions.

Middle Phase of Therapy

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Chapter 3

Module 3: Doing Tools

B E H AV I O R A L A C T I VAT I O N

Goals ■

To monitor your activities

■

To schedule activities

■

To begin doing activities to feel better

Activity Monitoring You may be engaging in very few activities because of feeling depressed. However, you may also be underestimating the number of activities you are doing and how positive they might be. It is important to obtain an objective assessment of what you are doing during the week. To do this, write down your activities for the past week on the Activity Monitoring Form (see Figure 3.1 for an example). Include all activities even though small. Then evaluate the following: ■

Pleasure (P): 1–10 scale

■

Mastery/Accomplishment (M): 1–10 scale

■

Overall mood rating for the day

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Time

Monday

Tuesday

9–10

Got dressed m–2, p–1

Got dressed m–3, p–3

Slept

Got dressed m–5, p–5

10–11

Threw out trash m–5, p–3

Did dirty dishes m–6, p–5

Slept

Washed clothes m–5, p–4

11–12

Sat on porch m–1,–2

Watched CNN m–1, p–6

Slept

Talked to neighbor m–6, p–5

12–1

Lunch (oatmeal) m–5, p–3

Lunch (restaurant) m–6, p–5

Lunch (sandwich) m–5, p–2

Lunch (spaghetti) m–6, p–3

P=1

P=3

P=1

P=4

M = 10

M=9

M = 10

M=8

Mood = 2

Mood = 7

Mood = 1

Mood = 5

Pleasure, Mastery, & Mood Ratings (1–10)

Figure 3.1 Example of Partially Completed Activity Monitoring Form.

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Wednesday

Thursday

Activity Monitoring Form Time

33

Pleasure, Mastery, & Mood Ratings (1–10)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Once you have completed the form, review it and answer the following questions: 1. Were there periods of time when you experienced pleasure?

2. What kinds of activities gave you pleasure?

3. When do you have higher pleasure? When lower?

4. Do you see any connection between your mood and your activities?

Activity Scheduling: Scheduling Pleasant Activities It can be helpful to schedule pleasant activities into your week using the Activity Schedule (see Figure 3.2 for an example). Remember to keep activities simple and achievable. If you are unsure about doing any of the activities on your schedule or have problems completing them, be sure to discuss with your therapist. Time

Monday

Tuesday

Wednesday

Thursday

9–10

Dress Eat breakfast

Dress Eat breakfast

Dress Eat breakfast

Dress Eat breakfast

10–11

Do dishes and walk

Go to gym for 30 min

Do dishes and walk

Go to gym for 30 min

11–12

Watch CNN Read news

Go for coffee Read news

Watch CNN Read news

Coffee with best friend

12–1

Lunch at favorite restaurant

Fix lunch and read mystery

Try new lunch Read mystery

Have lunch with friends

Figure 3.2 Example of Partially Completed Activity Schedule.

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Activity Schedule Time

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

35

Behavioral Activation Sometimes, doing just one or two things can make a difference in how you are feeling. Your therapist can help you identify a couple of key activities and make a plan for doing them. Key Activity

Action Plan

Breaking Tasks Into Manageable Pieces

Remember that at times it is necessary to break tasks into small or manageable pieces in order to complete them successfully. Practice breaking a task into steps in the space provided. Task: Step 1: Step 2: Step 3: Step 4: Step 5: Step 6:

Exploring Thoughts and Expectations

You may have negative thoughts or expectations that interfere with successfully engaging in an activity. You may need to challenge these before attempting the activity. For example, you might examine the evidence to determine if your thoughts are accurate. You might also try replacing your negative thoughts with more helpful ones. You might want to practice challenging a negative thought in the space provided on the next page.

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Negative Thought:

Evidence For:

Evidence Against:

Replacement Thought:

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

37

Home Practice Assignments in this section might include the following:

✎

Monitor your activities using the Activity Monitoring Form.

✎

Follow through with activities on the Activity Schedule.

✎

Choose a couple of key activities and implement an action plan.

✎

Answer summary questions for this section.

INCREASING PLEASANT ACTIVITIES

Goals ■

To monitor your mood

■

To identify pleasant activities of interest

■

To keep track of personal pleasant events

■

To recognize the relationship between pleasant events and mood

Importance of Engaging in Pleasant Events You probably agree that doing things you like typically has a positive effect on your mood. One popular theory about the causes of depression stresses the functional relationship between depression and everyday life events. The theory reasons that when one encounters an event or maybe a series of life events that reduces the level of pleasure one experiences in daily life, one’s mood is lowered. Remember the downward spiral presented in Chapter 1? It can apply here as well. When your mood is lowered, your level of activity also decreases. When your level of activity is reduced, then you are even less likely to engage in activities that would be pleasurable. This tends to lower your mood even further, which in turn continues to reduce your activity level, and so on until you are in a vicious tailspin. However, remember the upward spiral? By increasing your level of pleasant activities on a daily basis, you can improve your mood and reduce your symptoms of depression.

38

Monitoring Mood The first step to increasing pleasant activities is to learn to monitor your mood more carefully. Perhaps, when you focus on your mood, you think of yourself as being happy or sad or maybe “just so-so,” without noticing the gradations in between. Noticing the “in-between” can help you pay attention to changes in your mood or to what you’re doing at those times when your mood gets better or worse. Consider the following example: Susan is a 67-year-old married woman who lives with her husband, granddaughter, and 2-year-old great-grandson. Her granddaughter has been living in the home for several months while she is attending graduate school. Her granddaughter’s arrival coincided with Susan’s partial retirement from her career as a florist. She decided to stop working gradually in order to help take care of the 2-year-old boy while her granddaughter is in class. Lately, Susan has become quite depressed about the amount of her household tasks as well as the fact that babysitting has slowly cut off her social activities. On one particular day, Susan finds that she has the day to herself when her husband is away on business and her granddaughter is visiting her parents during a school break. On this day, she gets up preparing for a full day out in her garden. She feels refreshed and reasonably happy. As she starts to work, she suddenly realizes that she does not have several supplies she needs for the tasks she wishes to complete. Slightly frustrated, she decides to go out and pick up these supplies. During these errands, she gets stuck in a long traffic jam resulting from construction on a major thoroughfare. In the nursery, she feels rushed and annoyed when a young salesperson is rude to her when she asks a question regarding some supplies. As a result, she doesn’t get everything that is on her list, which causes her to return to the store, thus spending more time on this unplanned errand. The traffic is once again terrible on the way home. Susan plans to return to her garden immediately upon getting in the house, but finds an upsetting phone message on her machine from her granddaughter, who is stranded because her car broke down. Susan gets her granddaughter, takes her home, and is irritated when her granddaughter does not acknowledge that she has disrupted the day that Susan planned for herself. Susan decides to go directly to the backyard in order to salvage whatever daylight hours remain. Susan works in her garden for 2 hours. During that time, she is able to feel less tense from the interruption in her plans, but she still believes that she had lost all control over that day, and she feels helpless in ever being able to carve out more personal time.

39

Notice that Susan started the day feeling happy, relaxed, and focused on a task for herself. By the end of the day, she was feeling sad, overwhelmed, and getting the impression that she had little control over events in her life. Like for most of us, this was “one of those days” for Susan where nothing seemed to go right, and it’s certainly understandable that she might feel down. Susan’s dilemma was complicated, however, by the fact that she couldn’t see how the specific events of the day had impacted on her mood. If Susan had been in the habit of paying closer attention to her mood variations, she would have seen the relationship between the different events during the day and the changes in her mood. She could then plan activities or strategies to enhance her mood or possibly prevent a dramatically lowered mood. If Susan had rated her mood upon awakening, at lunch time, at dinner time, and then at bedtime, she would get a better sense of how her mood fluctuates and what events were related to these moods. In order to expand Susan’s knowledge of the relationship between her mood and her behaviors, she completed a chart where she monitored her mood at different points during the day and identified the situations corresponding to these ratings (see Figure 3.3). Note the relationship between Susan’s mood and the events that she experienced. Susan’s low mood was related to planned personal time gone awry, as well as a lack of acknowledgment from her granddaughter that she deserves time alone. In fact, her lowest mood scores occurred when she believed that trying to do what she wanted was a lost cause. Yet, Susan did recognize that her mood elevated slightly as she finally engaged in her gardening. Try using the Daily Mood Rating Form to rate your mood at several key points during the day. Pay attention to the events that surround your moods and record them on the form. After you are done, review this chart. Are higher moods associated with more pleasant events? Are lower moods associated with unpleasant events? And, did your mood change throughout the day? You may be beginning to see the relationship between your mood and behavior from breaking down your day into smaller components.

40

Please rate your mood at different times during the day, that is how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

4

very depressed Time of day

5

6

7

8

9

“so-so”

Mood score

10 very happy

Reasons why I felt this way:

Morning

10

I woke up refreshed and excited about my garden.

Lunchtime

3

I never ate lunch due to my nursery mishap and rescuing my grand daughter. I was hurt that my grand daughter was unsympathetic to having interrupted my day.

Dinner

5

I felt a little better after working on the garden, but I am still quite disappointed about all of the time that I lost.

Bedtime

3

I rarely get time for myself. My personal projects will forever go unfinished.

Average for the day:

5

I constantly take care of others, and I rarely put myself first.

Figure 3.3 Susan’s Daily Mood Rating Form.

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Daily Mood Rating Form Please rate your mood at different times during the day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

very depressed

Time of day

42

3

4

5

6

7

8

9

“so-so”

Mood score

10 very happy

Reasons why I felt this way:

Identifying Pleasant Activities It is helpful to identify other pleasant activities that you might plan to try in the future. Your therapist will help you brainstorm what meaningful activities might be for you. Your results from the Activity Monitoring Form can be useful in identifying activities. It is best to focus on simple and “doable” activities. The following questions may be helpful: 1. What used to be pleasurable in the past?

2. Why did you stop specific pleasurable activities?

3. If barriers to an activity are real and can’t be modified, what might be a good substitute?

You may think “I don’t enjoy anything anymore” or “I can’t do anything anymore.” This is a type of all-or-none thinking that can keep you from engaging in pleasant activities. Your therapist can help you challenge these false beliefs. Keep in mind that an event doesn’t have to be pleasant or not, it can be “somewhat pleasant.” Or an activity can be shortened or simplified and still be enjoyable. It may be important for you to find activities that fit with your values and give you a sense of purpose. The following questions may be helpful in identifying meaningful activities. 1. When you think about your life, the past and the present, what stands out as being important to you? What are some of the reasons for this?

43

2. Who are some people that you admire in your life? What did they do that made you feel this way?

California Older Person’s Pleasant Events Schedule

You may have abandoned pleasant activities due to feeling down or overwhelmed. On the other hand, you may want to do more pleasant activities, but are unsure about how to start. In either case, it is important to identify activities you like as well as those you would find quite pleasurable if you had the time. This information can be obtained by filling out a questionnaire. The California Older Person’s Pleasant Events Schedule (COPPES) lists 66 activities that many older people find enjoyable. As the list is rather long, it is not important that you find all of these activities enjoyable. For each item, consider (a) how often you have engaged in this activity within the past month and (b) how much you enjoyed it. If you haven’t done a particular activity, you should rate how much you would like it if you did get to do it. A copy of the scale for you to fill out is provided in the appendix. Listing Activities of Interest

You can use COPPES to inspire your own personal lists of activities to add to your life. As you complete the questionnaire, start a list of pleasant events that catch your interest in the space provided in this chapter. For now, don’t be concerned about whether these activities are realistic or complicated. At this point, if it interests you, it belongs on the list. For example, when Susan completed this questionnaire, she was able to find a large number of activities that she once enjoyed and even some new ones that she would be interested in pursuing. In addition, some of the items from the questionnaire inspired Susan to think about past pleasant activities that she has enjoyed. A sample of her list is shown on the next page.

44

Taking a drive in the country ∗ Visiting with friends Doing a job well Helping someone ∗ Listening to music ∗ Buying flowers ∗ Reading for fun Solving a crossword puzzle ∗ Baking Having spare time

Having a picnic Going out to lunch Being with someone I love Taking a trip ∗ Gardening ∗ Watching a sunset ∗ Shopping ∗ Visiting a museum Having peace and quiet Reading the paper ∗

Susan was able to create a list of 20 pleasant events. After this task, she was asked to consider which of these activities she would like to try to introduce into her day starting right away. Susan selected the 10 activities that are asterisked on the list. Activities That Interest Me

Keeping Track of Personal Pleasant Events Completing the COPPES was an exercise to help you become aware of the types of activities that you would like to build into your daily life. Next, you must make a commitment to actually fitting some of these activities into your schedule. For this purpose, you can use the Pleasant Events Tracking Form. Review the example form for Susan (see Figure 3.4).

45

Pleasant Events

Days 1

2

3

4

5

1. Gardening

•

•

2. Watching a sunset

•

•

6

• •

•

3. Going out to lunch

•

•

4. Visiting with friends

7

• •

5. Going to a museum 6. Baking 7. Reading for fun

•

•

•

•

•

8. Buying flowers

•

9. Shopping

•

10. Listening to music Total

3

Figure 3.4 Susan’s Pleasant Events Tracking Form.

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•

2

4

0

•

•

4

5

3

Pleasant Events Tracking Form Pleasant Events

Days 1

2

3

4

5

6

7

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Total

Monitoring Mood: End-of-Day Rating Now that you’ve started to increase your pleasant events, you may want to do one rating of your mood at the end of the day instead of at different points throughout the day. However, do whichever works best for you. See Susan’s Endof-Day Mood Rating Form (Figure 3.5), which corresponds to the same days listed on her pleasant events chart. A blank copy of the End-of-Day Mood Rating Form is provided for your use.

47

Date: From 2/18 to 2/24 Please rate your mood at the end of each day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

4

5

very depressed Date 2/18

6

7

8

“so-so”

Mood score 5

9

10 very happy

Why I think I felt that way: 1. I did a few pleasant events 2. My friends canceled lunch

2/19

6

1. I spent the afternoon with an old friend 2. I started a new novel

2/20

6

1. I took myself out to lunch and went shopping 2. I listened to my Ella Fitzgerald CD

2/21

2

1. My great-grandson was a “holy-terror” and would not take a nap 2. I had no time for myself

2/22

6

1. I spent the day alone 2. I spent time reading after I cleaned the house

2/23

8

1. My granddaughter had no class and took the baby out for the day 2. I played with my friends all day

2/24

5

1. My granddaughter invited friends with small children over to play 2. I had some time to myself in the evening

Figure 3.5 Susan’s End-of-Day Mood Rating Form.

48

End-of-Day Mood Rating Form Date: From

to

Please rate your mood at the end of each day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

very depressed

Date

4

5

6

7

8

“so-so”

Mood score

9

10 very happy

Why I think I felt that way:

49

Graphing the Relationship Between Pleasant Events and Mood Graphing pleasant events can be a good exercise to see the results on mood. Figure 3.6 shows the relationship between Susan’s pleasant events and mood rating. Look carefully at this graph. For the most part, as Susan’s pleasant events increased, her mood increased. This suggests that in general, she could expect to feel better on days when she had more time for herself. Take a closer look at “day 2” on this graph. Notice that there were only 2 pleasant events performed, but the mood rating is a 6. Sometimes, certain pleasant activities boost mood more than others. For Susan, visiting with her friends after being isolated for such a long time was so important that it was largely responsible for increasing her mood from the previous day. Use the worksheet provided to develop your own personal graph. Can you see the relationship between mood and daily activities? 10

Pleasant Events Mood

8 6 4 2 0 Day1

Day2

Day3

Day4

Day5

Day6

Day7

Figure 3.6 Graph of Relationship between Susan’s Pleasant Events and Mood Rating.

10 8 6 4 2 0 Day1

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Day2

Day3

Day4

Day5

Day6

Day7

Four Pleasant Events a Day Keeps the Blues Away if they are Consciously Chosen and Deliberately Done Figure 3.7 Doing things every day will improve mood.

Our research has shown that four pleasant events a day keeps the blues away. These events or activities are consciously chosen and deliberately done; it is not enough for pleasant events to “happen” to you. They must be planned into your day and completed in order to be effective. The logo (Figure 3.7) can help you remember this information.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

51

Home Practice Assignments for this section might include the following:

✎

Monitor mood on a daily basis using either the Daily Mood Rating Form or End-of-Day Rating Form. Additional blank forms are provided in the appendix.

✎

Complete the COPPES.

✎

List activities of interest.

✎

Track pleasant events using the Pleasant Events Tracking Form. Additional blank forms are provided in the appendix.

✎

Graph the relationship between pleasant events and mood.

✎

Answer summary questions for this section.

P R O B L E M S O LV I N G : B R E A K I N G T H E B A R R I E R S

Goals ■

To learn the steps to problem solving

■

To overcome obstacles to increasing pleasant events

Introduction to Problem Solving Problem solving is a skill that can be helpful in learning to use many of the different ideas and skills presented in this manual. You may need to problem solve barriers to increasing certain specific activities or pleasant events in your life. In the previous sections, you learned how your unhelpful thought patterns lead you to feel depressed, angry, or overwhelmed. When you are feeling this way, it is often hard to see potential solutions that will help change the situation into a more positive or hopeful one. This section presents a five-step technique that

52

will facilitate the development of more alternatives and options for managing a situation or solving a problem. It is referred to as DEEDS: Define the problem Explore possible solutions Evaluate solutions Decide on one alternative Select another alternative The following example will be used to illustrate the problem solving steps. Sally is a recent widow who has started to attend a grief support group at the suggestion of her friend Luisa. Luisa provides Sally’s transportation each week since Sally no longer likes to drive herself. This week, Luisa told Sally that she could not take her. Sally ended the conversation feeling alone and sad.

Step 1: Define the Problem

The first task is to define the problem as specifically as possible. This step can often be the most challenging, as sometimes several different problems can be embedded into one. You will need to sort out each problem and pick the one that appears to cause the greatest distress. Sally lists her problems: 1. getting to the support group 2. finding an alternative activity 3. managing her feelings of loneliness and sadness Sally decides that she is quite committed to getting to the support group and feels more distressed about having no transportation than the other two problems listed.

Step 2: Explore Possible Solutions

This is a brainstorming step in which potential solutions to a problem are proposed. The key to brainstorming is NOT to evaluate each potential solution, but just to allow suggestions to be presented.

53

Sally came up with the following options to address the problem of getting to her support group: 1. I can walk to the Senior Center. 2. I can ask a neighbor for a ride. 3. I can drive myself. 4. I can call a taxi. 5. I can ask my daughter for a ride. 6. I can invite the support group to my house. 7. I can call a support group member and ask him/her for a ride. 8. I can not go.

Step 3: Evaluate Solutions

This step allows possible solutions to be evaluated based on any criteria desired. For example, you may evaluate whether you have time to devote to one solution or another, or you may evaluate each solution based on money, energy, or how much help you would need from other people. As each item is examined, some of the alternatives proposed may seem unrealistic and therefore will get a lower rating than others. In rating the options, you may assign numbers to them or may choose to just use plus (+) or minus (−) signs. Sally’s rating is as follows: Possible Solutions

54

Rank

1. I can walk to the Senior Center.

4

2. I can ask a neighbor for a ride.

1

3. I can drive myself.

7

4. I can call taxi.

3

5. I can ask my daughter for a ride.

6

6. I can invite the support group to my house.

5

7. I can call a support group member and ask him/her for a ride.

2

8. I can not go.

8

You can see from Sally’s rating that she believes that asking a neighbor for a ride is her first choice, followed by asking a fellow support group member, and then calling a taxi, and so on. Step 4: Decide on One Alternative

Select the first alternative solution and see what develops. After Sally decided that asking her neighbor for a ride was the best option, she called her and found out that her car was not working. Step 5: Select Another Alternative

Go back to the list of options and select another alternative. When Sally could not find her list of support group members’ phone numbers, she remembered that the Senior Center is just six blocks away, so she decided to walk. Now use the Problem-Solving Worksheet to do an example on your own. It includes step-by-step instructions to help you problem solve.

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Problem-Solving Worksheet Step 1: Define the problem. What was the problem? What did you need to solve?

Step 2: Explore solutions. Remember, do not worry about the quality of each solution. Just write down whatever comes to mind.

Step 3: Evaluate and rank choices. Start by picking out the most realistic, then the second, then the third, and so on. What criteria are you going to use to rank your choices?

Possible Solutions

Rank

Step 4: Decide on an alternative. What are you willing to try?

What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

continued

56

Step 5: Select another alternative, if needed. What alternative are you willing to try now?

What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

57

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

58

✎

Complete the Problem-Solving Worksheet.

✎

If introduced in session, complete an Unhelpful Thought Diary (UTD) about how you solved the problem. The UTD is formally introduced in Chapter 4 on Thinking Tools.

✎

Answer summary questions for this section.

Chapter 4

Module 4: Thinking Tools

IDENTIFYING UNHELPFUL THOUGHTS

Goals ■

To identify unhelpful thoughts

■

To rate the strength of unhelpful thoughts

■

To rate the strength of emotions

■

To recognize unhelpful thought patterns

Introduction of Unhelpful Thought Diary An important part of CBT is knowing that our unhelpful thoughts create negative emotions. Yet, this process happens so quickly that we are often unaware that thoughts occur between a stressful event and uncomfortable emotions. In fact, many cognitive therapists have referred to these as “automatic thoughts”; they appear so fast that unless we make a conscious effort to notice them, we’ll never know what they are. Thus, it becomes important to slow down your thought processes in order to identify the thoughts associated with the stressful events that lead to intense negative feelings. An Unhelpful Thought Diary (UTD) can help to slow down your thoughts and to keep track of what you are thinking once you have noticed a strong emotional reaction. There are several types of UTDs, but let’s start with a simple one first. This UTD has three parts or columns for the following information: 1) a brief description of the stressful event you experienced 2) a list of the automatic thoughts you had in connection with this event 3) a list of the emotions you experienced as a result

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Recording these three pieces of information on the UTD form will help you practice noticing and monitoring the thoughts that immediately follow a stressful event. You cannot make any changes in your mood or thoughts unless you know what to change! The following case example shows how to use an UTD. Case Example: Jane’s UTD ■ Jane is a 68-year-old woman who has had several depressive episodes in the past.

Her most recent episode began after she had a bout of pneumonia that left her weak and isolated for 5 weeks. During her initial physical illness, Jane had frequent contact with her friends via telephone, but as her activity declined, her depressive symptoms exacerbated, and she became more and more withdrawn and less interested in speaking to anyone. It has now been 2 months since her recovery from pneumonia, but Jane’s depression continued. She began treatment 6 weeks ago at the encouragement of her family. Her primary goal was to decrease her isolation and regain her social connections. Recently in treatment, Jane was encouraged to make short calls to friends, which initially was quite difficult for her, but now she has been invited to join two long-time friends for lunch. While socializing with her friends is consistent with her stated goal, it also served to increase Jane’s anxiety as she would rather not have her friends see her struggling with her depression. As Jane continues to experience low energy and lack of interest in most things, she is hesitant to join her friends believing that she “should” wait until she feels better. ■ Figure 4.1 shows Jane’s completed 3-column UTD. Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

1. How can I go? I have become a “sick person.” I am no longer the same as I was. 2. I am no longer interesting. I won’t have anything to talk about. I should wait until I feel better. 3. Why bother going? It won’t be any fun - for them or me.

anxious depressed hopeless

Invited to join Esther and Lillian for lunch on Tuesday

Figure 4.1 Example from Jane’s Unhelpful Thought Diary.

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Rating the Strength of Unhelpful Thoughts In order to understand the impact that unhelpful thoughts have on your mood, it is helpful to assign some value or rating to these thoughts to indicate how strongly you believe in each one. The rating exercise can help you identify which thoughts are the hardest for you and which may need immediate attention. These ratings are also useful later in comparing how the strength of these thoughts has changed after beginning cognitive therapy.

Rating Scale

For this rating, you’ll be asked to use the scale 0% (not strong at all) to 100% (strongest possible). Please note that you can indicate any number you want that falls within the range of 0%–100% (see Jane’s example in Figure 4.2).

0% 10 not strong at all

20

30

40

50 60 Moderately strong

70

80

90

100% strongest possible

Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

1. How can I go? I have become a “sick person.” I am no longer the same as I was 90% 2. I am no longer interesting. I won’t have anything to talk about. I should wait until I feel better. 80% 3. Why bother going, It won’t be any fun - for them or me. 95%

anxious depressed hopeless

Invited to join Esther and Lillian for lunch on Tuesday

Figure 4.2 Example with Thought Ratings from Jane’s Unhelpful Thought Diary.

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Case Example

In Figure 4.2, ratings have now been added for each of Jane’s automatic thoughts. As Jane rates the strength of each of her thoughts, we learn which thoughts are more troublesome to her and may require immediate attention. For example, her belief that she will never get better is rated at a strength of 95%. This rating is an important one to remember because as Jane participates in therapy, one way for her to measure improvement is by periodically re-rating the strength of this belief.

The Strength of Emotions Likewise, it is important to measure the strength of your emotional consequences as you record the situation. The range of the rating scale is the same, 0% means that the emotion is not at all present and 100% means that the emotion is completely present, or as strong as it could possibly be. We can gain similar information regarding which emotions are the strongest, and we can also compare initial ratings to those of the later emotions that you will experience as your thoughts change. In Figure 4.3, Jane gives high ratings to her emotions of anxiety, depression, and hopelessness, with hopelessness and depression ranked as stronger than anxiety. Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

1. How can I go? I have become a “sick person.” I am no longer the same as I was. 90% 2. I am no longer interesting. I won’t have anything to talk about. I should wait until I feel better. 80% 3. Why bother going, It won’t be any fun - for them or me. 95%

anxious 85% depressed 90% hopeless 90%

Invited to join Esther and Lillian for lunch on Tuesday.

Figure 4.3 Example with Emotion Ratings from Jane’s Unhelpful Thought Diary.

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Identifying Unhelpful Thought Patterns As stated earlier, this program focuses on helping you make the connection between your unhelpful thoughts and the emotional and behavioral consequences of these thoughts. As you begin to identify and examine your unhelpful thoughts, you will begin to notice specific patterns in both the types of thoughts that you have and the situations that are difficult for you. We may even go as far as to say that you have a particular manner or style to the way you interpret stressful situations. Consider, for example, what happens when you are listening to a radio station with a headset. The station, or signal, will come in clearly if the headset is correctly connected to the radio receiver and positioned securely on your head. If the headset is not used properly, then you may mishear or misinterpret the signal or information from the radio. The same is true for the way we interpret situations around us and conversations that we have with others. Our interpretation of these events also happens through a kind of personal headset, or a set of thoughts that we use to make sense of our world. When we are depressed, our headset is tuned in to a negative signal that interprets situations (whether stressful or not) in a negative way. A negative headset can be exhibited through different patterns, or styles of thinking, and a person can be employing several different styles at any one time. Following is a list of negative thought patterns that are common among depressed, older adults. You may want to mark these pages for easy reference as you begin to identify the kinds of thought patterns you use. People often find that some of these thought patterns fit them better than others.

Signals From Your Negative Headset Name Calling

When you attach a negative label to yourself or to others, you are engaging in a style of name calling. Often, these statements have a blaming tone. For example, “I’m a loser,” “I was a bad parent,” or “My spouse is a real disappointment.”

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Obligations a.k.a. “Tyranny of the Shoulds”

This type of thinking refers to the rules you have about the way things should be. These rules are often unrealistic expectations that result in strong feelings of guilt or anxiety when not met. For example, “I have to have a clean house before I can have anyone over to visit.”

Tune in the Negative/Tune out the Positive

You recognize only the negative aspects of the situation and ignore or discount the positive accomplishments. Consider this example: If after making five pies for a church social, one pie is a bit overdone and you think, “I can’t make good pies at all anymore.”

This or That (No In-Betweens)

This signal refers to viewing a situation in terms of extreme outcomes. You see your choice of outcomes as “either-or” with no room for the options that fall in the middle. For example, “I’m a total failure,” or “I never get things right, I am always messing up.”

Overinterpreting

You have a tendency to blow events out of proportion or “make a mountain out of a molehill” when you don’t have all the information. You also take the little information you have as truth without confirming its validity. This type of thinking occurs in three basic ways:

Generalization

You overinterpret situations, drawing conclusions with only a few facts. For example, you forget to write an important item on your grocery list and you begin to imagine that you’re probably making mistakes in other things that you do, like you’ve forgotten to pay an important bill or you’ve no doubt messed up your checkbook balance and will be penalized for overdrawing on your account.

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Personalization

You assume that others have negative intentions toward or views of you. For example, if your TV repair person calls to say that he will be a little late, you immediately assume that he is unhappy doing work for you.

Emotional Thinking

You use your feelings as the basis for the facts of the situations. For example, “I feel so bad, the situation must be hopeless.”

What’s the Use?

This pattern of thinking is common for people who believe that their thoughts or behaviors are not effective in changing their situation. The common consequences of this type of thinking are beliefs that your difficulties are hopeless. This pattern can also intensify depressed mood and inactivity. For example, “Whenever I plan an outing for myself it never goes as planned, why try at all?”

Doomsday Thinking

You engage in doomsday thinking when you convince yourself that the future looks hopeless and bad outcomes are inevitable. People who use this way of thinking are often called “eternal pessimists.”

If Only

The theme of this style of thinking is regret. Here, you spend time thinking of past events, wishing that you had acted or said something differently. People who engage in this style are often “stuck in the past” and find it difficult to shift to present issues or situations.

Case Example

See Figure 4.4 for examples of Jane’s unhelpful thought patterns. With this additional information, Jane is able to identify which signals from her negative headset she is using. It appears from this exercise that Jane is prone to doomsday thinking and name calling.

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Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

1. How can I go? I have become a “sick person.” I am no longer the same as I was. 90%

anxious 85% depressed 90% hopeless 90%

Invited to join Esther and Lillian for lunch on Tuesday

NAME CALLING, PERSONALIZATION 2. I am no longer interesting. I won’t have anything to talk about. I should wait until I feel better. 80% DOOMSDAY THINKING, NAME CALLING, TYRANNY OF THE SHOULDS 3. Why bother going, It won’t be any fun - for them or me. 95% WHAT’S THE USE, DOOMSDAY THINKING

Figure 4.4 Example with Thought Patterns from Jane’s Unhelpful Thought Diary.

Practicing Completing a UTD Now practice completing a UTD with a stressful event that you experienced this week. Put a check in the box after you have completed each step:
1. Identify the distressing event.
2. Identify the thoughts.
3. Rate (from 0% to 100%) how strongly you believe in these thoughts.
4. Identify emotions.
5. Rate (from 0% to 100%) how strongly you are experiencing these emotions.
6. Re-read the Signals From Your Negative Headset section and indicate which ones you experienced.

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3-Column Unhelpful Thought Diary Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

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Was it easy or difficult for you to come up with the automatic thoughts associated with the stressful event and your negative emotions? If it was difficult, don’t be too alarmed; remember you are being asked to slow down your thought process to find thoughts that have become automatic for you. The only way to make this easier is to practice it! You may photocopy the blank 3-column UTD as needed. Blank copies are also provided in the appendix. At this point, don’t be concerned with changing the thoughts that you identified. The current skills to master are recognizing that stressful events are fueled by our negative thoughts and learning to identify such thoughts as soon as they occur. Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

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✎

Record negative thoughts using the 3-column UTD.

✎

Begin to identify negative thought patterns.

✎

Answer summary questions for this section.

CHALLENGING UNHELPFUL THOUGHTS

Goals ■

To learn the steps to challenging unhelpful thoughts

■

To learn techniques for changing your thoughts

■

To begin using a 6-column UTD

Introduction to Challenging Negative Thoughts As you practice identifying the signals from your negative headsets, you may notice the process of recognizing negative thoughts becomes automatic. Once you become familiar with the types of unhelpful thought patterns you use, it is time to challenge the validity of these thoughts to determine if they can be replaced with more helpful thoughts. There are two main steps to challenging unhelpful thoughts. Step 1: What is your headset? Identify your thoughts. Write down your negative thoughts to see which patterns of your negative head set you are using to see the problem in a more realistic way. Step: 2: Challenge and fine-tune your headset. There are several techniques you can use to challenge negative thought patterns and create a clearer head-set. Some require you to perform actual behaviors in challenging your thoughts, and others ask you to analyze the thoughts from a different perspective.

Fine-Tune Your Signal: Changing Your Thoughts Next is a set of techniques to start you off on the task of creating a clearer head set. Again, mark this section for easy reference, as was done with the Signals From Your Negative Headset section. This section includes examples of how Jane used these techniques to help challenge and replace her unhelpful thoughts with more adaptive ones.

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Action

Many people engage in specific behaviors to obtain additional information to challenge unhelpful assumptions about situations or people. You could try various actions such as asking friends for their thoughts about certain situations or practicing smaller behaviors before trying a larger task. For example, Jane could challenge her thoughts about being a “sick person” by asking others how they view her during this difficult time. Also, Jane could utilize small outings to challenge her concerns that she is no longer an interesting person. She will learn that as she is more comfortable with small outings, she will hopefully gain the confidence to attend more frequent social events. Language

As you have probably noticed from recording your own negative thoughts, much of the negativity in our thoughts stems from the harsh language we use in talking to ourselves. We often create labels for ourselves or others without considering the true definitions of these words or we believe that we must behave, think, or feel according to some “rules” of unknown origin. Changing the actual language from negative to positive or from harsh to compassionate will replace a negative headset with a clearer one. If Jane were to define her label of “sick person,” she will discover that she could not possibly fit that definition. She could also substitute “I will never get better” with beliefs related to the fact that she has already made some progress while she has been in therapy. As If

When you are talking to yourself in a harsh and negative way, consider changing your tone and language similar to that of someone whose opinion you greatly respect. For example, as Jane believes that she should avoid social interaction because she has nothing to talk about, she could ask herself whether her friends will care about that or will just want her to join them because they care about her.

Consider Alternatives, In-Betweens

When people think of only the extreme outcomes of situations, scores of alternatives get ignored. Think of a ruler that is marked 0 inches at one end

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and 12 inches at the other end—there are many inches in between, as well as even smaller and smaller measurements. Could Jane consider other alternatives to avoiding all social interaction? Must she think of herself as either a “sick” person OR a “normal” person? Scale Technique

This technique is very helpful when we are “stuck” on a particular thought or feeling. The scale technique is designed to weigh the advantages and the disadvantages of maintaining the thought (or emotion, or behavior). What are the advantages of Jane remaining socially isolated? What are the disadvantages? Which side would carry the most weight? (See Figure 4.5 for an example.) What could Jane summarize from this exercise? Examine the Evidence

By asking yourself, “what data do I have that supports my negative thoughts?” and “what data do I have that goes against them?”, you can learn that most negative thought patterns do not have a lot of real data to support them. Most often, if you look at situations carefully and objectively, you generally will realize that you may be overgeneralizing. Further, when you do this, you may discover that you have no hard facts either to support or to refute your thoughts. In this case, you may work with your therapist to set up a procedure to collect information that will either support or refute your negative thoughts.

Advantages

Disadvantages

Avoids risks

Depression

Avoids confirmation of her belief that she is not interesting

Increased loneliness/hopeless/frustration

Temporarily relieves anxiety

Health worsens

Increased isolation/loss of friends

Figure 4.5 Weighing the Advantages and Disadvantages.

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Evaluate Consequences

You already know that an overall consequence of maintaining your negative headset is depression. Yet, specific thoughts also have specific consequences. As you examine the specific consequences for a thought or belief, you may find that you have less interest in maintaining it. Jane maintains the belief that she must be all better before engaging in social activities; it is likely she will continue to experience negative emotional consequences of hopelessness and depression. Furthermore, she will also experience a further decrease in her motivation and interest that will make attending any events more difficult. Why keep this belief? Credit Positive

Focusing on your depression is a constant pull for negative interpretations; however, positive events, thoughts, or feelings do still occur. Spend a few moments thinking of the more pleasant outcomes of events, positive thoughts you’ve had, and the positive emotional consequences that resulted. For example, what positive events has Jane experienced from attending to her social needs? In what ways have her symptoms improved? Can she give herself credit for starting to call her friends on the phone and making gains? Thought Stopping/Substitution

This technique is helpful for people who find it hard to extinguish a particular negative thought. When you find yourself repeating the thought over and over, try shouting “STOP” to yourself out loud. Then, you need to replace it with a more helpful thought. As Jane continues to think, “I am a sick person and I no longer contribute to my friendships,” she could say, “STOP! I know I am having a hard time right now, which is not a character flaw. If I try to go out with my friends, maybe I will be able to temporarily stop thinking about my depression.”

The 6-Column UTD The UTD that you have been using up to this point has had 3 columns to catalog the stressful event, the automatic, unhelpful thoughts, and the emotional

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consequences. As you begin to challenge the unhelpful thoughts, you will find that you need to use the expanded version of the UTD. This form contains six columns for the following information: 1. a brief description of the stressful event or situation 2. a list and rating of the automatic thoughts that occurred in conjunction with this event and discussion of patterns that are present 3. a list and rating of the emotions that were experienced as a result 4. a list and rating of the more realistic adaptive thoughts to replace the unhelpful thoughts 5. a list and rating of the former emotions (or new emotions that result) 6. a brief description of behavior that will follow. How will you function differently now that there has been a change in your unhelpful thinking patterns? Case Example: Jane ■ The following is a continuation of Jane’s example as she works through a

6-column UTD: Jane was able to immediately identify that her negative headset included themes of name calling, doomsday thinking, tyranny of the shoulds, and what’s the use. She learned that she has a tendency to believe the worst about a situation. She was asked to consider several questions to challenge these automatic thoughts that resulted in such intense emotions as anxiety, depression, and hopelessness: 1. How does she know how her friends view her? 2. What are the advantages/disadvantages of remaining isolated? 3. Is it true that she will NEVER get better? Is it true that she is not better at all? Jane was also able to identify the negative consequences of the unhelpful belief that she should join her friends once she feels better. By avoiding opportunities to expand her socialization and activate her interest and energy, she is perpetuating her strong emotions of depression, anxiety, and hopelessness. Once Jane realizes that engaging in activities, despite having a lack of motivation, will result in more positive emotions, she will likely be more willing to change her other unhelpful thoughts and continue to participate in more adaptive behaviors (e.g., seeing friends on a more regular basis). ■

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Practicing Completing a 6-Column UTD Complete a 6-column UTD using the following checklist of steps:
1.

Identify the distressing event.


2.

Identify the automatic thoughts.


3.

Rate (from 0% to 100%) the strength of each belief.


4.

Identify the emotions.


5.

Rate (from 0% to 100%) the strength of each emotion.


6.

Re-read the Signals From Your Negative Headset section and indicate which ones were used.


7.

Review the section “Fine-Tuning Your Signal: Changing the Way You Think” and begin to ask if your thoughts are realistic.


8.

Replace the negative thoughts with more adaptive thoughts, and rate the strength (from 0% to 100%) of each of these new thoughts.


9.

Re-rate the emotions experienced earlier and/or list new emotions.


10. Describe what you will do differently in your daily life, now that you’ve changed your negative thinking. It is quite common for people to have difficulty with the first 6-column UTD they complete. It is also true that even if you are able to come up with helpful responses to your negative thoughts, you may not have a great deal of confidence in these new thoughts. It takes time for the newer, more helpful thoughts to “sink in.” Remember, you are challenging thoughts that you have had for a very long time. At this point, it is more important to become aware that beliefs you thought would stay with you forever can be changed. And the way that changes can be made is through practice, practice, practice! Try to get into the habit of completing a UTD each time you experience a stressful event. You may photocopy the form as needed. Blank copies are also provided in the appendix. However, you don’t even need to have the form with you—you could make 6 columns on a blank piece of paper, or you may find that with enough practice with this technique, you won’t need paper at all!

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6-Column Unhelpful Thought Diary A

B

C

D

Antecedents or Situation:

Beliefs or Thoughts:

Consequences or Emotions:

Develop Adaptive Responses:

Describe the situation or an event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Challenge your negative thoughts. What is the evidence for and against each thought? What are more helpful ways of thinking about the experience?

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

Rate how strongly you believe in these thoughts from 0% to 100%.

E Effect: What is the impact or effect of changing your negative thoughts? Write down the emotions you are feeling now. Rate how strong your emotions are from 0% to 100%.

F Function: Now that you have considered more helpful thoughts, what will you do differently in similar situations? How is changing your thinking likely to affect your daily life?

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Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

✎

Continue to identify negative thought patterns.

✎

Begin to challenge negative thoughts using the 6-column UTD.

✎

Answer summary questions for this section.

O V E RT H I N K I N G

NOTE: Some of the material in this section overlaps with topics covered in the Feeling Tools module in the next chapter. Several techniques mentioned here, such as thought stopping, are described in greater detail in that module. You

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should consult with your therapist to determine how you want to integrate the overlapping topics.

Goals ■

To identify overthinking

■

To use thought stopping

■

To use “worry time”

Introduction to Overthinking Cognitive-behavioral therapy clearly emphasizes attending to how you are thinking, but excessive thinking can lead to another problem. Sometimes, people can’t put some thoughts, especially worries, out of their minds as quickly as others. You may find that some thoughts stay with you longer or will not respond to the kinds of skills that you have already mastered in this program. Case Example: Geri’s Overthinking ■ The following example illustrates overthinking:

Geri is a 67-year-old woman whose 70-year-old husband, John, has serious cardiovascular disease. John is a CPA in private practice and has been told by his physician that he should retire because of job-related stress. John is reluctant to retire immediately, because tax time is approaching and he doesn’t want to leave his clients without service. Otherwise, he is following all of the recommendations made by his physician. He has changed his diet, is exercising regularly, and is losing weight as planned. His condition is monitored weekly by a nurse, which includes stress tests, and there is evidence of substantial improvement. John’s progress provides little solace to Geri because he is continuing to work in his stressful job. She lost her first husband 15 years ago because of heart trouble and she doesn’t want this to happen again. She was very depressed and anxious when she started therapy. She is currently doing well in a program of cognitive-behavioral therapy, but she finds that some very negative thoughts continue to occur relentlessly, making it difficult for her to sleep or to enjoy any activities. She continually thinks that something is going to happen to John, just like with her first husband, and she will never be able to cope with the trauma. The slightest perturbation in John’s health immediately triggers a negative thought

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sequence, ending in severe catastrophizing. Geri often wonders, “There’s nothing I can do about getting my husband to stop working. What can I do? If I could just get him to stop working. I must do something about this. Why can’t he learn to eat without using salt? No matter what I do, he still uses salt. I must do something.” ■

How Can I Tell I Am Overthinking?

Overthinking or “worrying” occurs when a thought or a set of thoughts stay around without any clear solution. Worrying involves “stuck” thoughts that may also cause you to feel more anxious or sad instead of feeling better. Sometimes after worrying, you may come up with a solution, but the time you spent may keep you from thinking about other important things. Ask yourself, “Have I ever thought so much about one thing that I forgot other important things?” If so, it may be time to introduce a couple of new tools. First, can you identify any signs that you are overthinking? Does anything typically occur before or after you overthink?

Thought Stopping This technique involves actively halting “the worries” and moving to thoughts about other things. Once you recognize that you are worrying, you should try to say “STOP!” out loud. This may feel very unusual at first but it can be very effective. You can also try saying (to yourself or out loud) “I am thinking about (the worry) right now, instead I want to think about (new thought).” Repeat the new thought several times or work it out with a UTD until you feel more in control. Case Example: Geri’s Thought Stopping ■ For example, if Geri was “worrying” about her husband’s salt intake when she

needed to be focusing on something else, she could say “Stop! I am always worrying about my husband’s eating. Right now, I need and want to be thinking about (X).” In Geri’s case, she wanted to focus on the fun she would have getting her granddaughter’s graduation present. Geri could say, “I’m going to make a mental list of all the things she wanted. Then I’m going to memorize them, so when I go shopping, I’ll know exactly what to look for. Oh it’ll be fun. Let’s see, I’ll go to Macys first and I’ll look for . . . .” ■

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Exercises

Are there any topics or situations that cause you to overthink? Briefly describe the situations and their corresponding beliefs in the space provided.

Situation/Topic

“Worry” Thoughts

Try the following exercises for practice. 1. Pick one situation/topic and start to think about it and yell out “STOP!” after about 10 seconds. Did you startle yourself? If you did, you have started to redirect your attention in order to either concentrate on this matter in a different way or think about something else entirely. 2. Take that “worry” thought and try to write it out by attending to what you would rather be thinking about. Stop! I am worrying about thinking about

, but I’d rather be .

Repeat this statement several times to get a sense of what it feels like.

Worry Time Sometimes, people feel better after they have worried about things a little. The act of thinking can help you feel better, but worrying can also eat up time that you’d rather spend on other things. “Worry time” is a scheduled time during the day

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to focus on worrying. When worries come up during the day, write them down on a “worry list” and avoid thinking about them for the moment. Schedule some time every day to look at your list and really think about these worries on the list. Limit the time to a specific amount, and stick to this time limit by planning something to do at the end of your worry time. For example, plan 30 minutes in the evening to worry right before a favorite television show. Look at the items on the list and think about each one, but stop as soon as your show starts. Many people find this technique helpful, although it may feel a little strange at first. You may want to set a kitchen timer whose sound will mark the end of “worry time” and remind you to shift your attention.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

✎

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Generate situations that cause overthinking, and record them in the table provided in the workbook.

✎

Practice thought stopping.

✎

Schedule “worry time.”

✎

Answer summary questions for this section.

CORE BELIEFS

NOTE: This is an optional part of therapy. The decision whether or not to proceed with this section needs to be made collaboratively with your therapist.

Goals ■

Identify your unhelpful core beliefs

■

Review your “life stages” to see how core beliefs operate at different phases of your life

■

Change or replace unhelpful core beliefs with more adaptive ones that can be more helpful in your present life circumstances

Getting to the Core By this point, you no doubt have completed several UTDs and probably have come up with a variety of ways to challenge your unhelpful thoughts. You probably noticed that some unhelpful thoughts were easier, and some were more difficult to change. Also, some come up only in particular situations, whereas others seem to occur in many different situations. Sometimes, unhelpful thoughts are very different from each other, and other times they are very similar, like slightly different versions of the same idea. Some may be fairly recent, while you may have had some for many years. When unhelpful thoughts are very difficult to change, occur in many different areas in your life, have a common theme, and have been around for a long time, they may reflect “core beliefs” that you may have held for most of your life. Many core beliefs are accurate, positive, and helpful (e.g., it’s good to work hard and save your money for the future), but others

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may be inaccurate, negative, and unhelpful (even harmful) for your well-being (e.g., “I don’t deserve to be happy” or “my life has been a failure”). We know that it can be difficult to change an unhelpful thought if it is based on an unhelpful core belief (UCB). There are special tools designed to address UCBs, and we’ll review some of these in this section. We’ll use Harold as an example to help you see how this works. Harold is a 77-year-old, divorced, retired man who came in due to feeling depressed. As he examined his unhelpful thoughts with his therapist, it became clear that he believed he was helpless to change anything in his life, including his feelings of depression. The issue came up several times in his thought records and in two “downward arrow” exercises. This thought also affected his therapy home practice. Harold very rarely completed or even started his therapy home practice, because he believed he could not do it right. Harold’s therapist suggested that they examine his thoughts of helplessness as a core belief.

Identifying Unhelpful Core Beliefs Do you have UCBs? Certain unhelpful negative thoughts may come up regularly for you when confronted with negative stressful events. If this is the case, UCBs may be slowing you down in developing adaptive thoughts that could help you respond better to negative life events. Here is a list of questions you can ask yourself to learn if this might be a problem for you: 1. Is there an unhelpful thought that has come up consistently in a lot of your Unhelpful Thought Diaries? 2. Is there a particular unhelpful thought that has been very difficult to change? 3. Is there something that keeps coming up which your therapist thinks is an unhelpful thought, but you believe is a “fact”—that is, not subject to dispute or to refutation because you’re convinced it’s true—you “KNOW” it’s true? 4. Do several different unhelpful thoughts continue to repeat that have the same general idea behind them? 5. Have you used the “downward arrow” technique and come up with the same answer several times? 6. Are there unhelpful thoughts that you can remember having for a very long time?

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1. Which unhelpful thoughts you have most often? I believe I am useless and helpless. I can’t do anything 2. Which unhelpful thoughts are the hardest for you to change? That I am incompetent 3. Which unhelpful thoughts are the most emotionally difficult for you? I am a burden to others because I am useless. 4. Which unhelpful thoughts have you had the longest? Being helpless 5. Which unhelpful thoughts seem the strongest? I’m no good because I can’t do anything 6. When you read your responses for the questions so far, do you see similar answers, or a theme? Yes, incompetence and uselessness 7. If you had to state the theme you see in one sentence, or even one word, what would that be? I am powerless and useless 8. When is the earliest you remember this theme in your life? Early childhood. I was a Watson baby. I remember it clearly. 9. How is that theme affecting your life now? I don’t see any way out of my depression, but I hope the therapist can fix it. I don’t believe I’m able to do much to help myself.

Figure 4.6 Harold’s Completed Unhelpful Core Beliefs Identification Form.

If you answered yes to several of the previous questions, you may be dealing with a UCB. Everyone has core beliefs about themselves, the world around them, and other people. Most of these core beliefs are healthy and helpful, but some of them create problems and make you feel worse than you need to feel about a variety of things in your life. Although it takes more time and energy to change core beliefs than unhelpful thoughts, this may be necessary so you can feel better and be less likely to become depressed in the future. First, you need to learn how to identify UCBs. Complete the Core Beliefs Identification Form and then consult with your therapist. See Figure 4.6 for an example of a completed form for Harold.

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Unhelpful Core Beliefs Identification Form 1. Which unhelpful thoughts do you have most often?

2. Which unhelpful thoughts are the hardest for you to change?

3. Which unhelpful thoughts are the most emotionally difficult for you?

4. Which unhelpful thoughts have you had the longest?

5. Which unhelpful thoughts seem the strongest?

6. When you read your responses for the questions so far, do you see similar answers, or a theme?

7. If you had to state the theme you see in one sentence, or even one word, what would that be?

8. When is the earliest you remember this theme in your life?

9. How is that theme affecting your life now?

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Core Belief Life Review If you clearly have unhelpful core beliefs, making the necessary investment in continuing your therapy will be very helpful, so that these UCBs can be modified and their negative impact on your present life reduced. It is both difficult and very important to understand, challenge, and modify your UCBs, as well as develop more adaptive alternative beliefs to use in your life now. We start with a procedure we call core beliefs life review. This will help you to track the development and effects of the UCBs throughout major stages in your life. This is a slow but valuable process that will take several weeks working with your therapist to complete. You start from your earliest memories, even if the belief was not present then, and attempt to identify life stages or points of transition in your life that were quite memorable and often resulted in a significant and persistent emotional/and or behavioral reaction, and you continue this process up to the present. Then, after that is completed, you will be asked to examine UCBs that are associated with each of these stages or transitions, and then evaluate the evidence in support of the UCB in question, as well as data that might challenge it. The third step is to change or replace the UCBs with more adaptive ones. The final step is to “try out” the new core beliefs in your current life situations. Ideally, you’ll find that these new perspectives will have a more positive influence on how you look at current stressful situations, which in turn will make it easier for you to develop more persistent counter thoughts to any unhelpful thoughts that may spring up. Recognizing Life Stages

Life stages, as we think of them, are large periods of time when things seemed to stay roughly the same for you. For example, you might feel that elementary school was a life stage. On the other hand, perhaps there was a time of several years between major life events, such as the time between moving to a new town and the death of a close family member, which might feel like a life stage. These periods will not all be the same amount of time and will probably not all be equal. The number of these will vary for different people, usually anywhere from 5 to 10 stages. At this point, we simply want to identify them, so that we can then carefully examine them and the accompanying transitions from one stage to another.

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Core Beliefs Life Review Form #1: Helping to Identify Unhelpful Core Beliefs and Relate Them to Different Periods in Your Life Life Stage 1 From: Birth to What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 2 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 3 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 4 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

continued

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Life Stage 5 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 6 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 7 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 8 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

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Figure 4.7 shows the completed Core Beliefs Life Review Form #1 for Harold.

Life Stage 1 From: Birth to seventh grade We moved houses—this was a tough period in my life. I told you I was raised very strictly so I never knew how to play and have a good time, it seems to me. I was always “on a schedule”—not like the other kids. We moved a couple of times. I think, so that was hard too. Life Stage 2 From: eighth grade to 20 years old Drafted for the Korean War. I did OK in school once we got settled and didn’t move anymore. Actually, I did pretty well, since I’d been raised on such a strict discipline model. I studied hard and got pretty good grades. I didn’t “rebel” and use drugs and that sort of thing. I’m sorry that I didn’t complete college—I wanted to, but got drafted instead. I didn’t know how to “beat the draft” like some rich kids did. I was always good with English and other languages in high school, so I was assigned to office jobs at first in the war. But then as things heated up, I was assigned to combat duty. I survived but the CO always kept saying that I was a “bad soldier” and didn’t look out enough for the other guys in my unit. I hated the military and couldn’t wait to get out. Life Stage 3 From: 20 to 26 Before I got married, it was really hard being in the Army. I was scared a lot and didn’t feel I had many skills. I am lucky to have survived. Once I got married, it wasn’t too bad. We made a pretty good adjustment I guess, but it was difficult initially since Kitty was pregnant when we got married. I wish we had gotten married sooner, when pregnancy wasn’t an issue. In those days, if you were pregnant and not married, it was a scandal, so we got married. Life Stage 4 From: about 30 to 45 Relatively happily married, but didn’t do as well in my work as everyone seemed to expect. Lack of college degree hurt me as far as my work history goes. My wife complained a lot about money. We didn’t have enough to send the kids to private school, which she wanted to do, and I often felt like a “loser”.

Figure 4.7 Harold’s Completed Core Beliefs Life Review Form #1.

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Life Stage 5 From: about 45 to 60 Changed jobs, wanted to earn more money, wanted to be more of a success, not sure I was—tried a new field: computer science. Definitely not for me! I should have stayed in finance, where I was doing OK but Kitty wanted us to save more for retirement and an opportunity came up that looked good so I took it. Life Stage 6 From: about 60 to 65 Felt myself going “downhill” at work and knew I had to retire. I wanted to wait as long as possible to do so, so my Social Security would be higher. I thought it would be a good thing and by this time, I really wanted to spend more time with my wife. Life Stage 7 From: about 65 or so (when I retired) to now I’m miserable and not adjusting well. Kitty divorced me at age 70. She wanted to do things: travel, etc. and we didn’t have the money, plus I was too depressed. She decided she’d have a better life without me. That was the straw that broke the camel’s back. I’ve been haunted by these thoughts and feelings from the past, since then. I look back and regret a lot of what I did and didn’t do.

Figure 4.7 continued.

Examining the Core Beliefs Associated With the Stages

Examining the UCBs in each stage of your life is the key component of the life review. This will help you see how the belief developed, how it has affected you, and what you can do to change the belief or replace it with an alternative, which in turn will show you how it has been affecting you for many years. In each stage, you can ask yourself the following questions, which you and your therapist will carefully review and talk about during your sessions: 1) What was this time of life like for me in general? It is helpful to refresh yourself on what you think and how you feel about yourself and your experiences from that time in your life. Talk with your therapist about these thoughts and feelings. 2) How strongly did I believe this core belief at the beginning and end of this stage? You are trying to uncover how much this period in your life impacted your UCB, so you want to start by thinking about how strong the core belief was at the beginning of this life stage and then again at the end of this stage.

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3) What happened during this stage that may have made the UCB stronger? Understanding the events of this time and your interpretation of these events is the primary focus of this exercise. Think about experiences and your understanding of these experiences that contributed to your belief system. 4) What happened during this stage that may have made the UCB weaker? Sometimes, our core beliefs are so strong that we minimize or completely forget things that challenge UCBs. This can be one of the more difficult things to do in this process, but think carefully about whether you had experiences during this time that were contrary to your core belief. 5) What feelings and behaviors were associated with this belief back then? Think about your experience of living during that time, and how it was impacted by your UCB. Were there things you did because of this belief? Where there things you didn’t do, but wish you did, because of this belief? Were there any opportunities you missed because of the impact of your belief? 6) What would have been different if I did not believe this UCB? This relates both to what you would have done differently and to how others around you might have acted differently. 7) Were there some reasons why it made sense to think this way back then? It is important to recognize that sometimes we end up in situations where a belief that is “unhelpful” right now was actually helpful at the time. For example, a core belief that “the world is a very dangerous place” could be a very helpful belief for someone serving in the Army during the Vietnam War, even though that belief could interfere with their happiness if they held to it today. 8) If I could talk to my “younger self,” what would I say to challenge this UCB? How would my younger self respond? Even though you are struggling with this core belief now, people can usually think of things they would want to say to their “younger self ” that would help change their understanding for the better. Think about what you would say, and think about how that advice would help you in the present. 9) What would I think or do differently if I got a chance to “do it over”? With the experiences and wisdom gained over the years, what would you do differently? The point of this is not to “cry over spilt milk,” but rather to examine how you might think differently about the past and see if any of that can translate to helping you in the present.

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10) Are there ways that I am being affected now by what happened then? How can I reduce that? Understanding the “carryover” of holding a UCB from the past is very helpful in challenging it in the present. Think about whether the conditions are the same as they were back then, and whether it helps to have this UCB even if they are. For example, let’s look at how going through these questions could be applied to understanding one particularly difficult stage in Harold’s life. We recommend that you engage in this process for each life stage or era. With repetition, this process becomes easier to do, and you will learn a great deal from going through all the important stages of your life. The Core Beliefs Life Review Form #2 on page 95 can help you with this process. Figure 4.8 shows how Harold responded to the previous questions for this particular stage in his life: The time between being drafted for the Korean War and getting married was a critical time for Harold. His belief that he was powerless and useless grew much stronger.

1) What was this time of life like for me in general? Bad. I thought I would die, or something else bad would happen, at any moment. 2) How strongly did I believe this core belief at the beginning of this stage? 100%, because I was drafted. 3) What happened during this stage that may have made the UCB stronger? When I was drafted, I thought I was doomed to die in the war. My sergeant always told me that I was the worst and laziest soldier he had and that I would never make it, and I believed him. Also, I got married because my wife Kitty got pregnant and in those days, that’s what you did. 4) What happened during this stage that may have made the UCB weaker? I got a job at a furniture store and made a lot of sales. My boss always said I “made the customer comfortable.” 5) What feelings and behaviors were associated with this belief back then? I didn’t go to college because I thought I was too dumb and lazy. I also felt very guilty for making it out of Korea when some of my friends died there, who were much better soldiers.

Figure 4.8 Harold’s Completed Life Stage Questions.

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6) What would have been different if I did not believe this UCB? I might have gone to college. I also might have proposed to my wife before she was pregnant. I think if I’d had more confidence in myself and not had such negative beliefs about myself, I would have done better in life, overall. 7) Were there some reasons why it made sense to think this way back then? I don’t know. I don’t think it was entirely true that I was a bad soldier—but there were times that I didn’t “watch my buddies’ backs” enough, that’s true. 8) If I could talk to my “younger self,” what would I say to challenge this UCB? How would my younger self respond? I would say “you are smarter than you think you are, and you are doing things to keep yourself alive, so you have some power.” I would also say “go to college!” My younger self might have listened. 9) What would I think or do differently if I got to “do it over”? I would go to college, and I would propose to Kitty earlier. I would still have doubts, but I would at least go for it, like a lot of guys did. 10) Are there ways that I am being affected now by what happened then? How can I reduce that? I still feel guilty about making it home from the war and I’m very depressed by the fact that Kitty left me. I could try to do more things to show that I am useful—to myself at least. Maybe I could volunteer at the VA–I live near a big one . . . I have a lot of time on my hands since Kitty divorced me and I’m not really doing anything productive. Do you think that would help my depression?

Figure 4.8 continued.

It is also very helpful to examine how your UCBs are impacting your life at the present time. As you get to the end-of-life review, you will use the same questions to examine your thoughts, feelings, and behaviors in the present. It can be helpful to add three more questions:

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■

Is this unhelpful thought related to a deeper belief I have, and if so, what is it?

■

What in my past has led me to hold and keep this belief?

■

What have I learned about this belief in my life review?

Core Beliefs Life Review Form #2 Life Stage

Core Belief

Evidence For

Evidence Against

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As a result of going through this process thoroughly, over several weeks’ time (working on it both in session and for home practice), Harold was able to make considerable improvement in his views and beliefs about himself—and you will too! Harold began to believe he was both powerful and useful. Here are two examples in Harold’s life of how his core belief was affecting him, and how that changed. First, he did not do his home practice assignments at the beginning of therapy. Harold explained that this was because he believed he was powerless and could not do anything to change his life, but that he came to therapy because he hoped the therapist could change his life. As he began to believe he was somewhat more powerful, he began to do home practice exercises, which he found helpful. Second, before therapy started, he bought an exercise bike, opened the box, but left the parts on his living room floor for 3 months. He never put it together because he didn’t think he could do it. After challenging his core beliefs, he put it together and began riding it on a regular basis. Harold also looked into volunteering a few hours a week at the nearby VA medical center and found that while he enjoyed reading to some of the very lonely veterans, it was depressing for him. He decided instead to volunteer as a “meals on wheels” driver, which gave him some structure to his day, plus social contacts, and a sense that people depended on him. This was gratifying to him and clearly reinforced his new, more adaptive, beliefs.

Other Techniques for Changing or Replacing UCBs As mentioned earlier, changing core beliefs can take a great deal of time and effort. However, many older adults have found that examining core beliefs very carefully has helped them gather stronger evidence against them and to believe that evidence (as illustrated in the case examples in this section). They have been able to change their beliefs enough to think more positively and feel much better about themselves in the present. This will have a big impact on your depression. Examining the evidence and the use of other specific techniques that can be helpful in challenging UCBs are illustrated in the case example of George. This case example also shows how more adaptive beliefs are developed and how they can be implemented in one’s everyday life. George, a 74-year-old concert violinist, divorced for three decades, had suffered from depression for most of his adult life. He had been in therapy numerous times, particularly around the time of his divorce. A major underlying theme for him was worthlessness, despite his successful career. It was fact to him that people

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associated with him only because of his talent as a violinist. If they knew him, they would see how empty and useless he was. From his perspective, this was clearly why his wife left him. She saw the real George, and he wasn’t worth the time and energy it took to be with him. His primary compensatory strategy was avoidance of any meaningful contact with others, and as a result, he lived a very lonely perfunctory life, having only his musical skill as a close companion and attribute. Now, with his skill waning in these later years, he had little to look forward to and little reason to continue his life. The therapist posed a challenge to George: T: OK George, let’s assume for the moment your belief that you are worthless and no one sees any value in you as a person but only as an outstanding violinist is really true. Let’s form a testable hypothesis and do an experiment. Would you be willing to do that? G: I don’t know. I guess I would. T: OK, based on your core belief, let’s predict how people might evaluate you as a person, if asked to do so. What would you predict they would say if your belief is true? G: Well, I think doctor it depends on the people. Some will say anything that pleases me just because they like my music. T: OK, can you think of several people that you think would not do that? G: I know of only one person in the world who would not do that! T: Are you willing to test your theory about yourself by predicting how that person would evaluate you? G: I don’t know. Knowing me, I’ll have a thousand ways to discount what she says, no matter what it is. T: That’s right, you probably will, but we can deal with that when it comes up. Are you willing to give it a test? G: OK, I’ll do it. The therapist and George then constructed a letter asking for an objective evaluation of George, including his personal traits, professional capabilities, and past accomplishments. The person responded in a detailed letter rating George in all three categories. While her comments about his professional accomplishments and skills were laudatory, she was most impressed with the quality of his personal

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traits, and she provided numerous points of evidence justifying each positive rating of his interpersonal and intrapersonal characteristics. After studying the letter for several days, George met with the therapist: T: You’ve had a chance to read the letter? G: Yes. This letter—part of me doesn’t want to believe it, but I just can’t ignore it. T: Let’s read the letter together here, now. (George read the letter slowly to the therapist.) Well George, what do you make of the letter? Does the information in the letter support or refute your hypothesis? G: You know, it’s puzzling to me. She said a lot of things that I never would have expected. T: Are you concluding that this information does not support your hypothesis? G: Well doctor, it does not. I cannot discount this information. I have too much respect for the person who wrote it. T: George, what does that say about your belief, your theory that we were testing? G: You know I have to find a way to integrate this. I have to find a way to revise my thinking. I’ve had this idea almost my whole life!

Flash Cards

Working together, the therapist and George came up with the idea of using flash cards that pointed out the lack of evidence for his belief. The therapist made several copies on 3 × 5 cards. George agreed to place most of them around his apartment in places were he would notice them and to carry one with him. His assignment was that anytime he noticed the occurrence of negative thoughts reflecting his core belief, he would read the card to help him come up with a reasonable counterargument. It is not necessary to use actual cards: Post-it® notes work just as well. So does recording statements in a personal notebook (or for those of you who use computers regularly, having these statements in a file that only you can access). The idea is that the positive self-statements that are on the cards or notes are readily accessible, so that you can refer to them frequently during the day as UCBs come up. For example, with George, some of his statements were: “I have value as a

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person, above and beyond my technical skills”; and “It’s taken me a long time and a lot of hard work and sacrifice to get where I am but I have to face facts: I can’t do it anymore. Maybe—just maybe—there’s more to life than being a concert violinist. I will have to find out in the months and years ahead. But at least now, I’m going to try.” You will need to think of your own notes that are appropriate for your life and your belief system. It’s a good idea to develop these with assistance from your therapist since at first you may have difficulty coming up with any. But as you proceed, more will come to mind. You can feel free to add to the cards or notes anytime that you want to. And the more visible they are in your home, car, etc., the more likely you are to refer to them, and the more likely they are to be helpful to you.

Role Plays to Develop More Adaptive CBs

After a few weeks, George had begun to accept the idea that he was not totally worthless, and perhaps some people might actually find him enjoyable to be with. Role playing was then used, in session at first, to help him “test out” the new beliefs about himself in a safe environment. It allowed George to see if he felt any differently now about himself: Was he less depressed when acting in ways consistent with the new core beliefs? Usually that is the case: although you may be reluctant at first to engage in role playing, we encourage you to do so, as it will help you to feel better about yourself and what you can do outside of the session to improve your quality of life. Of course, the particular content of your role plays will have to be specific to your situation and will be determined by discussion with your therapist. The example of George illustrates the effective use of role playing to reinforce cognitive change: George had developed some new, more adaptive beliefs about himself and his self-worth but was not at all sure how other people would respond to him, now that he was no longer on the concert circuit. He expressed an interest in checking this out in real life but needed support and practice. An annual social event for musicians was coming up and he decided to attend and conduct an “experiment.” He wanted to take some risks in his interactions with others and to disclose more of his internal thoughts and feelings and see the results. The therapist agreed this would be a good opportunity to “collect data” to test his new

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idea (that he was a worthwhile human being whom people might want to spend time with). For a couple of sessions, George and the therapist constructed possible interpersonal situations and did extensive role plays, with both pleasant and unpleasant outcomes, while also noting what kind of negative thoughts George had and how he could counteract these. He planned to do some self-disclosure of inner strengths and limitations, but in the context of “being a scientist collecting data.” George was able to distance himself from the interaction so that he could be objective in observing the outcomes. He did attend the event and was very surprised at the results. He singled out three people to apply his test. One person excused himself immediately and left the scene rather uncomfortably. George’s immediate rational reconstruction to counteract the automatic thought that “This person sees the real me—nothing!” was, “Bob gets uncomfortable when people try to get too close. Maybe, he just avoids this like I do—I mean did.” The other two responded favorably, and both expressed an interest in getting together with George soon for another evening. George wrote down some of the comments and his reactions and reviewed these with the therapist to see how they supported his new belief about himself. This is an example of how role playing in session gave this client confidence to test out new core beliefs. Although it does not always go smoothly, no matter what actually transpires, you will learn from it and with repeated practice, you will be able to “fine-tune” your belief systems so they are more functional. George’s termination date was approaching, so the therapist spent the remaining sessions reviewing his progress and helping him to maintain the gains he made with a “survival guide.” Your therapist will help you do that too. More details about the “survival guide” appear later in this workbook.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

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3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

✎

Finish the Core Beliefs Identification Form and discuss with your therapist.

✎

Complete Core Beliefs Life Review Forms 1 and 2 and discuss with your therapist.

✎

Use selected techniques to challenge UCBs.

✎

Develop more adaptive core beliefs to replace UCBs.

✎

Try out adaptive core beliefs in your everyday life, after some opportunity to role-play (practice) using them in sessions with your therapist.

✎

Fine-tune adaptive core beliefs as needed.

✎

Answer summary questions for this section.

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Chapter 5

Module 5: Feeling Tools

R E L A X AT I O N T R A I N I N G

Goals ■

To become aware of anxiety and tension

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To learn relaxation exercises

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To practice relaxation

Importance of Relaxation Strong feelings of anxiety often accompany depression. Many people report that increased anxiety worsens their negative thinking, creates significant physical tension, and intensifies any physical pain they are experiencing. Relaxation can be an effective tool to break this vicious cycle. You may feel “overwhelmed” by emotions, unable to find a way to reduce their impact. It is also common for these feelings to be so intense that you find it hard to imagine a time when they were absent. Relaxation skills can help you gain at least some control over your anxiety.

Awareness of Anxiety How do you know that you are anxious? Perhaps, you are already aware of specific situations that make you anxious or physical symptoms that you experience when you are anxious. Awareness of your anxiety is the first step to putting a stop to it.

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Specific Situations

What types of situations bring on intense feelings of anxiety for you? Common examples include having to go for medical tests, waiting for the results of the medical tests, or anticipating that a particular family gathering or an event will be difficult and stressful. Anxieties may also include fears, such as fear of enclosed places or travel (e.g., air, car, or plane) or fear that you will be taken advantage of (by family, unscrupulous sales people, strangers, etc.). List your anxiety-provoking situations in the space provided:

Physical Symptoms

Physical symptoms—bodily tension, headaches, rapid breathing, and so on— also let us know that we are tense. These physical symptoms are typical signs of anxiety referred to as “danger signals.” Spend a few moments thinking about what are your physical symptoms that are signals of anxiety and tension. Record them here:

Stop Signs

Danger signals are the body’s way of announcing that we must stop what we are doing to calm down and refocus our thoughts. When a danger signal arises, it is time to introduce a “stop sign,” which is a behavior or a thought that will put the breaks on the negative feelings. Some examples of “stop signs” are taking a deep breath, leaving the room, turning the lights off for a moment, or even a

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combination of all of these things. It is important to pick a personal stop sign that works for you. Write down ideas in the space provided:

After you introduce a stop sign, assess your level of tension, then do an appropriate relaxation exercise to reduce the anxiety/tension. Relaxation will help you think more clearly (without the interference of the anxiety) and get “back on target.”

Tension Diary Using a Tension Diary is often very helpful to understand the sources of anxiety and types of danger signals experienced. On the Tension Diary, you will record your most stressful times, least stressful times, and physical symptoms of tension. Here is an example of how one client used a Tension Diary: Mark is a 70-year-old married man who retired 2 years ago from a 30-year career in sales. He lives with his wife of 50 years in a house they have shared since they were first married. She has never worked outside the home and busies herself with home-oriented projects. Mark reports that tension has increased between him and his wife since he’s “always under-foot” and “gets in her way a lot.” He used to play golf with his two adult sons but now says he’s concerned about his health (golf may be too strenuous for him), and he complains that he “gets palpitations” a lot and doesn’t want to be on the golf course and “have something happen” so that his sons would have to take care of him. He avoids spending time with his six grandchildren, saying he is “too tense” and “no fun to be around.” Mark first enjoyed being retired since he was in good health and able to keep up contacts with former colleagues. After about a year, however, he found that he didn’t have much to talk about with them; at the same time, he developed a serious heart problem that limited his activities. Although well controlled now with medication, he is fearful that “something will happen” when he’s away from home. He expresses his tension and fears through mental worrying, feeling “stressed,” and having frequent headaches (not explainable by any medical cause). Mark is aware that he won’t be able to improve his depression until he is less tense, overall, so he is eager to work with his therapist to reduce his tension

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Directions: For each day, rate your average tension score. Indicate the situations in which you were the least relaxed and most relaxed, as well as any physical symptoms that you experienced. 1 = Least tense you have ever been

Tension rating:

10 = Most tense you have ever been Day

Monday

Tuesday

Wednesday

Average score for the day

6

9

7

Most tense score

9

10

7

When & Where?

9:00 a.m.

8:00 p.m.

1:00 p.m.

Breakfast

living room

study

What was the situation?

son was frustrated that I won’t go out to play golf with him

on the phone with my grandson, can’t seem to “connect” with him anymore

on the phone with former colleagues from work, nothing to talk about

Least tense score

2

5

4

When & Where?

12:00 p.m. Restaurant

2:00 p.m. garden

3:00 p.m. car

What was the situation?

lunch with an old work buddy that I can still talk to

reading paper, but thinking running errands but stuck of discussion with family & in traffic how hard it is to connect with them

Figure 5.1 Mark’s Tension Diary.

and anxiety. His therapist asks him to complete a Tension Diary for the week. (see Figure 5.1.) Mark’s diary shows that he does experience variations in tension throughout the day, which is very common. He notices that headaches appear each day as a physical sign of tension. This information has helped him recognize “danger signals,” as well as begin to learn his patterns of stressful situations. In addition, Mark noticed that when he is engaged in a few pleasant events, his tension decreased significantly.

Relaxation Training Your therapist will work with you to select appropriate relaxation exercises for different situations. Learning about a variety of relaxation methods will let you pick the ones that work best for you. You may already be practicing some form of relaxation, but it may not work so well anymore. Or your current relaxation 104

method may take too much time or energy to be effective at this point in your life. Be sure to discuss with your therapist what you are already doing and whether or not it’s working for you.

Tension Rating

To gauge whether relaxation is helpful, try getting in the habit of using the rating scale shown here. You will be rating your tension before you start an exercise and again after you complete the exercise.

1 not tense

2

3

4

5 “so-so”

6

7

8

9

10 extremely tense

When giving a rating, ask yourself why you feel this way. Try to identify the danger signals you are experiencing that contribute to your rating. If after an exercise, your tension level has not dropped, try to figure out what the problem is. Did you have intrusive thoughts? Did you have difficulty focusing attention on the breath? Your therapist can help you problem solve for a remedy. There is a Relaxation Practice Log included at the end of this chapter, as well as in the Appendix, to help you rate your tension before and after you practice. This allows you to fine-tune your efforts and see how well a particular technique is working (or not working) for you.

Relaxation Exercise

You will most likely be learning the following relaxation exercise in session. Your therapist may also ask you to practice the exercise at home. Use the following instructions: 1. Sit in a comfortable position, keeping arms and legs uncrossed. 2. Keep your eyes closed and try to block out all external sounds. 3. Breathe very slowly, inhaling through the nose and exhaling through the mouth. Focus on your breathing, and breathe with a steady pace. 105

Visual Imagery Option #1

Once you are comfortable with the breathing, you may want to try adding imagery to relax more deeply. Here are some basic suggestions for using visual imagery: ■

Imagine a safe and relaxing place where there are no worries or cares or concerns.

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Now imagine yourself in that place.

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Gently keep that image in your mind’s eye while breathing, all the while inhaling and exhaling slowly and deeply.

■

Let all thoughts that float into awareness, float out again. This is not a time to think about things, but to just relax.

Option #2

Another option for using visual imagery is to use the following script. You may want to make an audio recording of someone (yourself or your therapist) reading the following script and then listen to it during your practice. Make yourself as comfortable as possible. First I’d like you to remove any objects from your lap and to place your feet on the floor. Place your hands on your thighs. Don’t cross your legs or your arms. Close your eyes, so you can’t see the light and so you won’t be distracted by what’s going on around you. Now breathe deeply, and imagine that your stomach is a balloon that you have to fill up with air. Inhale deeply again, and exhale . . . . While you’re exhaling say the word “relax” (or any other word that signifies relaxation to you) silently to yourself . . . . Continue breathing as deeply as possible . . . always taking in enough air so you are filling up your stomach and then exhaling . . . . Right now, notice where your body is most tense. Make yourself as comfortable as possible. Relax the tension in your neck, shoulders, arms, back, legs and feet. . . . Keep breathing deeply and exhale, saying to yourself the word that you’ve chosen. Now imagine that you are some place that is peaceful and safe. Perhaps, you are on a beach or near a lake or in a meadow lying in the soft grass. It’s a beautiful, warm day and you are alone. Look closely at your surroundings. What do you see? Miles of clean white sand? The cool, tranquil water of the lake? Soft, green

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grass and flowers for miles? Wherever you are, you are warm and comfortable and surrounded by beauty. Imagine now that you are lying on the sand or in the grass with your feet stretched out and your arms comfortably beside you. Imagine you are closing your eyes, and pay close attention to the sounds around you. Listen to the sounds of nature. Do you hear waves or the wind passing through the leaves of the trees? Do you hear birds chirping? Listen to the sounds of your peaceful place. You feel warm and relaxed. As you lay there, you feel your body becoming more and more relaxed. You feel at peace. All your bodily systems have reached a state of balance, of harmony. Pay attention to the feelings of relaxation in your body. Take a few moments to enjoy the sense of balance, peace, and calm. Soon I am going to ask you to come back from your peaceful place, knowing that you can always go back to this place just by closing your eyes . . . and by breathing deeply three times Slowly leave your place and focus all of your attention on your breathing . . . Little by little, you will leave your place, and tell yourself that you can always return to this place just by closing your eyes and breathing deeply three times. Now, I am going to count backwards from 5 to 1, and when I reach 1, I will ask you to bring your focus and attention back to this room. 5 . . . 4 . . . 3 . . . 2 . . . and 1. Open your eyes now and mentally come back to this room.

Additional Relaxation Options You and your therapist may explore other options for relaxation, such as music, walking, or religious/spiritual activity. If you have more ideas for relaxation, be sure to discuss these with your therapist. The goal is to find several types of relaxation that you enjoy and can use in different situations. Music

Music can be very relaxing and improve your mood. If you enjoy music, try using it as part of your relaxation practice. Make sure you know how to use the equipment needed to play whatever you have: audiotapes, CDs, music through a TV channel, or some other medium. Your therapist can help you select appropriate music for relaxation. Many commercial products specifically

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designed for relaxation are available, and you may want to purchase a special CD or tape (or to borrow it from the local library). Music can help greatly with certain tension-producing situations such as sleep problems. Playing soothing music may help you fall asleep initially. (Also, when you awaken during the night, it can be helpful for falling back to sleep.) Music can also help calm you down before or during anxiety-provoking situations. Music can be played with headphones, for example, in the dentist’s office while you are having work done. Or music (using headphones) can be soothing “background” when traveling. Music might also be helpful in doing a difficult task (e.g., by taking your mind off of the pain of arthritis, at least temporarily, while gardening).

Walking or Mild Exercise

Walking (or any other mild exercise that you enjoy) can also be a reliable form of relaxation. Walking to relieve stress can also be a “pleasant activity” that you could be doing more of on a day-to-day basis. Besides walking, you may want to try other forms of gentle exercise for stress reduction, such as stretching exercises (often done to music), gentle yoga, Tai Chi, Qui Gong, or chair exercise programs. Check your community settings, such as a senior center, for classes. There are also many videos that can be played at home.

Religious/Spiritual Activity

You may find significant stress reduction in prayer, listening to or singing along with church-affiliated music, reading religious or spiritual material, and/or attending a religious or spiritual gathering or church service. Learning to meditate can also be very effective for stress reduction. There are many varieties of meditation and many pathways for learning that can be explored.

Relaxation Practice You should practice relaxation at least once a day to reduce your anxiety. If possible, do the exercise when you are tense, so that you feel some immediate benefit. Be sure to complete the Relaxation Practice Log before and after doing each relaxation exercise. This will help you notice even small decreases in your tension rating and encourage you to continue to practice.

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You may also start out by setting aside specific times of day to practice. Think of relaxation as a treat you can give yourself. Remember that practice is needed to enhance the effects of relaxation. Also, different methods will likely have different results at different times. Relaxation can also be used to prepare for an upcoming stressful event. For example, if visits to a particular family member are stressful, you could spend a few moments in your “relaxation spot” prior to the visit. In addition, you may want to try relaxation exercises as a nice way to start the day, even if you are not in a highstress moment. Relaxation can also create a calm break to refocus throughout the day. You might find that you expected your tension to decrease more than it does after your first few practices. Remember that the more relaxation is practiced, the more relaxed you will feel immediately following the exercise. Also, with increased practice, it will take less time to reach a relaxed state. Some people report that their bodies and minds become completely relaxed by the first deep breath! Use the Relaxation Practice Log to gauge your progress.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

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Home Practice

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Complete the Tension Diary at least once each day, preferably every time you experience significant anxiety. You may photocopy this form as needed. Additional copies are provided in the appendix.

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Practice the selected relaxation exercise on a daily basis and record your efforts on the Relaxation Practice Log. You may photocopy this form as needed. Additional copies are provided in the appendix.

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Bring to next session problems you are having with relaxation.

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Answer summary questions for this section.

Tension Diary Directions: For each day, rate your average tension score. Indicate the situations in which you were the least relaxed and most relaxed, as well as any physical symptoms that you experienced. Tension rating:

1 = Least tense you have ever been

Day Average score for the day

Most Tense score When & Where? What was the situation?

Least tense Score When & Where? What was the situation?

Monday

Tuesday

10 = Most tense you have ever been

Wednesday

Thursday

Friday

Saturday

Sunday

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Relaxation Practice Log

Directions: Rate your level of tension from “1,” least tense, to “10,” most tense, before and after the relaxation exercise. Record the time of day that you did the exercise and some comments regarding the prior stressful situation and whether the relaxation helped you. Do this each day.

Date

Time

Relaxation Score

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

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Comments

I M A G E RY A S A T O O L F O R N E G AT I V E T H O U G H T S A N D S T R E S S M A N A G E M E N T

Goals ■

To learn how to use imagery as a tool

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To identify negative beliefs through imagery

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To challenge negative beliefs through imagery

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To use imagery for stress management and effective communication

Introduction to Imagery Imagery is another tool to manage intense feelings: A “picture” of the stressful situation and its possible solutions are created in your mind. Visualization skills can help you challenge perceptions of the outcomes of stressful situations and manage intense emotions.

Identifying Negative Beliefs Through Imagery To use imagery to identify negative beliefs, follow these steps: 1. Think about a particular situation that produces intense, negative emotions. Briefly describe that event. 2. What emotions are present? 3. Now sit back, placing arms and legs in a comfortable position, and imagine the situation. Try to capture all of the components of the situation: the people, the sights, the sounds, the colors, and so on. Try to determine what is specifically problematic; isolate the thoughts that occur. If you find yourself getting upset as you “revisit” the situation, try to think of some calming images before continuing with the exercise. Next record the thoughts about the stressful situation recalled during the imagery exercise in a UTD. Review the negative thoughts—are any perceived outcomes

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catastrophized? Rate how strongly you believe these outcomes will occur (from 0% to 100%).

Challenging Negative Beliefs Through Imagery Now return to imagining the situation, this time picturing the outcome as you predict it will happen. Are your original perceptions likely? Rate how strongly you believe in your original outcome at this moment (from 0% to 100%). Can you replace the unhelpful beliefs in column 2 of the UTD with more helpful ones (column 4)? If so, how do you feel? Record any changes in your emotions considering your new perceptions (column 5). Now consider what you will do differently in similar situations. How is changing your thinking likely to affect your daily life (column 6)?

Imagery for Stress Management and Effective Communication Imagery can also be useful in helping you to prepare for a stressful event. For example, if you become anxious about meeting with someone, try using the imagery exercise to practice and plan the kinds of things you would like to say. Imagery skills also come in handy when you want to practice being assertive before you are placed in a “face-to-face” situation. See Chapter 6 on Communication Tools.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

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3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments in this section might include the following:

✎

Use imagery to identify and challenge negative beliefs.

✎

Practice imagery for stress management/effective communication.

✎

Answer summary questions for this section.

M A N A G E M E N T O F F R U S T R AT I O N A N D A N G E R

Goals ■

To identify sources of frustration and anger

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To defuse anger or frustration through relaxation

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To learn steps to cope with an unchangeable situation

Sources of Frustration and Anger Many older people experience feelings of frustration or anger associated with their depression. Potential sources of frustration and anger include the following.

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Lack of Knowledge

One source of frustration and anger is lack of knowledge about depression and other common negative emotions that people tend to experience more of as they age. A certain amount of depression, frustration, or anger may be very appropriate, given your circumstances. For example, it’s reasonable to become frustrated when your adult son or daughter always seems “too busy” to visit or call or when your phone calls to the doctor’s office are not returned promptly and courteously. However, these kinds of feelings become “problems” when they are out of proportion to the situation or become chronic and intense. For example, it may be difficult to have a positive contact with one’s adult child, for instance, because of so much built-up anger and frustration over time as a result of being ignored by him or her.

Negative Thoughts and Attitudes About Yourself and the World

Many people who have high levels of anger and frustration have strong negative views about themselves. Often, they see themselves as a failure for not living up to unrealistically high expectations formed earlier in life. For some individuals, this turns into anger rather than classic depression. Similarly, an individual might become angry at how the world “let me down.”

Skill Deficits

People who do not know how to manage their feelings of anger and/or frustration and disappointment effectively may find that these feelings increase over time. After awhile, these feelings may “take over” so that the person is chronically irritable. This generally has a negative impact on those around the person, who then often withdraw—sometimes out of fear but more often because it’s unpleasant to be around a person who is chronically angry. This in turn reinforces the person’s feeling that no one cares, or the “world is out to get me,” and that in turn tends to increase depressive feelings. When a person does not know how to communicate feelings effectively, she may passively suppress anger or may vent feelings in an angry and aggressive manner, neither of which are particularly effective for problem solving. Thus, a “vicious cycle” where anger and depression feed into one another is created. Refer to Chapter 6 on communication tools.

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Lack of Control

Anger is also a common response to dealing with people or situations over which a person has no control, but believes she should have control. Of course, there are many circumstances in life over which an individual has little or no control; most people adapt to those kinds of situations (e.g., chronic debilitating illness) but some do not and continue to insist that they should be “in charge” of the world and of what happens to them. This viewpoint will necessarily lead to increased feelings of anger and frustration that can become very entrenched over time.

Defusing Anger or Frustration Through Relaxation Training What typically happens to the person who becomes angry or frustrated frequently? The body tenses up—for example, tension may be consciously experienced in the jaw, neck, and shoulder areas, which seem particularly vulnerable to this feeling state. Usually, certain movements characterize the person (such as walking quickly, counting aloud, clenching the fists, standing in a certain challenging or aggressive pose, etc.). In addition, the person often uses certain verbal expressions (e.g., curse or swear words, other forms of negative or critical language). When you find yourself becoming angry, try doing a brief relaxation exercise (refer to the relaxation section of this chapter). With practice, relaxation can reduce negative feelings such as anger. Remember to complete the Tension Diary before and after each relaxation exercise to measure if it was effective.

Coping With an Unchangeable Situation There are three possible responses to a situation over which one has little or no control: ■

Assertively try to change the situation

■

Leave the situation if you can

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Adapt yourself so that you can live with it and feel less frustrated about it

While the first two solutions are possible in some instances, more often than not, you must learn to adapt to reduce you anger and distress.

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There are several steps to managing strong feelings of anger and frustration: 1) Recognize that the anger is getting out of hand. This includes being aware of danger signals and which stop signs need to be employed in order to dampen the negative feelings. 2) Identify the thoughts that fuel the anger. 3) Evaluate these thoughts and attempt to see the event or situation from different angles. 4) Change the thinking; that is, develop more helpful or adaptive thoughts that promote positive coping. 5) Behave or do things differently in the situation that typically provokes the anger or frustration, thus leading to a different outcome.

Step 1: Recognize That the Anger Is Getting Out of Hand

To keep anger from getting out of hand, you will need to know your “danger signals” and “stop signs.”

Danger Signals

Danger signals are the particular changes in the body that occur when feelings of anger are rising, such as breathing heavily, heart feels like its racing, and sweating. Everyone has their own unique danger signals; your therapist will help you identify yours.

Stop Signs

Stop signs are strong visual images that interrupt the negative feelings and the “train of thoughts” long enough to enable you to gain control. When used correctly, they let you take a short breather when feeling overwhelmed by negative emotions or the physical sensations associated with them. Stop signs are mental images that make you STOP & THINK. To be effective, they need to be powerful, meaningful to you, and able to interrupt negative feelings. For example, many people think of the traditional red STOP sign they encounter many times each day while driving. If they are good drivers, they will always stop at that

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sign. You might instead need to visualize a red hot fire and see yourself pulling back from it, or visualize yourself at the edge of a waterfall where your natural instinct is to stop and not go any further; or you might imagine a horse rearing up and find yourself getting out of the way and maybe shouting “whoa” to tame the horse; or you might envision a poison sign on a label or a KEEP OUT sign on property that’s been boarded up. Use whatever image is both dramatic and meaningful to you. Step 2: Identify the Thoughts That Fuel the Anger

The A-B-C model can help you recognize thoughts that fuel anger: Action: action or situation that is creating or fueling the frustration Belief: beliefs or thoughts about the situation that are making me upset Consequences: consequences in terms of my feelings (rated for intensity) in reaction to this situation Complete A-B-C Forms to help yourself “tune in” to what you are thinking.

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A-B-C Form A = Action A situation that causes me frustration.

B = Belief My thoughts/beliefs about the situation that are making me upset.

Identify the Unhelpful Thinking Patterns

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C = Consequence My feelings about the situation that are making me upset.

Step 3: Evaluate Thoughts and Attempt to See the Situation From Different Angles

We want you to evaluate the thoughts that fuel anger and see the situation from a different perspective. In order to do this, you must first learn to stop (interfere with) your negative emotional responses. You cannot think clearly until the strong negative emotions are in check. Keep in mind that strong emotions can be like a steam locomotive: Once you begin to feel them, they slowly grow and gradually develop a lot of momentum. Generally, the thoughts associated with these feelings occur so automatically that they are difficult to identify or modify. Like speeding trains, strong emotional responses are hard to stop. However, you can learn to do so, and in fact must learn how to do this, or else you will not be able to develop alternative thoughts and/or more adaptive behaviors.

Case Example: Bob ■ Bob is a 75-year-old widowed man who had been a company manager earlier in

life and was married for 45 years to his high school sweetheart who died from cancer about 5 years prior to his being referred for therapy; they’d raised four children (two of whom lived nearby with their families) but he was now retired (for the past 10 years) and living alone. His health had deteriorated since his wife’s death: He has multiple medical comorbidities, including serious heart disease, prostate cancer (that he has recovered from), and osteoporosis that is so severe that if he falls he breaks bones. He was referred for therapy because he often became so angry that he cursed in public, raised his voice to people on the street, clerks in stores, receptionists in doctor’s offices, and so on, and was causing his family to worry over his “loss of control,” which they thought represented “frontal lobe damage” (loss of impulse control) associated with dementia. Neuropsychological evaluation found no evidence of dementia, but the psychiatric interview determined that he was significantly depressed—although anger was what he expressed more openly, with his depressed feelings being more “hidden.” He revealed that growing up, there was considerable anger and acting out in his family; he learned that that was a “man’s way” of resolving difficulties. Later in life, he learned to channel those feelings and not express them on the job or to his family; he was able to find other outlets for his frustration, such as sports, gambling, and heavy drinking. He was not able to play contact sports anymore, had to stop gambling due to lack of funds, and had to stop consuming alcohol due to his health problems. Thus, his prior ways of coping with stress were no longer available to him,

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and he expressed his frustration openly and inappropriately. Bob was motivated for treatment because he realized he was alienating his adult children (and their kids) and was losing his final sources of support. To gain control of these feelings and respond more adaptively to situations that got under his skin, Bob was taught the A-B-C model, plus how to recognize his danger signals (e.g., heavy breathing, throat constriction, raising his voice, or becoming impatient) and use stop signs (vivid images of a wildfire with him stepping up to the line but not crossing over it). He was also taught a model for remembering this: A-B-C (STOP) D.

A-B-C (Stop) D

The A-B-C (Stop) D model is as follows: A (action) leads to B (Beliefs) leads to C (Consequences), add in the STOP SIGN, and then go to D (what are you going to do differently now, now that the emotions are under control?). The following steps will help you slow down the “automatic” processing enough so that you can regain control and stop yourself from behaving in ways that you will only regret: 1) DO consider other possibilities for what you are thinking. 2) DO come up with alternative ways to respond to the situation that is making you upset. 3) DO take advantage of your ability to reason things out. 4) THEN ACT.

Step 4: Change the Thinking

The fourth step involves developing more helpful or adaptive thoughts that promote positive coping. 1. Ask yourself (out loud or in your mind): Is this always the right way to perceive or to respond to this situation? Or is there a time when it’s not? Think back to prior experiences and compare. 2. Ask yourself: What is the evidence supporting my point of view? What is the evidence for and against my beliefs? Listen to the evidence you tell yourself

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so that you can come up with a more balanced view. Be honest with yourself. 3. Ask yourself: Are there alternative explanations or possibilities to consider? Case Example Continued ■ For example, next time Bob is kept waiting in the doctor’s office and feels his

anger rising, he can ask himself: Is it reasonable for me to be so angry? Why do I get so upset? Do I think they are ignoring me (that’s not really true)? Do I think the doctor is just an inconsiderate person who doesn’t care what impact he has on his patients (that’s not really true based on my experience with him when I was so sick)? Do I think the staff are just “out to get me” (that doesn’t seem to be true either—I guess they are just the “messenger” for the doctor: what’s that saying—“don’t shoot the messenger?” maybe I need to remember that)? Once you have asked and answered these kinds of questions in your mind or out loud in session, the final two parts of this process involve ■

learning to replace the negative thoughts with more adaptive ones, and

■

thinking about a better course of action instead of continuing to do the more “automatic” response Now, when it comes to doing a new behavior, Bob can tell himself, “I will try to be polite. It’s not going to get me anywhere to just sound off, and maybe it’ll take that much longer to see the doctor, since they’ll be upset with me and they might retaliate. So I will be polite, even though I don’t really feel like it. I will try this out and see what happens.” Bob is pleasantly surprised when, after 10 additional minutes, he is called to see the doctor.

Other Challenging Techniques

When angry, the following two techniques are helpful in challenging thoughts. Keeping Things in Perspective: Try and “keep things in perspective”—nothing is all good or all bad. Remember that often when in a tough situation, we think that it won’t improve but the fact is that things change. “What happens today will not happen forever. I can make it through today” can be a helpful reframe. Positive Self-Statements: “Mental filtering” is tuning out the positive and focusing on the negative. To reframe, try coming up with and using positive self-statements

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(some call them “affirmations”). It can be very helpful to write these statements down on Post-it® Notes and to put the notes around the house or in your car or bag and review them regularly. With Bob, for example, he can be taught to say to himself such statements as: “I have my flaws (flying off the handle too easily), but I also have my strengths. I’m not going to beat myself up over this. I can figure out what else to do so the situation cools down. I’ve got a good brain, and I’m going to use it.” Having worked through the first four steps, you are now ready to see how stopping or interfering with the “train of negative thinking”—and thereby reducing the experience of negative emotions—can lead to more helpful and adaptive problem solving (the “D” or “doing things differently”). Complete the A-B-C (STOP) D Form on the next page.

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A-B-C (STOP) D Form Danger Signals

D = Do

What I notice about myself that tells me that I am upset and that I need to stop. (Physical)

What I think about and do now after using my stop signs. How I will handle this differently in the future. New Thoughts

Stop Signs What I can use in this situation to interrupt my train of unhelpful thoughts or to stop myself. (Visual) New Actions

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Step 5: Behave or Do Things Differently

In situations that typically provoke your anger or frustration, it is crucial that the coping approach lead to new behaviors and better outcomes. Consider the following example: Mary is an 80-year-old woman who is still living with her 85-year-old husband John in an assisted living community. She was referred for therapy because she became very easily angry and irritable as her husband’s memory was becoming increasingly worse. She told her doctor that “he is doing this deliberately: he could always remember better than me, why is he repeating questions and statements over and over? It’s driving me crazy, and I just find I can’t help flying off the handle. I’m so impatient with him, but it’s now bothering me too—it’s making me sick, having to yell at him all the time to try and get him to remember and it doesn’t work anyway.” This kind of frustration is very common among family members who have some responsibility for providing care and assistance to individuals who are developing memory impairments that quite possibly are the early signs of a dementing disorder. Mary knows her way of responding is not helpful to either of them but she can’t seem to come up with alternatives on her own. She is an excellent candidate for the approach outlined in this section. In therapy, Mary learned that her most common unhelpful thinking pattern was “labeling”—she thought of herself as a bad wife because she lost her temper. But she also tried to defend herself (in her mind) by reasoning with her husband, which of course did not work. She learned that when she was upset with her husband, she had knots in her stomach and had trouble breathing (her “danger signals”). She used the red road sign that says STOP (in her mind; she was still driving in her local neighborhood so it had meaning to her) to slow down her thoughts. She also learned to tell herself that her husband could not help it—these short-term memory problems were a very unfortunate change that happens to many older people, and could signal the beginning of a more serious illness that may have to be checked out in the future. The therapist referred her to the Alzheimer’s Association local chapter (see appendix of national resources for older adults) to learn more about this disease and to obtain support and ideas from other people dealing with the same sort of problem. Mary accepted the referral gratefully and reported that it helped a lot, but she needed the therapy too, since her anger was quite extreme at times and she was fearful she might really lose control and become abusive to her beloved spouse. Mary learned to challenge her thinking and to use positive self-affirmations to help her calm down

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and think about how she would actually respond next time. Some of her statements were: “I am a good wife; I just didn’t understand what was happening. Now that I understand, I can learn to be more patient with John.” And “I want to have more harmony in our household and in our relationship. I need to work on how to bring that about; I can’t expect him all of a sudden to have a perfect memory again. I’m the one who needs to adapt, and I can do this; look at all that I’ve been through and handled all my life. I can do this now too.” Then, on a behavioral (DOING) level, Mary learned to use music and simple household tasks (like folding laundry) to distract her husband from his repeated questioning. This calmed them both down, so they were able to have more pleasant times together at home. She also learned to place reminders around the house such as big calendars with important appointments recorded, so she could direct John there if he kept asking questions (e.g., “When are we going to see our daughter? When is her next visit?” or “When do I go get my hair cut again?”). These simple actions made a great deal of difference in Mary’s ability to manage her negative emotions. Besides challenging her thinking, Mary learned that she could have more of a sense of efficacy or mastery over this difficult situation, if she stopped long enough to think about it, instead of just “reacting” to her husband.

Summary To summarize, the steps involved in anger management are a consolidation of several different skills presented in this program, as well as some of the unique content presented in this section of the manual. These steps include the following: 1. Recognize the situations that result in an emotional reaction of anger. 2. Recognize the danger signals (i.e., How does the body feel?). 3. Engage in an activity to physically calm down, such as relaxation, breathing slowly, or even exercise. 4. Use thinking tools to identify and modify the automatic thoughts that lead to intense anger and frustration. 5. Use assertiveness skills if needed (see Chapter 6 for more details). 6. Reward yourself for managing these feelings.

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Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments in this section might include the following:

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✎

Complete the Tension Diary before and after relaxation exercises to reduce anger.

✎

Practice relaxation on a regular basis, and record on the Relaxation Practice Log.

✎

Complete an A-B-C Form when you find yourself becoming angry.

✎

Use the A-B-C (STOP) D Form when angry to challenge your negative thoughts.

✎

Answer summary questions for this section.

Chapter 6

Module 6: Communication Tools

C O M M U N I C AT I N G E F F E C T I V E LY

Goals ■

Learn about the communication continuum

■

Practice steps to effective communication

The Communication Continuum There are different styles of communication that exist across a continuum. What style of communication you may adopt often varies from person to person. For example, with your family members, you may tend to communicate in one way, whereas with business associates or friends outside the home, your typical style may be different. The central dimension of the continuum is the degree of respect you have for your own personal rights and for the rights of the other person with whom you are in conflict or disagreement. The communication continuum has three key anchors: passive, effective or assertive, and aggressive. Refer to Figure 6.1. Below each label on this continuum is the description of the consequences of selecting that style. Being passive means that your personal rights and feelings are dismissed in favor of the rights and feelings of the other person. Being aggressive means that your personal rights and feelings are valued higher than those of the other person, who may ultimately feel dominated or humiliated by the communication. Communicating effectively generally means that both parties feel

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Passive

Effective/Assertive

Aggressive

Your rights & feelings vs. others’

Your rights & feelings vs. others’

Your rights & feelings vs. others’

You Lose—They Win!

You Win—They Win!

You Win—They Lose!

(They dominate the interaction)

(A more equal exchange occurs)

(You dominate the interaction)

Figure 6.1 The Communication Continuum.

satisfied and valued in the interaction. The specifics of each style are described as follows:

Passive Communication When we communicate passively, we are not expressing our feelings and our thoughts honestly. Communicating passively means that we speak in an apologetic manner that results in others disregarding or putting down our statements. Passive communication also shows a lack of respect for others’ abilities to handle problems. In general, the goal of passive communication is to please others while avoiding conflict. Case Example: Lily’s Passive Style ■ Lily is a 76-year-old widowed woman with moderate depression that began upon

her husband’s death 3 years ago. She had been married to the same man since age 20. So when he died, she felt she “lost her identity” and had “nothing to do” with her time. She also has heart disease and osteoporosis and is on antidepressant medication, but is hard to medicate because of her overall physical frailty. About 1 year ago, her oldest daughter, Melanie, convinced her to sell the family home and move into an apartment near the younger daughter, Marcia. Marcia has two school-age daughters, so it was thought that Lily would be able to spend time with the grandchildren and babysit them for Marcia, who works fulltime. However, conflict soon developed over their ways of parenting: Marcia was very indulgent of the girls’ wishes, whereas Lily was stricter, insisting for example that they do their homework before watching TV and giving them fruit and nuts for a snack instead of cookies. The girls would complain to their mother, who would then instruct Lily to be more indulgent. Lily agreed to do this, but then would fall back on her old ways of being stricter with the children.

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Things escalated to the point that Marcia told Lily to leave “and don’t come back till you can follow my orders; they’re my children, after all.” Lily was crushed, became more depressed, and even refused to leave her apartment to go to the senior center (which she had started to do once a week for the lunch). She said the whole experience with Marcia triggered many nagging doubts about her own parenting of the two adult children. Without her husband to discuss things with, she became more convinced in her own mind that she’d been a “bad mother,” which further limited her ability to communicate with either daughter. She wanted to work on how to restore better communication with Marcia, and with Melanie, who refused to get involved in the conflict but whose distance really disturbed Lily. We began by reviewing the continuum and by asking Lily to put an X where she thought she was, most of the time, in these interactions with Marcia (starting with the more troublesome daughter first). She marked herself both at the aggressive end, saying that she “should have talked with Marcia about these things and gotten her permission about what to do with the girls after school” and “I shouldn’t have forced my will on the situation” AND at the passive end, saying that she really “folded” when Marcia criticized her and didn’t stand up for what she thought was right. Consider the following questions about the case example and try to answer them in the space provided, so that you and your therapist can discuss these at your next session. If you’re having trouble answering these and any of the other questions that follow, it might be a good idea to discuss them with your therapist beforehand. 1. How do Lily’s responses fail to show respect for her rights and possibly for her daughter’s rights and feelings?

2. What might be some possible outcomes for Lily? Consider what her thoughts and her feelings are and how this situation has already had several negative consequences both cognitively and behaviorally.

3. What kind of message do you think Lily’s communication style gives her daughter? What about the negative impact on the grandchildren? Assess the

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“damage” to everyone concerned if Lily doesn’t develop a more effective way to communicate with the harried, hassled daughter.

Passive Communication Exercise

Now consider the last time you acted passively. Complete a 3-column UTD for this situation to learn about your thoughts and feelings.

Antecedents or Situation Describe the situation or event that led to your unpleasant emotions.

Beliefs or Thoughts Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience. Rate how strongly you believe in these thoughts from 0% to 100%.

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Consequences or Emotions Write down what you were feeling during this experience (sad, angry, anxious, etc.) Rate how strong your emotions are from 0% to 100%.

Look over your UTD. What are some of the costs and benefits of passive communication? Costs

Benefits

What does this mean to you?

Aggressive Communication Aggressive communication involves making statements that usually disregard the rights of others. The goal of aggressive communication is to dominate others and get them to do what you want. It is basically telling people, “This is what I want, and what you want is not as important to me as what I want.” Case Example: Lily’s Aggressive Style ■ Lily was aggressive in the sense that she apparently did not discuss in advance with

her daughter what the daughter’s preferences and expectations were, so that when the confrontations occurred, she believed she was “right” and Marcia was “wrong.” Lily wanted to do what she thought was “right” even though Marcia clearly did not approve of it. One could say that Marcia was in error, since Lily’s ideas for what to do with the girls seem reasonable, but the fact remains that they are Marcia’s children and she ultimately has the last word about how they are to be raised. So the aggressive stance that Lily took did not lead to resolution of the situation, only to more escalation until finally she was told to leave. Again, one might argue that Marcia was the unreasonable one here, and that might be true, but Marcia is not the patient and Marcia’s behavior is not in question. By helping Lily see that she needs to do things differently, that is, approach the situation differently, it may turn out that Marcia’s response changes as well and there is more of a “meeting of the minds.”

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Consider the following questions about the case example and write your answers in the space provided: 1. How does Lily’s response fail to show respect for her daughter’s rights and feelings?

2. What might be some possible outcomes for Lily and Marcia, besides the ones mentioned in the case example? Think long-term: Continuing to have little or no contact with her granddaughters in the years ahead would be extremely difficult for Lily. Therefore, it makes sense to try to work out a compromise so that the contact can be reinstated, and Marcia can feel less threatened by her mother’s presence and ways of doing things (which reflect on Marcia, who may well be wondering if SHE’S a good mother). Consider what Marcia’s thoughts and her feelings might be.

3. What kind of message do you think Lily’s aggressive communication style gives her family?

Aggressive Communication Exercise

Consider the last time you acted aggressively. Complete a 3-column UTD for this situation to learn about your thoughts and feelings, and then discuss it with your therapist.

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Antecedents or Situation Describe the situation or event that led to your unpleasant emotions.

Beliefs or Thoughts Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience. Rate how strongly you believe in these thoughts from 0% to 100%.

Consequences or Emotions Write down what you were feeling during this experience (sad, angry, anxious, etc.) Rate how strong your emotions are from 0% to 100%.

Look over your UTD. What are some of the costs and benefits of aggressive communication? Costs

Benefits

What does this mean to you?

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Effective Communication In contrast to these two styles, communicating effectively involves expressing ourselves clearly and honestly, while considering both our personal rights and feelings and the rights and feelings of others. Effective, expressive statements are those communications that are done without humiliating, dominating, or insulting the other person. This is not as easy as it sounds, since the other person in the interaction may “hear” or interpret what you are saying differently from what your meaning is. Therefore, it is helpful to practice effective communication in session with your therapist. Case Example: Lily’s Effective Style ■ When Marcia (Lily’s daughter) tells Lily not to come over to babysit, Lily could

respond by saying: “It is very important to me that you and I have a good relationship, and that I am able to spend time with my granddaughters. Let’s find a way to work this out.” Although this, in itself, is not sufficient to change the situation, it is a necessary first step to opening up the channel for effective communication. Lily needs to learn how to make the first move. Then, she needs to practice what to say next, if the daughter agrees, or if she disagrees. Consider the following questions about the case example and write your answers in the space provided: 1. How does Lily’s response show respect for her rights and feelings as well as for her daughter’s?

2. What might be some possible outcomes in this situation (both positive and negative)? Consider what Lily’s thoughts, feelings, and behaviors might be.

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3. What kind of message do you think Lily’s effective communication style gives Lily’s daughter?

4. What kind of communication techniques, and role-play exercises, do you think would be useful in this situation?

Exercises for More Effective Communication

Consider the last time you believe you communicated effectively with someone, for example, with a person with whom you were in conflict. Complete a 3-column UTD to learn about your thoughts and feelings about being able to communicate in a way that was effective and reasonable for both parties. Antecedents or Situation Describe the situation or event that led to your unpleasant emotions.

Beliefs or Thoughts Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience. Rate how strongly you believe in these thoughts from 0% to 100%.

Consequences or Emotions Write down what you were feeling during this experience (sad, angry, anxious, etc.) Rate how strong your emotions are from 0% to 100%.

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Look over your UTD. What are some of the costs and benefits of effective communication? Costs

Benefits

What does this mean to you?

Case Example Continued ■ The outcome of effective communication is generally positive. For example,

if we continue again with the example of Lily: Lily was able to relate a number of positive exchanges with Marcia, and with Melanie, when they all went on vacation together as a family. There were, apparently, frequent differences of opinion then about where to eat, what to eat, how to spend the time, etc., but they were all very reasonable about it, and wanted to have a good time above all else, so everyone seemed to compromise a bit for the “greater good.” By discussing this situation with her therapist and by giving concrete examples of some of the interactions she had with both daughters that she felt were effective and did not cause conflict, Lily was able to see that the situation is not hopeless: it’s a matter of finding the right way to approach it and being willing “to give a little” in what she wants so that she can reach her goal of having regular contact again with the grandchildren. ■

Steps in Deciding to Communicate More Effectively in Conflicted Situations Before you are going to have an interpersonal interaction with someone with whom you are, or have been, in conflict, consider the following:

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1. What is the goal or objective of your message? 2. How might alternative styles of communication help you reach your goal? 3. Pick the communication style that will most likely provide the best outcome.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

✎

Review the case example of Lily and record answers to the questions in the space provided.

✎

Complete 3-column UTDs for passive, effective, and assertive communication and consider the costs and benefits of each style.

✎

Answer summary questions for this section.

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R O L E P L AY I N G

At some point, your therapist may ask you to engage in role plays. Role plays can be used in many different ways to help you improve your communications with others. For example, in the 3-part role-play exercise, the therapist can take on the role of a person in your life with whom you are having problems and try to act out an exchange that might help you develop more useful alternative thoughts and actions. Roles can be reversed and then you can play the other person, while the therapist plays your role. In this way, you get to experience what it might be like for the other person, and you get to see the therapist showing you a different way to approach the problem. Switching roles again where you play yourself and the therapist plays the other person gives you an opportunity to practice using a new style of interacting with the problematic person. At first, you may feel uncomfortable with this exercise, but we have found this to be extremely helpful to clients who have difficulty in communicating with others. Before you say no to the idea, give it a try with your therapist and see if it’s going to be helpful. Your therapist will guide you in this activity, but we’ve included an example here to illustrate how this technique works.

3-Part Role Play: Part 1 In part 1, you play yourself while the therapist plays a person in the interaction with whom you are having difficulty. Here is an example of a role-play scenario with Harold: Harold is a 80-year-old retired teacher who became depressed subsequent to his retirement 5 years ago from a full-time college teaching position. He was advised to retire when he was “at the top of his game” but he had not anticipated how lonely and bored he would be, without regular contact with students, a regular schedule, and purpose and meaning for his life. Therefore, he began contacting his former department chairperson to ask for his old job back. He describes that his last encounter with his former boss was very stressful and unsuccessful: He tried to explain why he needed his old job back and felt he was not heard, was “brushed off ” by the department chairman, and was doomed to failure.

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In the first role play, Harold plays himself asking his chairman for his job back, and the therapist plays the department chairperson. Enacting the situation as closely as possible to what actually happened helps both individuals become aware of thoughts, feelings, and actions that probably occurred and sets the stage for the next two parts of the role play.

3-Part Role Play: Part 2 In Part 2, Harold plays the part of the chairman, and the therapist plays Harold’s role, while attempting to communicate effectively with the chairman. Instead of demanding his old job back, the therapist could explore alternatives with the chairperson such as a part-time or volunteer position. Meanwhile, Harold (as the chairperson) can develop a greater empathy for being in that other person’s shoes. Typically, in this situation, Harold can become aware of concerns the other person may have that they were not aware of before. For example, the chairperson may not have the budget or the authority to hire a full-time person, no matter who they are. He may also be concerned that in the 3 years of retirement, Harold has “fallen behind” in his field and would not have the most up-to-date information to teach the students. If Harold can express one or two of these concerns, he will develop some empathy for the chairperson’s position, which can make it easier to discuss things in a rational, nonthreatening, manner.

3-Part Role Play: Part 3 In the third part of the role play, Harold again plays himself, and the therapist again plays the department chairperson. In this exchange, Harold is encouraged to practice other ways of making his request in a safe environment, with a “coach” right there to give feedback. Usually, this is a more successful experience than the first role play was, and that contrast is in itself informative. After about 5 minutes of role play, another 10 minutes or so are spent processing what was said, how it felt, what the thoughts were that were associated with it, and what the resultant feelings were. Generally, by now, Harold will have had the chance to practice, literally, different ways of making his request and can learn from the role play how these different ways of presenting the request may be received by the other person, which in Harold’s case would be the chairman.

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Your Role Play The next step is to try this exercise using one of your own examples of a difficult communication problem in a conflictual relationship. Part of your home practice might be to begin to think of difficult situations in your own life that you could practice with your therapist at the next session. Make notes about some of the key issues and bring them with you so you are prepared to do role plays next time.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

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✎

Begin to think of difficult situations in your own life that you could role play with your therapist. Make note of the key issues and bring to the next session.

✎

Answer summary questions for this section.

O T H E R WAY S T O B E C O M E I N T E R P E R S O N A L LY E F F E C T I V E

Goals ■

To learn how to use “I” statements

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To understand the importance of compromise

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To learn the “broken record” technique

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To learn some techniques to deal with loneliness

Using “I” Statements Using “I” statements (instead of “you” did this and that and it’s “your fault” or “you should do X or Y”) is a more effective way to communicate. For example, if Rebecca, a 90-year-old widowed woman living independently but alone, says “why don’t you come over more to visit” to her adult children, she is not likely to get many visitors. That kind of statement tends to make the other person defensive, or may sound accusatory. Instead, she could state clearly: “Mary Jo and Marlene, I would like you come to visit me more. I am lonely and I miss spending time with you. Can we figure out a day and time when you can drop by and spend an hour with me?”—this is a definite invitation, instead of a vague demand, and so is more likely to result in a positive response. Again, stating clearly what one wants or needs is an integral part of communicating effectively.

Compromise Another technique is learning “the art of negotiation and how to compromise” or “developing options if I can’t get exactly what I want.” Placing extreme demands on other people usually does not result in their going along with you; more often, they tend to back away. Consider the following example: Mary is a 76-year-old caregiver for her husband with dementia. She wants to take some time off from caregiving to get needed dental surgery done, but she has difficulty getting a reliable person to come in and “sit” with her husband while she is out. She would like to have a whole day off, but the caregiver who was

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recommended by a neighbor can only work 4 hours a day. If Mary argues with this person to try and convince her to stay for 8 hours instead of 4, she is very likely to lose her completely. On the other hand, if Mary is willing to negotiate with the caregiver, it can lead to a “win–win” situation in which Mary’s husband is supervised and Mary can do some things for herself that she’d been putting off. Alternatively, if Mary insists that the caregiver work a full 8-hour day, she could wind up with nothing of what she wants.

The Broken Record Technique Sometimes negotiation is not possible. The broken record technique is a method where one straightforward statement is repeated. This technique keeps the goal clearly in mind while being respectful of both one’s own needs and, to some extent, the needs of the other person in the interaction. This technique is particularly effective when dealing with obstinate people who may be pressuring you to do something you would rather avoid. It is also helpful in communicating with Alzheimer’s patients or post-stroke patients, who quickly forget information. Finally, it can be a useful way for you to get something that you want, depending on the other person’s willingness to respond. Case Example: Jillian’s Use of the Broken Record Technique ■ Jillian’s daughter often asks her to take care of her granddaughter without advance

notice, even though she may have plans to do something else. Jillian feels that her daughter takes advantage of her, and has little concern for her welfare. She is, after all, 80 years old! On one particular day, Jillian had made plans with her friends to go on a day trip that she had been looking forward to for a long time. On the morning of Jillian’s plans, her daughter calls and asks for help. Jillian clearly demonstrates her concern for her daughter’s dilemma, but she is not willing to change her long-awaited plans with her friends. Jillian uses the broken record technique in her communication. Their conversation goes as follows: Daughter: Mom, I need to get my car repaired, can Susie spend the afternoon with you? Jillian: I have plans today; I will not be able to watch her. Daughter: Where are you going? Maybe I can meet you? It’s just for the afternoon.

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Jillian: I’m sorry, but I will not be able to do it. I have plans. Perhaps, we could do this tomorrow. Daughter: Why not? I’m stuck. Jillian: I can see that you are in a bind. I’m so sorry, but I have plans. ■ Consider the following questions about the case example and answer in the space provided. 1. What was the major point that Jillian conveyed? How do you feel about how she went about it?

2. What was Jillian’s goal?

3. Do you think she was successful?

4. How would you describe the “broken record” technique?

5. Can you think of how and when you might use the “broken record” technique in your interactions? Do any specific situations come to mind?

Summary of Steps Involved in Using the Broken Record Technique

The “broken record” is a very effective technique for saying “no.” It also provides a framework for how to ask for things that are needed: asking repeatedly, in a

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calm manner, and “sticking to your guns” (assuming the request is reasonable). Here are steps to remember: 1. Stick to one point and don’t get side-tracked. 2. Show respect for the other person. The goal statement can be preceded with a supportive comment. 3. Repeat the goal statement with minor modifications. 4. Avoid explanations for the chosen statement. This is not necessary. Explanations will introduce negotiation to the conversation. When this happens, the focus of the goal is often lost.

Techniques for Developing New Relationships Many older persons have few (if any) close relationships at this time in their life, which can also pose problems. This occurs as a result of multiple losses that many experience in the later years: A spouse or partner dies; friends move away; retirement leads to loss of friends in the business world; health changes often make it difficult to engage in hobbies or activities that lead to social contacts, etc. So you may find yourself alone, lonely, and wanting to establish new interpersonal contacts. Many older persons in this predicament are unsure of how to go about the whole process of meeting people and making friends. During early and middle adulthood, we often participate in several social networks: at work; at college; with our families; with other parents who have children in school; and possibly in our recreational (vocational) pursuits. However, as we age, many of us begin to lose these networks. Further, we find that our skills for meeting and making friends are “rusty,” and we often do not feel comfortable in being with people whom we don’t know. Often, loneliness can increase symptoms of depression and anxiety. The two can sometimes go hand in hand, and can lead to a downward negative spiral—loneliness increases symptoms of depression, which decreases the likelihood for one to reach out to others and enrich one’s social network, which in turn leads to increased loneliness, social isolation, and symptoms of depression, which then leads to even greater isolation, and so on. Negative thoughts are common, such as, “I’m too old to make friends,” “No one would find me interesting enough to want to spend time with me,” and “I don’t have anything to say to people I don’t know. What would I talk about?” You can see how such thoughts might make it difficult for a person to engage in social

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gatherings where he would have to meet new people. Or if the person did attend such an activity, he might feel so uncomfortable that he would leave without talking to anyone, and this would more than likely just make it harder for him to reach out to others in the future. Becoming aware of these negative thoughts and challenging them (as discussed in Chapter 4 on Thinking Tools) is the first step toward change. However, by itself, this is usually not sufficient. You will need opportunities to practice some basic social skills, and your therapist will help you with these. Your therapist will also help you set up opportunities to check out the evidence supporting or refuting any such negative thoughts, much like the scientist doing experiments to check his or her theories. Again, role playing during your therapy sessions can be very helpful in getting started. The case example of Richard can help you understand this better. Richard is a 77-year-old retired software engineer whose wife died after a prolonged illness about 5 years earlier. Although he is intellectually active and uses his home computer daily to remain in contact with the “tech world,” Richard has gradually disengaged from friendships associated with work. For example, there are periodic reunions for former employees as well as several company events each year that he is invited to, but he begs off, saying he does not want to go alone, and he won’t know anyone when he’s there because all his old friends have died or moved away or are too physically ill to attend. Richard has a son who lives nearby, and there are four grandchildren with whom he has daily contact. He helps to babysit the grandchildren and has dinner regularly with his son’s family. He reports these to be pleasant events that he looks forward to eagerly. In the course of describing these relationships, he contrasted the time he spends with them (which is enjoyable) with the time he spends alone (which is most of the day and which he described as “empty”). This brought the issue to light and after some discussion of its importance, it became a focus for therapy. First, small goals had to be established, in a hierarchical fashion, so that each time he succeeded, it would encourage him to continue (e.g., driving to the senior center, going in to pick up a schedule; taking a tour of the facility; all of these things were done before any home practice assignment was given to go there for lunch and sit down beside someone and talk with them). Second, relaxation exercises were taught to reduce his anxiety: He was able to learn how to take slow, deep breaths and this seemed to calm him. Third, role playing was done in session to help him practice what to say to a stranger he’d just met. He realized he could discuss current events, as he reads a newspaper every day and keeps up on

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what is happening in the world. He decided he could read one or two books on the bestseller list and make notes about who the characters were and what the plot was (so he would not forget the details), as many people like to discuss the books they read. He is an enthusiastic computer buff and was able to talk about some technical subjects in the role plays, thinking he might run across another older person like himself who had done similar work in the past. Armed with these topics and having practiced what to say, he felt confident to go to lunch at the senior center and talk with the person next to him. This was successfully accomplished after two tries; the first time he was too anxious to eat and he left early. The second time he did the relaxation exercise before he entered the building and he said this gave him a sense of control and so he was able to follow through as planned. Subsequent therapy sessions focused on “next steps”—after you meet someone interesting to talk with, how do you invite them to lunch? Or to a movie? Or to do something else together? Again Richard did role plays with the therapist to develop effective ways to do this. Richard was fully engaged in this process and was able to take what he learned in the office into the senior center. He is now attending three times a week on average and is slowly expanding his social network. He has thought about returning to church services as well (something he had not done since his wife’s death). He believes he will find acceptance there and people to talk with, so this is likely to be his next step in the process of developing a meaningful social network. He no longer believes his negative thoughts so strongly, and although they do occur in some new situations, he is able to challenge them effectively, using the evidence he has gained in getting established with others in the senior center.

Summary Questions 1. What were the key points brought up in this section of the module?

2. What skills did I learn?

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3. What assignments might help me practice these skills?

4. Additional thoughts or questions I have about this material:

Home Practice Assignments for this section might include the following:

✎

Practice effective communication and try specific techniques, such as using “I” statements, compromise, and the broken record technique.

✎

Work with your therapist to develop a behavioral assignment you’re willing to try, such as calling an old friend or attending some type of social gathering.

✎

Think of a social event you might like to attend, and then complete a UTD to identify some negative thoughts that might keep you from going. Bring this to the next session and work with your therapist to develop behavioral or cognitive strategies that will counteract the negative thoughts.

✎

Answer summary questions for this section.

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Late Phase of Therapy

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Chapter 7

Module 7: Ending Therapy

Goals ■

To prepare for the end of treatment

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To think about what ending therapy means to you

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To review skills learned in therapy

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To plan for future stressful situations by creating a maintenance guide

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To identify danger signals and make a plan for dealing with them

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To use your workbook as a resource

Now that you are coming to the end of your therapy, it is important to spend some time preparing for the future, when you will be more “on your own.” There are several steps you can take while still in treatment to help yourself with this task.

Scheduling the Ending Process It is best to end therapy in a gradual and systematic way. The final few sessions will be “spaced out” (i.e., they won’t be held weekly, but perhaps biweekly or monthly). The reason for this is to help you to begin to disengage from the therapeutic relationship and to see how well you can handle things on your own. For example, Will you still do your “home practice” with less frequent reminders? Will you be able to use the tools learned in therapy to deal with negative moods? Hopefully, your schedule will allow you to work with this plan, so that you will not have to end abruptly. More gradual endings are usually easier for people to adjust to and are also associated with more long-term improvement. You will have an opportunity to try things out more on your own, yet with the “safety net” of knowing that you still have therapy sessions coming up in the near future.

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Also, you and your therapist can discuss the possibility of scheduling “booster sessions” after your last formal session. Booster sessions are a way for you to check-in with your therapist about how you are adjusting to using these skills on your own.

What Does Ending Mean to You? During the final sessions, your therapist will ask you to talk about the following: ■

what ending therapy means to you

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your ideas about what was more helpful and what was less helpful during the treatment

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your feelings about your relationship with your therapist

Talking directly about these issues will help you to create a more positive ending to therapy. It will also give you a sense of closure that is very important—we don’t want you to walk away from this experience without having gotten the most you can out of it! Come prepared to talk about these things—perhaps, you want to write out some notes on these topics or complete an Unhelpful Thought Diary (or two) about your fears and concerns about ending therapy. Other topics may also come up at this point in time. For example, you may consider whether or not you should continue with another professional therapist or go on antidepressant medication. Or perhaps you might want to join a selfhelp group or a support group of some kind. Be sure to discuss any personal needs with your therapist so that you can address them together before ending therapy, and appropriate referrals can be made as needed.

The Maintenance Guide During the last few sessions, you and your therapist will spend a fair amount of time developing your Maintenance Guide. This guide summarizes your therapy experience and will help you to review skills and to prepare for possible problems in the future.

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This chapter includes several forms that will help you prepare for creating your personal maintenance guide. A template for the Maintenance Guide is then included at the end of the chapter. It includes some general questions you might consider with your therapist in developing your maintenance guide. You and your therapist may also think of some other questions and comments to put in your maintenance guide that are special for you and your circumstances. In your final guide, you will have included the names and numbers of people to call if you need further help. It will also include very specific information about what to do in the event that you notice changes in your thoughts, your feelings, or your behaviors that signal you might be slipping into depression. If you follow your maintenance guide and act right away, chances are you will be able to avoid another depressive episode.

Example of Maintenance Guide

We have included an example of a maintenance guide to show you how it works. First, here is some background information about our client John: John is an 80-year-old married electrical engineer who retired at age 68 from a major aviation company. Following retirement, John became severely depressed and developed what is known as “excess disability.” Namely, his level of functioning was more impaired than one would expect for the kind of disorder he was experiencing. He couldn’t remember things. He rarely spoke, and when he did he often seemed confused. He couldn’t concentrate well enough to balance his checkbook, which was a task he always enjoyed doing prior to this episode. This was John’s first episode of depression, although earlier in his life he had experienced episodes of anxiety related to his job performance. His wife initially thought he was becoming demented and insisted he talk to his doctor about his cognitive problems. He was referred to a neurologist, and a behavioral assessment indicated that his major problem was severe depression. He was treated and recovered within six months. However, during the 12 years following his retirement, he’s had several depressive episodes which seem to get more intense and last longer with each recurrence. They also usually occurred after stopping some type of paid work activity. Generally, John is very self-critical and often finds himself ruminating regretfully about his past behavior—the things he should not have done but did, and the

155

things he should have done but didn’t. John took great pride in his job performance and his work seemed to be a primary source of his self-value. John always expected that he should be perfect in his work. He reported that he felt better when he was getting some recognition for his work, and so he was constantly trying to find a suitable job. However, as he aged, it became more difficult to find a job. Eventually, he became involved in being a volunteer math teacher for underachieving students in a local middle school. He adjusted to the fact that he was no longer being paid for his work and took some satisfaction in helping others. Gradually, however, he had become more hypercritical of both himself and the students he was teaching. After some time in this role, he became so depressed that he was again having difficulty functioning, and the superintendent recommended that he seek counseling. He reviewed several counseling methods and decided CBT would be the most effective for him. He responded well to CBT, and after 15 sessions, his level of depressive symptoms was within normal limits. Together, he and his therapist set up a maintenance guide for him to use following termination. They first reviewed the things that John thought he had mastered, and he recorded these in his workbook. Developing this guide has been extremely helpful to John in adjusting to his life situation following therapy. In fact, John returned for a second booster session one year following termination, and he reported that things had been going very well. He found that he frequently consulted his workbook for information, but he stated that he did this because he actually enjoyed reviewing the materials that he had learned and not because he was concerned that he might be slipping into an episode. Together at this session, he and his therapist reviewed the Maintenance Guide and made some slight changes based on how he had responded to several stressful occurrences during the year. In summary, John was enthusiastic about the results of his therapy and was pleased at how helpful the Maintenance Guide appeared to be in preventing a recurrence of depression, even in the face of a couple of crises that might otherwise have precipitated a reoccurrence of depression. At this point, he is optimistic that he will have minimal problems with depression, but he knows what to do if the need arises. As you go through the various steps of creating a maintenance guide, refer to John’s Maintenance Guide (Figure 7.1) to see what he included.

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1. What Skills Have I Learned in Therapy? Cognitive Skills I have learned to: ■

Be realistic about my self-worth.

■

Concentrate on the positives and what I do well.

■

Break things down. Don’t think globally.

■

Not dwell on my weaknesses. Remember everybody has some.

■

Monitor thoughts and identify unhelpful thoughts.

■

Replace negative thoughts with more positive ones.

■

Think in shades of gray—things are not either black or white.

■

Stop jumping to conclusions without the evidence.

Behavioral Skills I have learned to: ■

Use breathing technique to relax quickly in unpleasant situations.

■

Stop overthinking when it gets in my way.

■

Work out a schedule and stick to it.

■

Break seemingly overwhelming jobs into component parts.

■

Step back and use problem solving when things don’t go well.

Interpersonal Skills I have learned to: ■

Be patient with slow learners.

■

Stop assuming it’s my fault if people can’t understand what I’m saying.

■

Remember to be assertive, not angry.

■

Be open and straightforward.

■

Be calm and direct. It’s Ok to say no.

■

Remember to communicate that it’s good if everybody wins when there is conflict.

Figure 7.1 John’s Maintenance Guide.

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2. Which Future Situations May Be Stressful? ■

Not having a job where people look to me for help.

■

Getting my taxes finished and my insurance renewals in on time.

■

Getting the backyard shed completed.

■

Having nothing to do that makes me feel worthwhile.

3. How Will I Deal With Future Stressful Situations? ■

Use my favorite relaxation technique.

■

Remember that I am only human and can only do so much. My work doesn’t have to be perfect.

■

Focus and concentrate on one thing at a time. Step back and break things into their component parts. “You can eat an elephant if you chop it up into enough little parts.”

■

Organize: Estimate times for each task and try to stick to it.

■

Make sure the goals are attainable. Do things in little steps so I can see that I’m making progress.

■

Ask for help when I need it. I don’t have to do everything. It doesn’t mean I’m a failure if my wife helps with some things.

■

Try to remember that I’m important to my family, even if I’m not working on a job. When they get to be my age, they will look at what I’m doing now as a model to help them through the stresses that they’ll deal with. I’m a teacher for them in how to deal with life’s problems.

■

One’s self-worth is not determined by one’s financial worth. I must remember that!

4. What Are My Danger Signals? Thoughts and Behaviors ■

I start to think about how to get everything done at once. Start trying to do too many things at once and not getting closure on anything.

■

I begin to lose my focus on the here and now and think about all the things I should be doing instead.

Emotions ■

I start to become impatient and irritable with my wife and my kids and grandchildren for no reason at all.

■

I lose patience even with little inconsequential things that go wrong.

■

When I can see that I’m not enjoying things that I normally enjoy.

Figure 7.1 continued.

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Physical Symptoms ■

Trouble getting to sleep at night. Lying in bed and can’t stop thinking about all the things that need to get done.

■

I find myself pacing and feeling tense at times when I should be relaxed.

5. What Should I Do When I See These Danger Signals? ■

Review my workbook to see what has worked for me in the past.

■

Go back to basics: thought monitoring using the UTD: check my thinking to see if I am distorting things again.

■

Start doing more pleasurable things.

■

Do thought stopping.

■

Talk to my wife about the problems.

■

If necessary, make an appointment with my old therapist for a booster, or at least talk to her on the phone to help get back on track using the skills I know.

■

Keep monitoring and check my progress.

■

Be sure I have not slipped back to making unrealistic expectations about my goals.

Figure 7.1 continued.

Review of Skills To begin the preparation of your guide, list what specific skills you feel are going to be most useful to you in the future. Spend a few minutes now to think about all of the skills you have learned in therapy. Use the form provided to make notes about your cognitive, behavioral, and interpersonal skills.

159

My Skills Ask yourself: What skills have I learned? What tools did I use to achieve my goals? COGNITIVE SKILLS

BEHAVIORAL SKILLS

INTERPERSONAL SKILLS

160

Planning for Future Stressful Situations Certain situations are likely to arise in the future that might make you feel down again. Now is the time to think about these situations or events and how the tools you have learned in therapy can help you handle them. For example, you may be afraid that you will get depressed again if your health declines further or if you have to move to a new area. Both of these events are likely to be stressful, but neither of them have to result in depression. You can use your new skills to combat your negative thinking and to keep your level of pleasant activities high (despite the fact that negative things have happened). Use the form on the next page to make a list of your high-risk situations and what skills would be helpful. Your therapist will discuss the details with you and suggest additional ideas.

161

How Will I Handle Future Stressful Situations? First develop your own personal list of events or situations that are (a) likely to occur after therapy ends, and (b) likely to cause you to feel depressed (or some other strong negative emotion). Next, identify which specific cognitive, behavioral, or interpersonal skills would help in each particular situation. Potentially Stressful Situations

162

Skills to Use

Danger Signals Danger signals are warning signs that low moods are again present and getting more severe. Depressive reactions may still occur, despite your best efforts. For example, you may become overwhelmed by one very big negative event (such as death of a loved one) or several small bad things may happen at once, overtaxing your ability to cope. Remember this can happen to anyone—it is nothing to be ashamed of. Identifying Danger Signals

So how do you know when you are in danger? Think back to your most recent bout of depression and try to remember what your main symptoms were. Did you mainly have trouble eating, sleeping, or with your energy level? Were you mainly preoccupied with negative thoughts about yourself and the future? Were you primarily sad, angry, anxious, or perhaps lonely, in terms of mood? How did you function? What areas of your functioning seemed to be affected by your depression? Be sure to discuss your prior history in session—your therapist can clarify which symptoms are more significant in terms of signaling serious depression. Use the form on the next page to make a list of the symptoms that you would consider to be your danger signals. This way you can notice them right away so you can do something about your depression before it gets worse.

163

What Are My Danger Signals? THOUGHTS/BEHAVIORS

EMOTIONS

PHYSICAL SYMPTOMS

164

Making a Plan

So now you know what your danger signals are, but what should you do when you experience them? Your therapist will help you develop a concrete plan of action to be followed when certain symptoms resurface. Who should you call? What should you do if your current therapist is no longer in the area, or is not available, if you need therapy again? You should have specific answers to these questions so that you will know what to do if you need treatment in the future. Write some things you will do if you notice danger signals in the space provided. When I experience danger symptoms, I will. . . .

One Important Resource: Your Workbook! Remember the value of your workbook. You have worked very hard to make changes to improve your well-being. Your workbook serves as a written record of your work, containing all the notes, exercises, and forms. Keep this workbook in a place where you can find it easily. It can be a useful reference for reviewing tools; you may want to look over certain sections as needed. Your workbook is also a great reminder of your new ability to work through problems. Congratulations on completing the program!

165

Maintenance Guide 1. What Skills Have I Learned in Therapy? Cognitive Skills

Behavioral Skills

Interpersonal Skills

2. Which Future Situations May Be Stressful?

continued

166

3. How Will I Deal With Future Stressful Situations?

4. What Are My Danger Signals? Thoughts and Behaviors

Emotions

Physical Symptoms

continued

167

Maintenance Guide continued 5. What Should I Do When I See These Danger Signals?

6. Who Can I Call if I Need Further Help? Therapist:

Number:

Name:

Number:

Name:

Number:

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The California Older Person’s Pleasant Events Schedule (COPPES)

Name:

Date:

This is a list of 66 events that people tend to find pleasant. For each event, make 2 ratings: How often did this event happen to you in the past month? 0 = Not at all 1 = 1–6 times 2 = 7 or more times How pleasant, enjoyable, or rewarding was this event? If the event did not occur, then please rate how pleasant you think it would have been if it had occurred. 0 = Was not or would not have been pleasant 1 = Was or would have been somewhat pleasant 2 = Was or would have been very pleasant Here are two sample events with the answers properly filled in. Please remember to circle an answer for both HOW OFTEN and HOW PLEASANT for each event. HOW OFTEN in the past

HOW PLEASANT was it or

month?

would it have been?

0 = Not at all

0 = Not pleasant

1 = 1–6 times

1 = Somewhat pleasant

Please circle ONE number in

2 = 7 or more times

2 = Very pleasant

EACH column for each item

Circle ONE number

Circle ONE number

A. Winning the lottery

0


1

B. Writing a letter

0

1


2 2

0

1

2


0

1


2

169

HOW OFTEN in the past

HOW PLEASANT was it or

month?

would it have been?

0 = Not at all

0 = Not pleasant

1 = 1–6 times

1 = Somewhat pleasant

Please circle ONE number in

2 = 7 or more times

2 = Very pleasant

EACH column for each item

Circle ONE number

Circle ONE number

1. Looking at clouds

0

1

2

0

1

2

2. Being with friends

0

1

2

0

1

2

3. Having people show an interest in what I say

0

1

2

0

1

2

4. Thinking about pleasant memories

0

1

2

0

1

2

5. Shopping

0

1

2

0

1

2

6. Seeing beautiful scenery

0

1

2

0

1

2

7. Having a frank and open conversation

0

1

2

0

1

2

8. Doing a job well

0

1

2

0

1

2

9. Listening to sounds of nature

0

1

2

0

1

2

10. Having coffee, tea, etc., with friends

0

1

2

0

1

2

11. Thinking about myself

0

1

2

0

1

2

12. Being complimented or told I have done something well

0

1

2

0

1

2

13. Doing volunteer work

0

1

2

0

1

2

14. Planning trips or vacations

0

1

2

0

1

2

15. Kissing, touching, showing affection

0

1

2

0

1

2

16. Being praised by people I admire

0

1

2

0

1

2

17. Meditating

0

1

2

0

1

2

18. Listening to music

0

1

2

0

1

2

19. Seeing good things happen to family or friends

0

1

2

0

1

2 continued

170

20. Collecting recipes

0

1

2

0

1

2

21. Doing a project my own way

0

1

2

0

1

2

22. Seeing or smelling a flower or plant

0

1

2

0

1

2

23. Saying something clearly

0

1

2

0

1

2

24. Thinking about something good in the future

0

1

2

0

1

2

25. Looking at the stars or moon

0

1

2

0

1

2

26. Being told I am needed

0

1

2

0

1

2

27. Working on a community project

0

1

2

0

1

2

28. Complimenting or praising someone

0

1

2

0

1

2

29. Watching a sunset

0

1

2

0

1

2

30. Thinking about people I like

0

1

2

0

1

2

31. Completing a difficult task

0

1

2

0

1

2

32. Amusing people

0

1

2

0

1

2

33. Baking because I feel creative

0

1

2

0

1

2

34. Reading literature

0

1

2

0

1

2

35. Being with someone I love

0

1

2

0

1

2

36. Having an original idea

0

1

2

0

1

2

37. Having peace and quiet

0

1

2

0

1

2

38. Listening to the birds sing

0

1

2

0

1

2

39. Making a new friend

0

1

2

0

1

2

40. Being asked for help or advice

0

1

2

0

1

2

41. Bargain hunting

0

1

2

0

1

2

42. Reading magazines

0

1

2

0

1

2

43. Feeling a divine presence

0

1

2

0

1

2 continued

171

continued 44. Expressing my love to someone

0

1

2

0

1

2

45. Giving advice to others based on past experience

0

1

2

0

1

2

46. Solving a problem, puzzle, crossword

0

1

2

0

1

2

47. Arranging flowers

0

1

2

0

1

2

48. Helping someone

0

1

2

0

1

2

49. Getting out of the city (to the mountains, seashore, desert)

0

1

2

0

1

2

50. Having spare time

0

1

2

0

1

2

51. Being needed

0

1

2

0

1

2

52. Meeting someone new of the same sex

0

1

2

0

1

2

53. Exploring new areas

0

1

2

0

1

2

54. Having a clean house

0

1

2

0

1

2

55. Doing creative crafts

0

1

2

0

1

2

56. Going to church

0

1

2

0

1

2

57. Being loved

0

1

2

0

1

2

58. Visiting a museum

0

1

2

0

1

2

59. Having a daily plan

0

1

2

0

1

2

60. Being with happy people

0

1

2

0

1

2

61. Listening to classical music

0

1

2

0

1

2

62. Shopping for a new outfit

0

1

2

0

1

2

63. Taking inventory of my life

0

1

2

0

1

2

64. Planning or organizing something

0

1

2

0

1

2

65. Smiling at people

0

1

2

0

1

2

66. Being near sand, grass, a stream

0

1

2

0

1

2

172

Appendix of Forms

173

Target Complaint Worksheet Problem

a. In what situations does this occur?

b. Why do you think this problem occurs?

c. Has this problem come up before? If yes, please continue with section d If no, please go to section e d. What have you tried in the past to help you manage this problem? Did these strategies help before? If they did help, why aren’t they helping now?

e. Please circle the number that best describes how much this problem is bothering you now.

0% not at all

174

10

20

30 a little

40

50

60

70 very much

80

90

100 couldn’t be worse

Goal-Setting Worksheet Goal:

1. Is your goal:
Important to you?


Specific?


Positive?


Time-limited?


Realistic?


Measurable?

2. How could you or someone else determine whether this goal has been met or not at the end of treatment? Please specify some concrete behaviors or concrete events that might be used as criteria that the goal has been met. a. If treatment is a success in regard to this goal, I will probably:

b. If treatment is partially successful, I will probably:

c. If the goal is not met at all, I will probably:

175

176

Activity Monitoring Form Time

Pleasure, Mastery, & Mood Ratings (1–10)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Activity Monitoring Form Time

177

Pleasure, Mastery, & Mood Ratings (1–10)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

178

Activity Monitoring Form Time

Pleasure, Mastery, & Mood Ratings (1–10)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Daily Mood Rating Form Please rate your mood at different times during the day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

very depressed

Time of day

3

4

5

6

7

8

9

“so-so”

Mood score

10 very happy

Reasons why I felt this way

179

Daily Mood Rating Form Please rate your mood at different times during the day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

very depressed

Time of day

180

3

4

5

6

7

8

9

“so-so”

Mood score

10 very happy

Reasons why I felt this way

Daily Mood Rating Form Please rate your mood at different times during the day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

very depressed

Time of day

3

4

5

6

7

8

9

“so-so”

Mood score

10 very happy

Reasons why I felt this way

181

Daily Mood Rating Form Please rate your mood at different times during the day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

very depressed

Time of day

182

3

4

5

6

7

8

9

“so-so”

Mood score

10 very happy

Reasons why I felt this way

Daily Mood Rating Form Please rate your mood at different times during the day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

very depressed

Time of day

3

4

5

6

7

8

9

“so-so”

Mood score

10 very happy

Reasons why I felt this way

183

End-of-Day Mood Rating Form Date: From

to

Please rate your mood at the end of each day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

very depressed

Date

184

4

5

6

7

8

“so-so”

Mood score

9

10 very happy

Why I think I felt that way

End-of-Day Mood Rating Form Date: From

to

Please rate your mood at the end of each day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

very depressed

Date

4

5

6

7

8

“so-so”

Mood score

9

10 very happy

Why I think I felt that way

185

End-of-Day Mood Rating Form Date: From

to

Please rate your mood at the end of each day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

very depressed

Date

186

4

5

6

7

8

“so-so”

Mood score

9

10 very happy

Why I think I felt that way

End-of-Day Mood Rating Form Date: From

to

Please rate your mood at the end of each day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

very depressed

Date

4

5

6

7

8

“so-so”

Mood score

9

10 very happy

Why I think I felt that way

187

End-of-Day Mood Rating Form Date: From

to

Please rate your mood at the end of each day, that is, how good or bad you felt, using the 10-point scale shown below. If you felt good, put a high number on the chart below. If you felt “so-so,” mark a 5. And if you felt low or depressed, mark a lower number.

1

2

3

very depressed

Date

188

4

5

6

7

8

“so-so”

Mood score

9

10 very happy

Why I think I felt that way

Pleasant Events Tracking Form Pleasant Events

Days 1

2

3

4

5

6

7

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Total

189

Pleasant Events Tracking Form Pleasant Events

Days 1

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Total

190

2

3

4

5

6

7

Pleasant Events Tracking Form Pleasant Events

Days 1

2

3

4

5

6

7

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Total

191

Pleasant Events Tracking Form Pleasant Events

Days 1

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Total

192

2

3

4

5

6

7

Problem-Solving Worksheet Step 1: Define the problem. What was the problem? What did you need to solve?

Step 2: Explore solutions. Remember, do not worry about the quality of each solution. Just write down whatever comes to mind.

Step 3: Evaluate and rank choices. Start by picking out the most realistic, then the second, then the third, and so on. What criteria are you going to use to rank your choices?

Possible Solutions

Rank

Step 4: Decide on an alternative. What are you willing to try?

continued

193

Problem-Solving Worksheet continued What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

Step 5: Select another alternative, if needed. What alternative are you willing to try now?

What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

194

Problem-Solving Worksheet Step 1: Define the problem. What was the problem? What did you need to solve?

Step 2: Explore solutions. Remember, do not worry about the quality of each solution. Just write down whatever comes to mind.

Step 3: Evaluate and rank choices. Start by picking out the most realistic, then the second, then the third, and so on. What criteria are you going to use to rank your choices?

Possible Solutions

Rank

Step 4: Decide on an alternative. What are you willing to try?

continued

195

Problem-Solving Worksheet continued What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

Step 5: Select another alternative, if needed. What alternative are you willing to try now?

What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

196

Problem-Solving Worksheet Step 1: Define the problem. What was the problem? What did you need to solve?

Step 2: Explore solutions. Remember, do not worry about the quality of each solution. Just write down whatever comes to mind.

Step 3: Evaluate and rank choices. Start by picking out the most realistic, then the second, then the third, and so on. What criteria are you going to use to rank your choices?

Possible Solutions

Rank

Step 4: Decide on an alternative. What are you willing to try?

continued

197

Problem-Solving Worksheet continued What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

Step 5: Select another alternative, if needed. What alternative are you willing to try now?

What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

198

Problem-Solving Worksheet Step 1: Define the problem. What was the problem? What did you need to solve?

Step 2: Explore solutions. Remember, do not worry about the quality of each solution. Just write down whatever comes to mind.

Step 3: Evaluate and rank choices. Start by picking out the most realistic, then the second, then the third, and so on. What criteria are you going to use to rank your choices?

Possible Solutions

Rank

Step 4: Decide on an alternative. What are you willing to try?

continued

199

Problem-Solving Worksheet continued What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

Step 5: Select another alternative, if needed. What alternative are you willing to try now?

What happened ?

What thoughts do you have about the way you solved your problem?

How are you feeling about your problem now?

200

3-Column Unhelpful Thought Diary Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

201

3-Column Unhelpful Thought Diary Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

202

Rate how strong your emotions are from 0% to 100%.

3-Column Unhelpful Thought Diary Antecedents or Situation

Beliefs or Thoughts

Consequences or Emotions

Describe the situation or event that led to your unpleasant emotions.

Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience.

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Rate how strongly you believe in these thoughts from 0% to 100%.

Rate how strong your emotions are from 0% to 100%.

203

204

6-Column Unhelpful Thought Diary A Antecedents or Situation Describe the situation or an event that led to your unpleasant emotions.

B Beliefs or Thoughts Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience. Rate how strongly you believe in these thoughts from 0% to 100%.

C

D

Consequences or Emotions

Develop Adaptive Responses

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Challenge your negative thoughts. What is the evidence for and against each thought? What are more helpful ways of thinking about the experience?

Rate how strong your emotions are from 0% to 100%.

Rate how strongly you believe in these thoughts from 0% to 100%.

E Effect: What is the impact or effect of changing your negative thoughts? Write down the emotions you are feeling now. Rate how strong your emotions are from 0% to 100%.

F Function: Now that you have considered more helpful thoughts, what will you do differently in similar situations? How is changing your thinking likely to affect your daily life?

6-Column Unhelpful Thought Diary A Antecedents or Situation Describe the situation or an event that led to your unpleasant emotions.

B Beliefs or Thoughts Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience. Rate how strongly you believe in these thoughts from 0% to 100%.

C

D

Consequences or Emotions

Develop Adaptive Responses

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Challenge your negative thoughts. What is the evidence for and against each thought? What are more helpful ways of thinking about the experience?

Rate how strong your emotions are from 0% to 100%.

Rate how strongly you believe in these thoughts from 0% to 100%.

E Effect: What is the impact or effect of changing your negative thoughts? Write down the emotions you are feeling now. Rate how strong your emotions are from 0% to 100%.

F Function: Now that you have considered more helpful thoughts, what will you do differently in similar situations? How is changing your thinking likely to affect your daily life?

205

206

6-Column Unhelpful Thought Diary A Antecedents or Situation Describe the situation or an event that led to your unpleasant emotions.

B Beliefs or Thoughts Write down your negative thoughts and/or negative self-talk that occurred in connection with this experience. Rate how strongly you believe in these thoughts from 0% to 100%.

C

D

Consequences or Emotions

Develop Adaptive Responses

Write down what you were feeling during this experience (sad, angry, anxious, etc.)

Challenge your negative thoughts. What is the evidence for and against each thought? What are more helpful ways of thinking about the experience?

Rate how strong your emotions are from 0% to 100%.

Rate how strongly you believe in these thoughts from 0% to 100%.

E Effect: What is the impact or effect of changing your negative thoughts? Write down the emotions you are feeling now. Rate how strong your emotions are from 0% to 100%.

F Function: Now that you have considered more helpful thoughts, what will you do differently in similar situations? How is changing your thinking likely to affect your daily life?

Core Beliefs Life Review Form #1: Helping to Identify Unhelpful Core Beliefs and Relate Them to Different Periods in Your Life Life Stage 1 From: Birth to What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 2 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 3 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 4 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

continued

207

Core Beliefs Life Review Form #1: Helping to Identify Unhelpful Core Beliefs and Relate Them to Different Periods in Your Life continued Life Stage 5 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 6 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 7 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

Life Stage 8 From:

to

What were key events, situations, experiences during this time period that relate in some way to your unhelpful beliefs? Please write in this space.

208

Core Beliefs Life Review Form #2 Life Stage

Core Belief

Evidence For

Evidence Against

209

210

Tension Diary Directions: For each day, rate your average tension score. Indicate the situations in which you were the least relaxed and most relaxed, as well as any physical symptoms that you experienced. Tension rating:

Day Average score for the day

Most Tense score When & Where? What was the situation?

Least tense Score When & Where? What was the situation?

1 = Least tense you have ever been

Monday

Tuesday

10 = Most tense you have ever been

Wednesday

Thursday

Friday

Saturday

Tension Diary Directions: For each day, rate your average tension score. Indicate the situations in which you were the least relaxed and most relaxed, as well as any physical symptoms that you experienced. Tension rating:

Day Average score for the day

Most Tense score When & Where? What was the situation?

Least tense Score When & Where? What was the situation?

1 = Least tense you have ever been

Monday

Tuesday

10 = Most tense you have ever been

Wednesday

Thursday

Friday

Saturday

211

212

Tension Diary Directions: For each day, rate your average tension score. Indicate the situations in which you were the least relaxed and most relaxed, as well as any physical symptoms that you experienced. Tension rating:

Day Average score for the day

Most Tense score When & Where? What was the situation?

Least tense Score When & Where? What was the situation?

1 = Least tense you have ever been

Monday

Tuesday

10 = Most tense you have ever been

Wednesday

Thursday

Friday

Saturday

Tension Diary Directions: For each day, rate your average tension score. Indicate the situations in which you were the least relaxed and most relaxed, as well as any physical symptoms that you experienced. Tension rating:

Day Average score for the day

Most Tense score When & Where? What was the situation?

Least tense Score When & Where? What was the situation?

1 = Least tense you have ever been

Monday

Tuesday

10 = Most tense you have ever been

Wednesday

Thursday

Friday

Saturday

213

Relaxation Practice Log

Directions: Rate your level of tension from “1,” least tense, to “10,” most tense, before and after the relaxation exercise. Record the time of day that you did the exercise and some comments regarding the prior stressful situation and whether the relaxation helped you. Do this each day.

Date

Time

Relaxation Score

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

214

Comments

Relaxation Practice Log

Directions: Rate your level of tension from “1,” least tense, to “10,” most tense, before and after the relaxation exercise. Record the time of day that you did the exercise and some comments regarding the prior stressful situation and whether the relaxation helped you. Do this each day.

Date

Time

Relaxation Score

Comments

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

215

Relaxation Practice Log

Directions: Rate your level of tension from “1,” least tense, to “10,” most tense, before and after the relaxation exercise. Record the time of day that you did the exercise and some comments regarding the prior stressful situation and whether the relaxation helped you. Do this each day.

Date

Time

Relaxation Score

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

216

Comments

Relaxation Practice Log

Directions: Rate your level of tension from “1,” least tense, to “10,” most tense, before and after the relaxation exercise. Record the time of day that you did the exercise and some comments regarding the prior stressful situation and whether the relaxation helped you. Do this each day.

Date

Time

Relaxation Score

Comments

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10

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A-B-C Form A = Action A situation that causes me frustration.

B = Belief My thoughts/beliefs about the situation that are making me upset.

Identify the Unhelpful Thinking Patterns

218

C = Consequence My feelings about the situation that are making me upset.

A-B-C Form A = Action A situation that causes me frustration.

B = Belief My thoughts/beliefs about the situation that are making me upset.

C = Consequence My feelings about the situation that are making me upset.

Identify the Unhelpful Thinking Patterns

219

A-B-C Form A = Action A situation that causes me frustration.

B = Belief My thoughts/beliefs about the situation that are making me upset.

Identify the Unhelpful Thinking Patterns

220

C = Consequence My feelings about the situation that are making me upset.

A-B-C (STOP) D Form Danger Signals

D = Do

What I notice about myself that tells me that I am upset and that I need to stop. (Physical)

What I think about and do now after using my stop signs. How I will handle this differently in the future. New Thoughts

Stop Signs What I can use in this situation to interrupt my train of unhelpful thoughts or to stop myself. (Visual) New Actions

221

A-B-C (STOP) D Form Danger Signals

D = Do

What I notice about myself that tells me that I am upset and that I need to stop. (Physical)

What I think about and do now after using my stop signs. How I will handle this differently in the future. New Thoughts

Stop Signs What I can use in this situation to interrupt my train of unhelpful thoughts or to stop myself. (Visual) New Actions

222

A-B-C (STOP) D Form Danger Signals

D = Do

What I notice about myself that tells me that I am upset and that I need to stop. (Physical)

What I think about and do now after using my stop signs. How I will handle this differently in the future. New Thoughts

Stop Signs What I can use in this situation to interrupt my train of unhelpful thoughts or to stop myself. (Visual) New Actions

223

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National Resources for Older Adults

Organization Name

Brief Description

Contact Information

Eldercare Locator—Area Agencies on Aging

Links older adults and their family members to state and local area agencies on aging (AAAs) and community-based organizations that help older adults remain at home and in the community.

Eldercare Hotline: (800) 677-1116 Available weekdays 9 a.m.–8 p.m. Spanish-speaking information specialist available. www.eldercare.gov

American Association of Retired Persons (AARP)

Provides information on a variety of issues including long-term care, retirement, financial and legal resources, etc.

(888) 687-2277 Available weekdays 7 a.m.–midnight ET. www.aarp.org

Alzheimer’s Association

Provides information and care consultation on recognizing dementia, planning and paying for care, and linking local support and resources.

24 × 7 Hotline: (800) 272-3900 www.alz.org

Association for Frontotemporal Dementias (FTD)

Provides information and support to people with FTD and to their families.

(866) 507-7222 www.ftd-picks.org

Lewy Body Dementia Association, Inc.

Provides information and support to patients with Lewy Body dementia and to their families.

(800) 539-9767 www.lbda.org

American Cancer Society

The national call center provides information for cancer patients and their caregivers on community programs and services.

(800) 227-2345 www.cancer.org

Cancer Information, National Cancer Institute

Provides personalized, confidential responses to specific questions about cancer.

(800) 422-6237 Available weekdays 9 a.m.–4:30 p.m. EST.

General Information

Health-Related Issues

Spanish-speaking information specialists available. www.cancer.gov continued

225

continued American Chronic Pain Association

Offers resources for patients and their families to better manage chronic pain.

(800) 533-3231 www.theacpa.org

American Pain Foundation

Provides information on resources for patients with pain and their families.

(800) 615-7246 www.painfoundation.org

American Diabetes Association

Provides information on services to people with diabetes.

(800) 342-2383 Available weekdays 8:30 a.m.–8 p.m. EST. Spanish-speaking representative available. www.diabetes.org/

American Heart Association

Provides information on prevention and treatment of heart disease and stroke.

(800) 242-8721 www.americanheart.org

American Parkinson Disease Association, Inc.

Provides patient and caregiver support and referrals to local resources.

(800) 223-2732 www.apdaparkinson.org

Parkinson’s Disease Foundation

The toll-free line answers questions regarding Parkinson’s disease.

(800) 457-6676 www.pdf.org

American Stroke Association

Provides information and referrals to stroke survivors and their caregivers.

Stroke Family Warmline: (888) 478-7653 www.strokeassociation.org

National Stroke Association

Provides information and resources to stroke survivors and their families.

(800) 787-6537 www.stroke.org

Arthritis Foundation

Answers queries on arthritis-related information and provides linkages to community-based services to help with people suffering from arthritis.

(800) 283-7800 www.arthritis.org

Brain Injury Association of America

Offers a helpline providing information on brain injury and to assist families of brain injury patients seeking support.

(800) 444-6443 www.biausa.org

Caring Connections

A program of the National Hospice and Palliative Care Organization that offers free resources and information on advance care, financial planning, and hospice care.

(800) 658-8898 Helpline in Spanish: (877) 658-8896 www.caringinfo.org

Hospice Foundation of America

Provides information about end-of-life care.

(800) 854-3402 Available weekdays 8:30 a.m.–5:30 p.m. EST. www.hospicefoundation.org

Hearing Loss Association of America

Provides information on healthcare, education, local support, and other resources for people with hearing loss.

(301) 657-2248 www.hearingloss.org continued

226

The National Alcoholism and Drug Addiction Treatment Information Center

Provides information on drug and alcohol addiction treatment facts and other related questions.

(800) 784-6776. Available 24 × 7. www.addictioncareoptions.com

National Alliance on Mental Illness

Offers a helpline that answers questions regarding mental health issues and links to local resources.

(800) 950-6264 www.nami.org

Senior Site—American Foundation for the Blind

Offers information and support to older adults and their families coping with age-related eye diseases, and helps to locate local services.

(800)232-5463 www.afb.org/seniorsite/

Health Insurance/Legal Services/Financial Planning The Health Insurance Resource Center

Provides information on low-cost and affordable health insurance, health care, and hospice in each state.

(800) 798-8447 http://www.ahirc.org/

Housing Information for Seniors—U.S. Department of Housing & Urban Development

Provides information on housing options, financial assistance resources, and guides.

(202) 708-1112 www.hud.gov/groups/seniors.cfm

Identity Theft Resource Center

Provides information to prevent and recover from identity theft.

(858) 693-7935 www.idtheftcenter.org

National Crime Prevention Council

Provides crime prevention and personal safety information for older Americans.

(202) 422-6272 www.ncpc.org

Medicare

The toll-free line offers information on Medicare and health plans available in your local areas.

(800) 633-4227 Available 24 × 7. Spanish-speaking customer service representative available. www.medicare.gov

Medicare Rights Center

Provides information on rights and benefits of Medicare, health plan options, and drug coverage.

Counseling Hotline: (800) 333-4114 Available weekdays 9 a.m.–1 p.m. ET. www.medicarerights.org

American Bar Association— Commission on Law and Aging

Provides linkages to legal services in each state.

(202) 662-8690 www.abanet.org/aging

National Academy of Elder Law Attorneys

Provides help to locate an elder law attorney who deals with legal issues affecting older adults.

(520) 881-4005 www.naela.org

National Legal Aid & Defender Association

Provides linkages to local attorneys for people in need of legal assistance.

(202) 452-0620 www.nlada.org continued

227

continued Patient Advocate Foundation

Provides mediation between patients and their employers and/or creditors to resolve insurance, job retention, and/or debt crisis relating to the patient’s condition.

(800) 532-5274 www.patientadvocate.org

Federal Citizen Information Center

Answers questions about federal programs, benefits, and services.

(800) 333-4636 www.pueblo.gsa.gov/call/ncc.htm

Social Security

Provides information on benefits and other services, and retirement planning.

(800) 772-1213 Social Security representative available weekdays 7 a.m.–7 p.m. www.ssa.gov

Society of Certified Senior Advisors (CSA)

Helps with locating a CSA and provides information on issues relating to older adults’ health, housing, and finances.

(800) 653-1785 www.society-csa.com

National Center on Caregiving at Family Caregiver Alliance

Has a national hotline that provides informational assistance to family caregivers in the United States.

(800) 445-8106 Available weekdays 9 a.m.–5 p.m. PT. www.caregiver.org

National Family Caregiver Association

Provides support, information, and referral services to family caregivers.

(800) 896-3650 www.nfcacares.org

Well Spouse Association

Provides support for any spouse or partner caring for someone who is chronically ill or disabled.

(800) 838-0879 www.wellspouse.org

Safe Driving for Older Adults—U.S. Department of Transportation

Provides information about traffic and auto safety for older adults.

Auto Safety Hotline: (888) 327-4236 http://www.nhtsa.dot.gov/ people/injury/olddrive/ OlderAdultswebsite/

National Center on Elder Abuse

Provides links to local helplines to report elder abuse, neglect, or exploitation.

(202) 898-2586 www.ncea.aoa.gov

National Long-Term Care Ombudsman Resource Center

Provides information on the role of ombudsman in helping nursing home residents and their families and helps to locate local ombudsman services.

(202) 232-2275 www.ltcombudsman.org

Caregiving Resources

Other Resources

continued

228

Nursing Home Compare

A government resource providing information on the past performances of every Medicareand Medicaid-certified nursing home in the state.

(800) 633-4227 www.medicare.gov/NHCompare/ home.asp

National Center on Senior Transportation

Offers a hotline that answers questions regarding transportation services for older adults.

(866) 528-6278 Available weekdays 9 a.m.–5 p.m. EST. www.seniortransportation.net

National Suicide Prevention Lifeline

Provides suicide-prevention service to anyone in suicidal crisis.

(800) 273-8255 (Veterans press 1) Spanish Lifeline: (888) 628-9454 www.suicidepreventionlifeline.org

The Compassionate Friends

Offers assistance to bereaved parents, siblings, grandparents, and other family members during the natural grieving process after a child dies.

(877) 969-0010 www.compassionatefriends.org

229