Cognitive Behavioral Therapy Strategies PDF

COGNITIVE BEHAVIORAL THERAPY STRATEGIES KRISTI L. CRANE, PSY.D. KRISTY M. WATTERS, PSY.D.  INSTRUCTIONS This book is intended as a practical guide for clinicians who wish to use Cognitive Behavioral Therapy for Depression (CBT-D) with Veterans. It can be...

COGNITIVE BEHAVIORAL THERAPY STRATEGIES KRISTI L. CRANE, PSY.D. KRISTY M. WATTERS, PSY.D.  INSTRUCTIONS This book is intended as a practical guide for clinicians who wish to use Cognitive Behavioral Therapy for Depression (CBT-D) with Veterans. It can be used as an additional resource to Cognitive Behavioral Therapy for Depression in Veterans and Military Servicemembers: Therapy Manual (Wenzel, A., Brown, G. K., & Karlin, B. E., 2011). This resource was created to use in order of typical therapy. The first section (pages 6-31) correlates to the Initial Phase of CBT, the second section (pages 32-99) correlates to the Middle Phase of CBT, and the last section (94-107) correlates to the Later Phase of CBT. The Initial Phase includes a preliminary assessment and case conceptualization tool to assist the clinician with targeting problem areas and identifying evidence-based interventions aimed at reducing depression symptoms. The Initial Phase helps Veterans gain an understanding of the structure and process of CBT and is used to generate treatment goals. During the Middle Phase of therapy, the provider and Veteran work together to address treatment goals. The provider should select the most appropriate behavioral and cognitive techniques according to the case conceptualization. The central focus of this resource is on the actual course of therapy. As you review the interventions, we recommend that you consider how each intervention may be individually applied. The Later Phase of treatment focuses on the Veteran’s progress toward reaching their treatment goals. Specifically, evaluating whether they can apply techniques appropriately to help alleviate depressive symptoms. The Later Phase also focuses on creating a relapse prevention plan. Suggestions for using the guide: Select handouts you are most likely to use and provide the Veteran with their own copies. Keep quantities of selected handouts in folders so they will be easy to offer the Veteran. Handouts can reinforce and validate ideas you have presented in session. They can serve as transitional objects for the Veteran as they prepare for discharge and relapse prevention planning. The contents of this manual do not represent the views of the Department of Veterans Affairs (VA) or the U.S. government. This manual was supported by a clinical educator grant from the VA South Central Mental Illness Research, Education and Clinical Center (MIRECC).  Table of Contents What is Cognitive Behavioral Therapy?................................................................................................................... 6 What to Expect?........................................................................................................................................................7 What is Cognitive Behavioral Therapy?............................................................................................................8 Behavioral Model...................................................................................................................................................... 9 Cognitive Behavioral Model.................................................................................................................................10 Phases of CBT............................................................................................................................................................ 11 Steps of CBT.............................................................................................................................................................. 12 Session Format......................................................................................................................................................... 13 Assessment, Case Conceputalization, and Treatment Planning.................................................................... 15 Patient Health Questionnaire (PHQ-9)............................................................................................................ 16 Assessment/Case Conceptualization/Treatment Planning..................................................................... 17 Case Conceptualization Worksheet Example.............................................................................................. 24 Case Conceptualization Worksheet................................................................................................................ 26 GOAL SETTING................................................................................................................................................................ 27 SMART Goals............................................................................................................................................................ 28 Cost-Benefit Analysis of Change....................................................................................................................... 31 Behavioral Strategies..................................................................................................................................................... 32 Activity Monitoring................................................................................................................................................ 33 Values Identification..............................................................................................................................................34 Activity Monitoring Log....................................................................................................................................... 36 Activity and Mood Log......................................................................................................................................... 37 Examples of Pleasant Activities........................................................................................................................ 39 Activity Scheduling................................................................................................................................................43 Increase Pleasure and Achievement...............................................................................................................44 Behavioral Activation............................................................................................................................................45  Graded Task Assignments...................................................................................................................................46 Relaxation: Benefits & Tips.................................................................................................................................48 Deep Breathing................................................................................................................................................ 51 Progressive Muscle Relaxation.................................................................................................................. 53 Guided Imagery.............................................................................................................................................. 56 Relaxation Practice Record........................................................................................................................ 58 Relaxation Training Apps............................................................................................................................ 59 Schedule Worry Time.........................................................................................................................................60 Worry Journal......................................................................................................................................................... 61 Problem Solving (ITCH) Example.................................................................................................................. 62 Problem Solving (ITCH)....................................................................................................................................64 Cognitive Strategies.......................................................................................................................................................66 Anatomy of an Emotion Example.................................................................................................................... 67 Anatomy of an Emotion.......................................................................................................................................68 Automatic Thoughts..............................................................................................................................................69 Emotions..................................................................................................................................................................... 71 Combining Thoughts and Behaviors............................................................................................................... 72 Thought-Stopping Techniques.......................................................................................................................... 74 Downward Arrow Technique.............................................................................................................................. 75 Thought Record Example.................................................................................................................................... 77 Thought Record...................................................................................................................................................... 78 Thinking Traps.......................................................................................................................................................... 79 Socratic Questioning Example.......................................................................................................................... 82 Socratic Questioning............................................................................................................................................. 83 Challenging Questions Worksheet Example................................................................................................84 Challenging Questions Worksheet................................................................................................................... 85 Thought Record......................................................................................................................................................86  What is the difference between thoughts and core beliefs................................................................... 87 Life History Review................................................................................................................................................ 88 Healthy Core Beliefs..............................................................................................................................................90 Unhealthy Core Beliefs.......................................................................................................................................... 91 Modifying Core Beliefs.......................................................................................................................................... 92 Guilt and Blame....................................................................................................................................................... 93 Relapse Prevention.........................................................................................................................................................94 Life Events that May Influence Mood.............................................................................................................. 95 Monitoring Progress..............................................................................................................................................96 Relapse Prevention Plan...................................................................................................................................... 97 Coping Cards..........................................................................................................................................................100 Notes................................................................................................................................................................................... 101 Resources......................................................................................................................................................................... 103  WHAT IS COGNITIVE BEHAVIORAL THERAPY? (PSYCHOEDUCATION) 6  WHAT TO EXPECT? CBT is evidence based. CBT has been well tested in research studies and has been proven to be effective in treating depression. CBT is structured. You should expect to have a good idea of where you’re going and how to get there. So, we will set clear goals to create a roadmap that will help us find the best way to improve your symptoms. During each session we will set an agenda for what we want to discuss, we will discuss last week’s practice assignment, discuss agenda items, and then assign new homework. CBT is psychoeducational. The entire program is skill based and involves you enhancing your skill set. You will learn different “tools” to help cope with your current problems that you will be able to take with you when treatment is over. CBT is goal oriented. We will work together to identify and achieve specific treatment goals. We will track your progress on your goals and problem solve ways to reach them. CBT is time limited. Treatment is usually 16-20 weeks. CBT requires you to attend weekly sessions. Regular attendance is essential to recovery. Sessions are approximately 50 minutes long. CBT requires active participation. What you get out of treatment is a direct result of the effort you put into it. Just showing up is not enough. We need you to be an active partner in your treatment process. CBT has a home practice requirement. Treatment is challenging and takes daily commitment from you to be successful. CBT is not a one time therapy. It is not an instant change that you will immediately notice after one session. Practice assignments help put your new skills to use. CBT focuses on the here and now. Treatment emphasizes how depression is maintained in your present life. CBT is collaborative. Although the therapist is the expert on CBT, you are the expert on yourself. We will work together to tailor your treatment to your needs. 7  WHAT IS COGNITIVE BEHAVIORAL THERAPY? Cognitive Therapy + Behavioral Therapy = Cognitive Behavioral Therapy Cognitive Model: Cognitive refers to the act of knowing or recognizing our experiences. The cognitive model focuses on thinking and how our thoughts are connected to our mood, physiological responses, and behaviors Cognitive therapy will teach you to change your thoughts, beliefs, and attitudes that contribute to your depression. Two people can be faced with similar situations, but because they think about those situations in different ways, they have different reactions to them. 8  BEHAVIORAL MODEL “Depressed individuals do not get enough positive reinforcement from interactions with their environment to maintain happy, adaptive behavior” (Wenzel, Brown, & Karlin, 2011). Two behavioral patterns associated with depression: Low level of positive feelings from engaging in life activities No longer participating in enjoyable activities Not getting as much enjoyment in activities as in the past No longer enjoying socializing with others High rate of negative consequences Frequently noticing things are not working out Feeling a lack of support and understanding from others Wenzel, A., Brown, G. K., & Karlin, B. E. (2011). Cognitive Behavioral Therapy for Depression in Veterans and Military Servicemembers: Therapy Manual. Washington, DC: U.S. Department of Veteran Affairs. 9  COGNITIVE BEHAVIORAL MODEL Wenzel, A., Brown, G. K., & Karlin, B. E. (2011). Cognitive Behavioral Therapy for Depression in Veterans and Military Servicemembers: Therapy Manual. Washington, DC: U.S. Department of Veteran Affairs. 10  PHASES OF CBT Wenzel, A., Brown, G. K., & Karlin, B. E. (2011). Cognitive Behavioral Therapy for Depression in Veterans and Military Servicemembers: Therapy Manual. Washington, DC: U.S. Department of Veteran Affairs. 11  STEPS OF CBT Cognitive Behavioral Therapy helps people become more aware of the relationship between their thoughts, feelings, and emotions. Become aware of: Step 1 Automatic thoughts Feelings Core beliefs Behaviors Physical reactions Environment Examination: Step 2 Thoughts are not facts Examine the evidence, look for proof Question and challenge irrational beliefs Don’t believe everything you think Create alternative thoughts: Step 3 Increase positive self talk Reduce negative automatic thoughts Replace irrational beliefs with more rational ones 12  SESSION FORMAT £ Complete PHQ-9 in waiting room £ Check in: £ Review scores £ Review chart since last session £ Mood check What was your week like? What has your mood been like, compared to other weeks? £ Medication Are medications being taken? Changes in medications? £ Drug/Alcohol Has there been a change in your alcohol or drug use since last session? £ Bridge from last session What did we talk about last session that was important? What did you learn? Was there anything that bothered you about our last session? Anything you were reluctant to or did not say? 13 £ Agenda setting Did anything happen this week that is important to discuss? What topics do you want to put on the agenda? Therapist agenda items presented. £ Review of homework Which homework did you do? Which homework did you not do? What did you learn? £ Discussion of Agenda items Addressed in agreed upon order £ Identify key thoughts/behaviors £ Implement a CBT strategy Encourage the application of strategies Assists in generalizing strategies £ Periodic summaries/feedback What are you going to take away from our discussion? What are you going to do differently as a result of our discussion? £ Homework assignment for next week On a scale from 0 to 100, how likely are you that you will do your homework? £ Final summary £ Session feedback 14  ASSESSMENT, CASE CONCEPTUALIZATION, AND TREATMENT PLANNING 15  PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Over the last week, how often have you been bothered by any of the following problems? (circle to indicate your answer) Not at Several More than Nearly every all Days half the days day Little interest or pleasure in doing things 0 1 2 3 Feeling down, depressed, or hopeless 0 1 2 3 Trouble falling or staying asleep, or sleeping too 0 1 2 3 much Feeling tired or having little energy 0 1 2 3 Poor appetite or overeating 0 1 2 3 Feeling bad about yourself—or that you are a 0 1 2 3 failure or have let yourself or your family down Trouble concentrating on things, such as 0 1 2 3 reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed. Or the opposite—being so 0 1 2 3 fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead, or 0 1 2 3 of hurting yourself in some way Add columns: TOTAL: If you checked off any problems, how difficult Not difficult at all have these problems made it for you to do your Somewhat difficult work, take care of things at home, or get along Very difficult with other people? Extremely difficult Scores: 1-9 No Depression 10-14 Mild Depressive Symptoms 15-19 Moderate Depressive Symptoms 20-27 Severe Depressive Symptoms Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9 - Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613. 16  ASSESSMENT/CASE CONCEPTUALIZATION/ TREATMENT PLANNING By gathering specific information, you can better determine the factors that are contributing to your depression. Having a better understanding of your symptoms and how they developed will allow us to create a treatment plan specific to your needs. Work with your therapist to gather the information below: Symptoms Formative influences Biological, genetic, and medical factors Situational/interpersonal issues Strengths and barriers Typical automatic thoughts, emotions, and behaviors Core beliefs Hypothesis Goals Treatment plan and selecting strategies 17 Symptoms 1. Describe the problem: _______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 2. How long have you had this problem? ________________________________________ 3. What is the frequency of your symptoms and how long do they last? _______________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. What has worked and what has not worked in favor of change? ___________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Formative influences (Longitudinal analysis) 1. What may have triggered this problem? _______________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 18 2. What other developmental events and formative influences may have shaped your be­ liefs (family history)? ______________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Biological, genetic, and medical factors (Longitudinal analysis) 1. Are there any medical issues that contribute to your depression? ___________________ ________________________________________________________________________ ________________________________________________________________________ Situational/interpersonal issues (Cross-sectional analysis) 1. What are the circumstances under which the depression commonly and reliably occurs? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. What maintains the problem? _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. What is escaped or avoided as a result of depressive symptoms? ___________________ ________________________________________________________________________ ________________________________________________________________________ 19 4. How have you attempted to resolve the problem? _______________________________ ________________________________________________________________________ ________________________________________________________________________ 5. How would your life be different without this problem? ___________________________ ________________________________________________________________________ ________________________________________________________________________ Strengths and barriers 1. What strengths do you possess that will help you be successful in treatment (e.g., family support, motivated in treatment, compliant with medication)? _____________________ ________________________________________________________________________ ________________________________________________________________________ 2. What obstacles interfere with your ability to attend weekly sessions (e.g., transporta­ tion, work schedule, child-care, family obligations, etc.)?_________________________ _______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 3. Have you talked to your family members about coming to therapy? Are they supportive of your efforts? ___________________________________________________________ 4. On a scale from 1-10, how ready are you to make this change? _____________________ 5. On a scale from 1-10, how willing are you to make this change? _____________________ 20 6. On a scale from 1-10, how confident are you that you can change? __________________ Typical automatic thoughts, emotions, and behaviors 1. Think of the last time you were experiencing sadness. What was happening? _________ ________________________________________________________________________ ________________________________________________________________________ 2. What were you thinking? ___________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. What images were going through your mind? ___________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. What other emotions were your feeling? _______________________________________ ________________________________________________________________________ ________________________________________________________________________ Core beliefs 1. What negative beliefs have you had since childhood that may be contributing to your symptoms? ______________________________________________________________ ________________________________________________________________________ 21 Hypothesis __________________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________ Goals Short Term Goals: ___________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Long Term Goals: ___________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 22  TREATMENT PLAN/STRATEGIES: Behavioral Strategies: Cognitive Strategies: £ Activity Monitoring £ Recognizing Mood Shifts £ Values Identification £ Combining Thoughts and Emotions £ Activity Monitoring Log £ Thought Stopping £ Mood Log £ Downward Arrow Technique £ Pleasant Activities £ Use of Thought Change Records £ Activity Scheduling £ Identifying Cognitive Errors £ Increasing Pleasure and Achievement £ Socratic Questioning £ Behavioral Activation £ Challenging Questions £ Graded Task Assignments £ Generating Rational Alternatives £ Relaxation Training £ Life History £ Scheduled Worry Time £ Modifying Core Beliefs £ Problem Solving £ Guilt vs. Shame 23 CASE CONCEPTUALIZATION WORKSHEET EXAMPLE Veteran Name: Robert Jones Date: August 30, 2018 Symptoms: Major Depressive Disorder, Moderate, Recurrent Veteran presents with depressed mood, anhedonia, low energy, a decrease in appetite, feelings of worthlessness, hypersomnia, decrease in socialization, psychomotor retardation, and non-suicidal self-directed violence ideation. Convincingly denies preparatory behaviors, intent, or plan. He has had these symptoms for the past year and they reoccur at least once a month, lasting for two weeks at a time. When depressed he drinks more and isolates from family and friends. He noted this has not helped decrease his depressive symptoms. He noted playing his guitar and writing music helps decrease his symptoms. Formative Influences: Robert is a 21-year-old, Caucasian, cisgender, unmarried male that grew up in a small town in the Delta of Mississippi. He is the oldest of 4 (siblings aged 12, 15, 17). Mother and father are both deceased; they died in a car accident involving a drunk driver. Veteran was the first in his immediate family to graduate high school and he is the first to enlist in the military. He is now 4 credits away from graduating from college with a B.S. in Criminology. Veteran described himself as a “popular guy” in his hometown, played many school sports, and was Homecoming King his senior year. He enlisted in the Navy at 19 years old in the Submarine Electronics Computer Field (SECF) and worked with submarine communications systems. Veteran was involved in war games, but never deployed or engaged in combat. Veteran was stationed in Honolulu, HI when he received a Red Cross Emergency Notification that both of his parents were deceased. Veteran received a genuine dependency discharge, has moved back home, and is now the primary caregiver for his siblings. Biological, Genetic, and Medical Factors: Veteran believes his mother may have experienced postpartum depression after the birth of his youngest sibling, but denied any other family history. No known contributing medical factors. Situational Issues/Interpersonal Issues: There are limited opportunities for employment in his hometown and he’s concerned that he will have to relocate his family further south to find a job that will support him and his siblings. He is the primary caregiver of his siblings, no other family members within 50-mile radius. Several of Veteran’s friends from high school still live in town; however, he rarely socializes with them and has very limited finances. He has never attended therapy. His depression makes it difficult for him to search for more opportunities. If he wasn’t depressed he noted he would be more social, find a partner, and be able to feel better about providing for his family. 24 Strengths/Barriers: Veteran is young, able-bodied, and reports a willingness to work. He is seeking mental health support for the first time and reports a desire for change. He is intelligent, computer savvy, and loving. Event 1 Event 2 Event 3 Primary caregiver to siblings 4 credits away from Talked to best friend from completing college degree high school over the phone Automatic Thoughts Automatic Thoughts Automatic Thoughts “My life is ruined.” “I will never finish now; it’s “He sounds like he’s happy useless to try.” with his life.” Emotions Emotions Emotions Angry Depressed Resentful Disappointed Let down Behaviors Behaviors Behaviors Angry outbursts at siblings Dropped out of school and Does not respond to friend’s for “little things.” has not contacted school texts and will not call him has not gone back to about options. back. parents grave site. Core Beliefs: I am a failure. I am a bad son. People are better off without me. Hypothesis: Since the death of his parents, Robert has experienced a number of significant changes to his life. He has yet to grieve the loss of his parents or his identity as a service member and is struggling to accept the new reality of being the primary caregiver for his siblings. Veteran believes that his future possibilities are now significantly limited and he will be unable to live a fulfilling life. Veteran’s Goal: “I want to deal with my parents’ deaths and be able to better care for my siblings.” Treatment Plan/Strategies: (1) Behavioral skills to establish behavioral patterns, encourage participation in pleasant activities, recognize those activities that give a sense of accomplishment or fulfillment, and determine new goals. (2) Cognitive strategies to identify and modify problematic cognitions (negative automatic thoughts, working with core beliefs, and developing problem-solving skills). 25  CASE CONCEPTUALIZATION WORKSHEET Veteran’s Name: Date: Symptoms: Formative Influences: Biological, Genetic, and Medical Factors: Situational Issues/Interpersonal Issues: Strengths/Barriers: Event 1 Event 2 Event 3 Automatic Thoughts Automatic Thoughts Automatic Thoughts Emotions Emotions Emotions Behaviors Behaviors Behaviors Core Beliefs: Hypothesis: Veteran’s Goal: Treatment Plan/Strategies: Wright, J. H., Brown, G. K., Thase, M. E., & Ramirez Basco, M. (2017). Learning Cognitive-Behavior Therapy: An Illustrated Guide (Second ed.). Arlington, VA: American Psychiatric Association Publishing. 26 GOAL SETTING 27  SMART GOALS Setting goals assists in developing a pathway to making changes. Goals should be specific, measurable, achievable, realistic, and time limited. Specific Identifies a specific action or event that will take place Who? What? When? Where? How? Measurable Should be quantifiable so progress can be tracked Achievable Should be attainable and realistic given resources Realistic Should be personally meaningful and really matter Timely State the time period for accomplishing the goal Adapted from Doran, 1981 List the short-term goals (16 to 20 weeks) that you would like to achieve during this course of treatment: 1. _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________________________________ 2. ____________________________________________________________________________________________ _______________________________________________________________________________________ ______________________________________________________________________________________ 3. _______________________________________________________________________________________ ______________________________________________________________________________________ List the long-term goals that you would like to achieve in the next 6 months to 1 year. 1. _____________________________________________________________________________________ _____________________________________________________________________________________ ______________________________________________________________________________________ 2. __________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3. _____________________________________________________________________________________ _____________________________________________________________________________________ _______________________________________________________________________________________ 28 Instructions: What would you like to see different in these areas? 1. Family Relationships ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 2. Social Relationships ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 3. Intimate (Romantic) Relationships ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. Education/Training ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. Employment/Career ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 29 6. Hobbies/Recreation/Relaxation ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. Volunteer Work/Charity/Political Activities ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 8. Physical/Health Issues ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 9. Spirituality ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 10. Psychological/Emotional Issues ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 30  COST-BENEFIT ANALYSIS OF CHANGE Goal: __________________________________________________________________________ Cost-Benefit Analysis Advantages Disadvantages of Change No Change Change 31 BEHAVIORAL STRATEGIES 32  ACTIVITY MONITORING What is the purpose of monitoring activities? Helps to establish behavioral patterns Helps to identify times in which activities support or go against emotions Helps to encourage participation in pleasant activities Helps to recognize those activities that give a sense of accomplishment or fulfillment Helps identify things to change or include in regular routine Helps to determine new goals Helps put a spotlight on those activities that keep us stuck in a rut Helps identify ways to better organize time 33  VALUES IDENTIFICATION What do you value? What can you DO in service of these values? Circle the things that you value: Love Kindness Forgiveness Hobbies Family Education Intimate relationship Spirituality Career Cultural beliefs Social Relationship Mental health Financial success Parenting Self-esteem Community Personal growth Volunteer Physical health Goal/Value: Family Activity: Take sister to the park on Wednesday for one hour. Activity: Spend one hour teaching little brother how to play the guitar. Activity: Go out to eat as a family and spend at least 30 minutes talking. Goal/Value: ________________________________________________________________ Activity: _________________________________________________________________ Activity: _________________________________________________________________ Activity: ________________________________________________________________ 34 Goal/Value: ________________________________________________________________ Activity: _________________________________________________________________ Activity: _________________________________________________________________ Activity: ________________________________________________________________ Goal/Value: ________________________________________________________________ Activity: _________________________________________________________________ Activity: _________________________________________________________________ Activity: ________________________________________________________________ Goal/Value: ________________________________________________________________ Activity: _________________________________________________________________ Activity: _________________________________________________________________ Activity: ________________________________________________________________ Goal/Value: ________________________________________________________________ Activity: _________________________________________________________________ Activity: _________________________________________________________________ Activity: ________________________________________________________________ Goal/Value: ________________________________________________________________ Activity: _________________________________________________________________ Activity: _________________________________________________________________ Activity: ________________________________________________________________ 35  Time Sunday Monday Tuesday Wednesday Thursday Friday Saturday 5am-8am 9:00 10:00 11:00 12:00 1:00 2:00 3:00 36 4:00 5:00 6:00 7:00 ACTIVITY MONITORING LOG 8:00 9:00 10:00 11:00 to 5am  ACTIVITY AND MOOD LOG Date: Activity: Duration: Mood Rating: 1 2 3 4 5 6 7 8 9 10 Worst Average Best Date: Activity: Duration: Mood Rating: 1 2 3 4 5 6 7 8 9 10 Worst Average Best Date: Activity: Duration: Mood Rating: 1 2 3 4 5 6 7 8 9 10 Worst Average Best 37 Date: Activity: Duration: Mood Rating: 1 2 3 4 5 6 7 8 9 10 Worst Average Best Date: Activity: Duration: Mood Rating: 1 2 3 4 5 6 7 8 9 10 Worst Average Best Date: Activity: Duration: Mood Rating: 1 2 3 4 5 6 7 8 9 10 Worst Average Best Date: Activity: Duration: Mood Rating: 1 2 3 4 5 6 7 8 9 10 Worst Average Best 38  EXAMPLES OF PLEASANT ACTIVITIES Excursions/Community £ Taking a trip or vacation £ Going to a fair, carnival, circus, zoo, or amusement park £ Going to the beach £ Going on a picnic £ Going out to dinner £ Taking a road trip £ Riding on an airplane, hot air balloon, or helicopter £ Staying at a hotel or bed and breakfast £ Going to a museum or exhibit £ Shopping, garage sales, flea markets £ Going to the library or a book store £ Going out to the country £ Going for a hike £ Planning a trip or vacation £ Driving around £ Go to park £ Camping Interactions with others £ Going to or giving a party £ Giving and receiving physical affection £ Reminiscing, talking about old times £ Group activities £ Having a frank and open conversation £ Getting together with friends £ Discussing a topic of interest (sports, fashion, politics, news) £ Having family visit or visiting a family £ Meeting someone new £ Eating out with friends or associates £ Visiting friends or having friends visit £ Talking about sports £ Texting, emailing, or calling friends £ Communicating via Skype or Facetime £ Asking for help or advice £ Being around children or grandchildren £ Being with spouse or partner £ Going to a family reunion 39 Entertainment £ Watching TV or listening to the radio £ Playing bingo, gambling, playing the lottery £ Going to the movies £ Playing party games £ Going to concerts £ Going to the races (horse, car, boat) £ Going to a play, musical, comedy show £ Going to a sporting event Sports and Games £ Swimming, snorkeling, or scuba diving £ Biking, skating, or roller-blading £ Hunting or shooting £ Playing lawn sports (croquet, horseshoes, badminton) £ Jogging, hiking, or walking £ Playing tennis, racquetball, table tennis, handball, or squash £ Playing golf or miniature golf £ Fishing £ Birdwatching £ Playing board games £ Playing card games £ Working puzzles, crosswords, brain teasers £ Rock-climbing or mountaineering £ Playing baseball or softball £ Boating (canoeing, kayaking, sailing) £ Playing pool, billiards or shuffleboard £ Playing computer games £ Motorboating £ Taking a walk Education £ Learning something new (language, instrument) £ Completing a difficult task £ Surfing the internet £ Looking into classes you would like to take £ Learning something artistic (painting, pottery, crocheting) £ Reading £ Taking a course on something of interest £ Writing stories, novels, plays, poetry, essays, reports £ Reading a “How to Do It” book or article £ Going to a lecture or to listen to a speaker of interest £ Going back to school £ Taking a course in computers 40 Domestic Activities £ Cleaning the house £ Baking £ Cooking £ Working in the yard, gardening, landscaping £ Washing the car £ Sewing £ Being exempt from a domestic activity £ Buying flowers and plants £ Rearranging or redecorating a room or the house £ Freshening up the house with potpourri £ Fixing things around the house £ Working on machines, cars, bikes, motorcycles, tractors £ Walking dog £ Doing “odd jobs” around the house £ Organizing a room Hobbies, Arts & Crafts and the Arts £ Playing a musical instrument £ Singing £ Dancing £ Doing craft and art work (drawing, painting, sculpting, pottery, movie making, photography) £ Doing needlework (knitting, crocheting, embroidery) £ Restoring antiques or refinishing furniture £ Doing woodworking or carpentry £ Writing letters, cards, or notes, £ Writing a diary £ Writing or arranging a song/music £ Starting or finishing a project £ Collecting things Health/Appearance £ Having picture taken £ Getting new clothes, shoes, or jewelry £ Putting on makeup or purchasing it £ Getting haircut, going to the hairdresser £ Getting a manicure or pedicure £ Getting a massage or body rub £ Putting on perfume or cologne £ Preparing self to go out £ Improving one’s health (having teeth fixed, new glasses or contacts, eating healthier, starting an exercise program) £ Getting a makeover or facial £ Getting a workout £ Wearing expensive or formal clothes 41 Pampering self and other leisure activities £ Having free time £ Playing with or having a pet £ Meditating or doing yoga £ Taking a bubble bath or soothing bath £ Being alone £ Writing in a journal or diary or keeping a scrapbook or photo album £ Sleeping late £ Subscribing to a special magazine £ Breathing fresh air £ Listening to music £ Sunbathing £ Listening to the sounds of nature £ Telling and listening to jokes £ Going to a spa £ Daydreaming £ Buying things for myself £ Reading the newspaper or magazine £ Walking barefoot in the sand £ Sitting around a fire £ Staying up late Treats £ Chocolates £ Favorite candy £ Ice cream £ Desert £ Beverage £ Favorite dish Altruistic Acts £ Volunteering for a special cause £ Doing charity work £ Doing favors for others £ Making contributions to religious, charitable, or other groups £ Giving gifts £ Helping someone £ Defending or protecting someone Religious/Charitable Activities £ Going to a place of worship £ Attending a wedding, baptism, bar mitzvah, religious ceremony, or function £ Joining a prayer or spiritual group £ Hearing a good sermon £ Praying £ Reading sacred works £ Participating in a church fellowship function 42  ACTIVITY SCHEDULING List five activities you enjoy: 1. 2. 3. 4. 5. List five responsibilities you need to take care of: 1. 2. 3. 4. 5. 43  INCREASE PLEASURE AND ACHIEVEMENT Complete at least one activity or responsibility each day. Use the following scale to rate your depression, pleasant feelings, and sense of achievement BEFORE and AFTER the activity. 0 1 2 3 4 5 6 7 8 None Minimal Slight Mild Moderate A Lot Higher Very Extreme High Activity (location/ Depression Pleasure Achievement date/time) Before After Before After Before After Before After Before After Before After Before After Before After Before After Before After 44  BEHAVIORAL ACTIVATION The goal of behavioral activation is to gradually assist you in decreasing your movement toward isolation and avoidance and to help you become more active and engage in activities that are known to improve mood. Often, these are activities that you enjoyed before you became depressed. The activities vary from person to person and may include very simple activities, such as engaging in personal hygiene, showering, doing household chores, engaging in forms of exercise, taking classes, going out to dinner, or anything that you find personally rewarding. As you know, however, getting yourself to feel better is not an easy thing to do. Talking yourself into feeling better or trying to convince yourself to feel better unfortunately doesn’t work. Your thoughts and feelings are affected by your interactions with others and your overall quality of life. So, for you to have more positive thoughts and to feel better, you must first become more active and put yourself into more positive situations. This will probably be somewhat challenging when you first start. It will become easier as more and more positive experiences occur. This strategy requires hard work, and I understand that you may be questioning your ability to make changes at this time in your life, but I will help you through this process and we will work at a gradual pace together. 45  GRADED TASK ASSIGNMENTS This is a technique for turning overwhelming tasks into manageable achievements, in other words, breaking down a task step by step. This involves breaking a big goal into smaller goals that are then put in the most logical, achievable order. 1. Choose an activity or goal to break down. a. Look at all the activities you have scheduled for next week. Is there one that seems a bit too big? If not, think of a goal you would like to accomplish over the next month and practice on that. 2. Break it down into smaller steps. a. For example, if you scheduled in ‘go to the gym’ you could break that down to pack my gym bag, buy a bottle of water, find my membership card, etc. 3. Put the steps you’ve come up with into the most logical order. a. There may not be a point in packing your gym bag if you’ve lost your membership card. 3. Schedule your first step. a. If you chose an activity from your schedule, perhaps reschedule the various steps now so that you are definitely going to get the activity done. If you are working with a general goal, pick one task to get started on and either do it now if you have time or schedule it into your week. b. Match the task you choose to your present energy levels. Do not assume you can accomplish what you might have previously during a time when life was not as challenging. It’s better to choose a task that is too easy but you will accomplish than something you won’t. 46  GRADED TASK ASSIGNMENT Primary Goal:________________________________________________________________ Step 1: _____________________________________________________________________ Date/Time:__________________Materials:___________________________________ Step 2:_____________________________________________________________________ Date/Time:__________________Materials:___________________________________ Step 3:_____________________________________________________________________ Date/Time:__________________Materials:___________________________________ Primary Goal:_______________________________________________________________ Step 1:_____________________________________________________________________ Date/Time:__________________Materials:___________________________________ Step 2:_____________________________________________________________________ Date/Time:__________________Materials:___________________________________ Step 3:_____________________________________________________________________ Date/Time:__________________Materials:___________________________________ 47  RELAXATION: BENEFITS & TIPS The goal of relaxation is to reduce the effects of stress on your health. Since chronic pain produces chronic stress on the body, it is important to regularly practice relaxation techniques that can help your mind and body recover. Relaxation is more than resting or enjoying a hobby – it involves using specific strategies to reduce tension. Benefits of Relaxation Relaxation is important for good health. When you are relaxed, your muscles are loose, your heart rate is normal, and your breathing is slow and deep. Learning how to relax can help especially when you feel pain. Relaxation prompts your body to release chemicals that reduce pain and produce a sense of well-being. Relaxation won’t cure pain or other chronic symptoms, but skills that relax the body and the mind may help decrease muscle tension, prevent muscle spasms, and relieve the stress that can aggravate pain and other symptoms. Taking time to relax and refuel your energy provides benefits such as: Improved mood Increased energy and productivity Improved concentration and focus Improved sense of control over stress and daily demands Improved nighttime sleep Increased self-confidence Greater ability to handle problems Decreased anxiety and other negative emotions such as anger and frustration Increased blood flow to muscles and reduced muscle tension Lower blood pressure, breathing rate, and heart rate Decreased pain, such as headaches and back pain Relaxation Practice Tips Relaxation is a skill that requires practice. You may not feel the benefits immediately, so don’t give up! Remain patient and motivated and you’ll reduce the negative impacts of stress. And remember: If relaxation feels foreign or unnatural, that likely means you are a person who needs it most! Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 48 Establish a routine Set aside time to practice relaxation at least once or twice a day. Pairing relaxation with a regular activity may help you remember to practice (for example, take 10 relaxed breaths before bed or whenever you sit down to eat). Practice at various times throughout the day until relaxation becomes natural and you can use it readily when you feel stressed. You may want to leave “reminders” for yourself to relax (for example, sticky notes on the bathroom mirror, kitchen cabinets, or car dashboard with the words “relax” or “breathe”). Be comfortable Practice on a comfortable chair, sofa, mat, or bed. Dim the lights. Loosen tight clothing and remove shoes, belt, glasses or contact lenses, if you like. Concentrate Eliminate disruptions. Turn off the TV, radio, or telephone. Practice in a quiet, calm, environment. Close your eyes to reduce distractions and improve concentration. If you prefer, keep your eyes open and focus on one spot. Move your body as little as possible, changing positions only for comfort. Don’t worry if you have some distracting thoughts—it happens to everyone. Just notice that your thoughts have wandered and then gently, without judgment, return your attention to your breath. Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 49 Relax Begin and end relaxation practices with relaxed breathing techniques. Use a relaxation CD if it helps. Gradually, learn to relax without a CD so that you can use relaxation techniques anywhere. Let relaxation proceed naturally and spread throughout your body. Do not try to resist it. Be patient Give yourself time to learn relaxation skills. Practice is required for these techniques to become automatic. Try not to become upset if you have trouble concentrating. A wandering mind is normal and expected. Keep bringing your attention back to your breath. Don’t worry about how well you are practicing. After a few weeks, select a word, such as “calm,” “relax,” “peace,” or “patience” that you can say during relaxation practices. Eventually, simply saying that word may help you relax. Incorporate relaxation into daily life Over time, move relaxation practices from planned, quiet settings to “real life.” The goal is to be able to calm yourself when necessary, no matter where you are. Use relaxation whenever you notice yourself feeling stressed or anxious, such as waiting in line, at a doctor’s appointment, or during a difficult meeting. Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 50  DEEP BREATHING First, start by becoming aware of your breathing... Place one hand on your abdomen at the waistline and the other hand on the center of your chest. Without trying to change anything, simply notice how you are breathing. Notice where you are breathing from… whether your shoulders are rising and falling, whether your chest is rising and falling, or perhaps your belly is rising and falling. Notice how your hands move as you breathe… (PAUSE) Now notice the rate of your breathing. Are you breathing rapidly or slowly? Are you breathing deeply or more shallowly (PAUSE) Now as you slowly inhale, imagine the air flowing deeper into your belly. Feel your belly fill with air as your lower hand rises. Pause at the top of your breath, and then follow your breath out as you completely exhale… Slowly take a breath in... 2, 3, 4... and slowly exhale…2, 3, 4. Let any tension melt away as you relax more deeply with each breath... (PAUSE) Notice how the air feels, as cool fresh air enters your nose, passes through the little hairs in your nasal passage, reaches the back of your throat, and descends deep into your lungs. Notice what happens as that breath of fresh air enters your lungs. Notice what happens when you exhale. Feel the temperature of each breath, cool as you inhale, and warm as you exhale. Count your breaths as you breathe in and out. Notice your breath becoming smooth and slow. Feel your belly and ribcage expand outward with each breath... and feel yourself become more relaxed with each exhale. Allow your shoulders to become heavier with each exhale… (PAUSE 15 sec) Continue breathing slowly and gently... (PAUSE 15 sec) As you breathe, notice the cool temperature of the air, as it enters your nose or mouth. Notice how the air becomes warmer as you follow it deep into your belly and out through your mouth. Continue breathing slowly and gently... (PAUSE 15 sec) Again, slowly take a breath in... 2, 3, 4... and slowly exhale… 2, 3, 4. Feel yourself become more and more relaxed with each exhale… (PAUSE 15 sec) (Skip if going on to other relaxation exercises) Now, as I count from 5 to 1, feel yourself become more alert… 5 bringing your attention to this room… 4 feeling calm and relaxed… 3 start to wiggle your fingers and toes… 2 slowly start to move and stretch your muscles… 1 open your eyes, feeling refreshed and rejuvenated. Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 51 52  PROGRESSIVE MUSCLE RELAXATION First, build up the tension in the lower arms, by making fists with your hands and pulling your fists up by bending the wrists. Feel the tension through the lower arms, wrists, fingers, knuckles, and hands. Focus on the tension… (PAUSE 5 sec) Now release the tension. Let your hands and lower arms relax onto the chair or bed beside you. Focus your attention on the relaxing sensations in your hands and arms. Feel the release from tension as you relax the muscles fully, feel it get warm… (PAUSE 10 sec) Now build up the tension in the upper arms by pulling the arms back and in toward your sides. Feel the tension in the back of the arms and radiating towards the shoulders and into the back. Focus on the tension. Hold this tension… (PAUSE 5 sec) Now, release the arms and let them relax – almost feeling heavy at your sides. Notice the difference between the prior feelings of tension and the new feelings of relaxation. Your arms might feel heavy, warm, and relaxed… (PAUSE 10 sec) Now bring your attention to your lower legs. Build up the tension by flexing your feet and pulling your toes toward your upper body. Feel the tension as it spreads through your feet, ankles, shins, and calves. Hold this tension… (PAUSE 5 sec) And release all of the tension in your lower legs. Let your legs relax onto the chair or bed. Feel the difference in these muscles as they relax. Feel the release from tension, the sense of comfort, the heaviness of relaxation... (PAUSE 10 sec) Build up the tension in your upper legs and buttocks by pressing your knees together and lifting the legs slightly off of the bed or chair. Focus on the tightness through the front of your thighs and buttocks. Hold this tension… (PAUSE 5 sec) Now release all of the tension in your upper legs. Let your legs sink heavily into the chair or bed. Let all of the tension disappear as your legs sink heavier into the chair or bed. Focus on the feeling of relaxation and comfort… (PAUSE 10 sec) Build up the tension in your abdomen by pulling your abdomen in toward your spine, very tightly. Feel the tightness and focus on this tension… (PAUSE 5 sec) Now let the tension in the abdomen relax… Notice how smooth and calm your breathing has become. Feel the comfort of relaxation… (PAUSE 10 sec) Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 53 Build up the tension in your chest by taking in a deep breath and holding it. Your chest is expanded and the muscles are stretched around your chest. Feel the tension in your front and your back... (PAUSE 3-5 sec) Now, slowly let the air escape and resume normal breathing, letting the air flow in and out smoothly and easily. Feel the difference in sensations as the muscles relax, compared to those of tension… (PAUSE 10 sec) Build up the tension in your neck and shoulders by pulling your shoulder blades back and up towards your ears. Feel the tension around your shoulders, radiating into your neck and back. Hold this tension… (PAUSE 5 sec) Now release the tension. Let your shoulders drop down, sinking further and further until they are completely relaxed. Notice the difference in the previous feelings of tension and the new feelings of relaxation. Enjoy these feelings… (PAUSE 10 sec) Build up the tension in your mouth, jaw and throat by clenching your teeth and turning the corners of your mouth back into a forced smiled. Hold. Feel the tightness… (PAUSE 5 sec) Now, release the tension. Let your jaw drop down and the muscles around your throat and jaw relax. Notice the difference between the feelings of tension and the feelings of relaxation… (PAUSE 10 sec) Now, build up the tension around your eyes and lower forehead, by squeezing your eyes tightly shut and pulling your eyebrows down… hold this tension (PAUSE 5 sec) Now release all the tension in your eyes and lower forehead. Let the tension disappear from around your eyes. Feel your forehead and eyes smooth. Feel the difference as the muscles relax… (PAUSE 10 sec) Build up the tension in your upper forehead and scalp by raising your eyebrows as high as possible. Feel the wrinkling and pulling across the forehead and top of the head. Hold this tension… (PAUSE 5 sec) Now release all the tension in your forehead, letting the eyebrows gently rest down. Focus on the sensations of relaxation… (PAUSE 10 sec) Your whole body is feeling relaxed and calm. Scan your body for any last bits of tension and if you notice any, let that tension go. Enjoy the feelings of relaxation… Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 54 As I count from 1 to 5, feel yourself become more and more relaxed… 1 … let all tension leave your body… 2 … sinking further and further into relaxation… 3 … feel more and more relaxed… 4 … feel very relaxed… 5 …deeply relaxed… (PAUSE 30 sec) As you spend a few minutes in this relaxed state, think about your breathing. Feel the cool air as you breathe in and the warm air as you breathe out. Your breathing is smooth and regular. Every time you breathe out, think to yourself “relax… relax … relax”… you are feeling comfortable and relaxed… (PAUSE 1-3 min) (Skip if going on to other relaxation exercises) Now, as I count from 5 to 1, feel yourself become more alert… 5 bringing your attention to this room… 4 feeling calm and relaxed… 3 start to wiggle your fingers and toes… 2 slowly start to move and stretch your muscles… 1 open your eyes, feeling refreshed and rejuvenated. Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 55  GUIDED IMAGERY Imagine yourself walking slowly down a path toward your special place. This path can be inside or outside. The path is comforting and peaceful. As you walk down this path, imagine all of your stresses, worries, and tension are leaving you. Enjoy this journey to your special place. As you walk down this path, notice the ground beneath you…how it feels as you walk. Notice the sounds…the comfortable temperature of the air. Take a breath in, feeling all your tension leave you as you exhale. Notice any fragrance that may be here. Notice the view around you. Reach out and touch something around you. Feel its textures… You feel calm and safe. All your worries and anxieties being left behind as you move toward your special place… (PAUSE 30 sec) Walk down this path until you arrive at your own special place…and when you have reached this special place, go ahead and enter… (PAUSE 10 sec) You have arrived at this relaxing and peaceful place. Notice the ground underneath you… whether it is hard or soft. Notice how the ground feels below your feet. Listen to the sounds in this place, both close and distant. Smell the air, the fragrances. Notice the temperature of the air around you. Look above you… Notice the colors and sights above you. Look out into the distance… as far as you can see… Take in all of the sights, fragrances, and sounds around you. Reach out and touch something in this place… Notice its texture and how it feels against your skin. Notice the different objects around you… their shapes, textures, and colors. Notice the light and shade of this place and how it reflects off of these objects. Used with permission. Muphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 56 There is a comfortable place for you to sit or lie here as you take in all the smells, sounds, sights, and textures… As you sit or lie in this place, away from it all, you feel calm and secure, refreshed and renewed, strong and at peace. As you enjoy this place for a few minutes, you know that you can come here whenever you please, and that this place will always be waiting for you… (PAUSE 3-5 min) Now it’s time to come back… leave by the same way you came, enjoying the path… and as you return on this path, you start to also notice the room in which you are sitting… start to wiggle your fingers and toes… and when you are ready, slowly open your eyes and stretch. Used with permission. Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D. & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. 57  RELAXATION PRACTICE RECORD Use this record to chart your relaxation practice over time. Before and after your practice, rate your level of tension (1 = lowest level of tension, 10 = highest level of tension). Remember, it may take a number of sessions before you notice improvement. Relaxation How long did Date Technique you practice? Level of Tension (minutes) 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 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 58  RELAXATION TRAINING APPS Virtual Hope Box Simple tools to help with coping and positive thinking Mindfulness Coach Audio exercises, a self-guided training program, and resources to support practice Breathe2Relax Learn breathing and relaxation skills. Tactical Breather Learn breathing skills to gain control over heart rate, emotions, and concentration during stressful events. PTSD Coach Learn skills to help cope with trauma symptoms. Anger and Irritability Management Anger management tools, education and support PTSD Family Coach For family of people with PTSD 59  SCHEDULE WORRY TIME There is a drastic difference between “thinking” versus “worrying.” ° Thinking involves reflection and analysis that leads to clarity and purposeful action. ° Worrying is problem-solving gone awry. ° Many chronic worriers tend to believe they can’t control their thoughts. With practice, you can learn to control how often and when you worry. When you give in to unproductive worry throughout the day, the pull to worry repetitively will only grow stronger. Alternatively, if you limit the amount of time and energy you spend on worrying, the intensity and frequency of this unhealthy habit will start to diminish over time. Step 1. Schedule worry time each day for one week. Set aside 15-30 minutes during the morning or afternoon (avoid scheduling worry time in the evening or before bed). Step 2. During the 15-30 minutes write down all your worries. Do not start to problem solve yet! Do not fight or struggle with your thoughts. Just write them down as they come to mind. Step 3. In between scheduled worry time, if you notice that your mind is being pulled to worry, remind yourself that you will have time to worry again and give yourself permission to let go of those thoughts for now. Step 4. At the end of the week, look over the list of worries you wrote down. Do you notice any patterns? Changes in the content of your worries? Reflect on what you have learned from this list. Ideally, you may start to notice that it is difficult to worry for the entire time you have set aside every day. This strategy may seem a bit strange at first. Give it your best and keep an open mind. 60  WORRY JOURNAL Sunday: Worry Time: ______________________ 1. __________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. _________________________________________________________________________________ Monday: Worry Time: ______________________ 1. ___________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. _________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. __________________________________________________________________________________________ Tuesday: Worry Time: ______________________ 1. __________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. _________________________________________________________________________________ Wednesday: Worry Time: ______________________ 1. ___________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. _________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. __________________________________________________________________________________________ Thursday: Worry Time: ______________________ 1. __________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. _________________________________________________________________________________ Friday: Worry Time: ______________________ 1. __________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. _________________________________________________________________________________ Saturday: Worry Time: ______________________ 1. __________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. _________________________________________________________________________________ 61  PROBLEM SOLVING (ITCH) EXAMPLE Identify the Problem: Not enough time to take care of the responsibilities at home and have dinner with a friend. Goal: Be able to do things I enjoy, but also meet my obligations at home. Think About Potential 1) Don’t go visit with a friend. Solutions 2) Don’t take sister to soccer game. 3) Get someone else to take sister to soccer game. 4) Bring friend to soccer game, then everyone go out to eat. 5) Stay at home. 62  Pros: Cons: Solution 1 Sister gets to go to I don’t get to catch soccer game. up with an old friend. Pros and Cons Solution 2 I get to catch up with Sister misses an an old friend. important game. Solution 3 I get to catch up with I miss sister’s an old friend. important game. Solution 4 I get to see game Friend may not like and hang out with a soccer. friend. Solution 5 I don’t have to make No one gets to do a decision. anything they would enjoy. Choose The Best Solution: Bring friend to soccer game; then everyone goes out to eat. ACTION PLAN Steps to Achieve Solution Tools Needed To Complete Steps 1) Ask friend to go to soccer None 2) Find somewhere good to eat after Money 3) Have fun! Friends and family How Well Did it Work? Everyone had fun. I got to spend time with my friend and see my sister’s game. 63  PROBLEM SOLVING (ITCH) Identify the Problem: Goal: Think About 1) Potential Solutions 2) 3) 4) 5) 64  Pros: Cons: Solution 1: Solution 2 Pros and Cons Solution 3 Solution 4 Solution 5 Chose Best Solution: ACTION PLAN Steps to Achieve Solution Tools Needed To Complete Steps 1) 2) 3) 4) How Well Did it Work? 65  COGNITIVE STRATEGIES BENEFITS OF COGNITIVE STRATEGIES Help identify unhlepful thoughts, beliefs, and images Learn to distance self from unhelpful thoughts BEFORE acting on them Determne the accuracy of these thoughts Develop alternative, more realistic thoughts Practice challengig thoughts the moment they arise Wright, J. H., Brown, G. K., Thase, M. E., & Ramirez Basco, M. (2017). Learning Cognitive-Behavior Therapy: An Illustrated Guide(Second ed.). Arlington, VA: American Psychiatric Association Publishing. Anatomy of an Emotion 66  ANATOMY OF AN EMOTION EXAMPLE Trigger (situation): Since the death of my parents, I have to put the things I want to do on hold (school and military) in order to take care of my siblings. Feeling: frustrated, angry, sad Bodily Sensations: Tense, heart racing Urges (Potential actions): Most Helpful Don’t help siblings. Don’t finish school to help take care of siblings needs. Take online classes to Take online classes to make more time to meet make more time to meet more obligations. obligations. I need to get more organized to see what all HAS to be Thoughts: accomplished. I love my siblings, but I can’t do everything for them. I didn’t ask to be a parent. I can’t get everything done today. I need to get more organized to see what all HAS to be accomplished. Action plan to help choose most helpful thought and behavior the during next situation: 1. Buy a calendar, and write down all events/tasks that need to be completed. 2. Call to get more information about online classes. 3. Create a chore list so everyone in the home is helping. 67  ANATOMY OF AN EMOTION Trigger (situation): _________________________________________________________ Feeling: ____________________________________________________________________ Bodily Sensations: _________________________________________ _________________________________________ _________________________________________ _________________________________________ Urges (Potential actions): Most Helpful __________________________________________ __________________________________________ __________________________________________ __________________________________________ Thoughts: __________________________________________ __________________________________________ __________________________________________ __________________________________________ Action plan to help choose most helpful thought and behavior the during next situation: 68 AUTOMATIC THOUGHTS Automatic thoughts can be words, an image, a memory, a physical sensation, an imagined sound, or based on intuition. It is a surface-level, nonvolitional, stream-of-consciousness, meaning they just happen, popping into your head; often you won’t even notice them. We tend to automatically believe our thoughts whether they are positive or negative. Automatic thoughts seem to repeat over and over, and the more they repeat, the more believable they seem. As the name indicates, these automatic thoughts cannot be directly controlled by people, since they are reflexive reactions based on the beliefs people hold about themselves. However, people can indirectly control these thoughts by challenging the beliefs that lead to them. Examples: “Nothing feels good anymore.” “I can’t stand this anymore.” “I can’t get started.” “What’s wrong with me?” “I wish I were somewhere else.” INTERMEDIATE BELIEFS Intermediate beliefs are just below the surface of automatic thoughts. These thoughts are responsible for maintaining anxiety and depression. They are often expectations or assumptions about ourselves or others. Intermediate beliefs are rules or guidelines that we follow. Examples: “I should avoid meeting new people at all costs.” “Danger is always present.” “People will always take advantage of me.” CORE BELIEFS Core beliefs are considered to be at the root, or deepest level, of our thinking. These beliefs represent our views of ourselves, others, and the world around us. They have an absolute quality to them. Examples: “I am unlovable.” “All men are dangerous.” “The world is completely dangerous.” 69 EXAMPLES: “I am unlovable.” “All men are dangerous.” “The world is completely dangerous.” Automatic Thoughts Intermediate Beliefs Core Beliefs 70  EMOTIONS Emotions are one word that describes a feeling. (See emotion worksheet, pg. 69) WHAT IS THE DIFFERENCE BETWEEN MY THOUGHTS AND FEELINGS? If it’s a full sentence, it’s a thought. Feelings are one word and are expressions of emotions. Thought Emotion Nobody likes me Depressed I will never get better Hopeless I am comfortable with life Content I had a good day Happy 71  COMBINING THOUGHTS AND BEHAVIORS Negative Thought Possible changes in behavior to solve/help the problem Steps needed to make changes: Tools to make changes: Negative Thought Possible changes in behavior to solve/help the problem Steps needed to make changes: Tools to make changes: 72  Neg