Behavior Therapy. Pavlov: pair bell with food. Skinner: "punish an action to stop it, reward an action to encourage it." Example of behavior therapy: "Here’s what we’re going to do, if you’re up for it. We’ll make a list of situations that trigger your fear, and we’ll rate each activity for how challenging it would be. Then we’ll work through the list systematically, starting with the easier ones and working up to the harder ones. When you face your fears, they diminish. It shouldn’t take long before you’re feeling more comfortable on bridges, as your brain learns that bridges actually aren’t that dangerous."
CBT. "CBT can’t be done to a person. Instead, the therapist is an expert on CBT, and clients have specialized knowledge about themselves. Success in CBT requires bringing together these perspectives to tailor a treatment to the client’s needs. "CBT begins with setting clear goals and then designing a roadmap-like treatment plan."
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Week 1: Setting your goals and getting started
Beginning: "What brought you in? How long have you been dealing with these issues? How often do they come up? Why now--what made you decide that it was time to take action."
What are your strengths? "What are you good at? What do the people who know you best appreciate about you?"
Assess (a) Relationships, (b) Education and career, (c) Faith/meaning/expansion, (d) Physical health (including physical activity, substance use, food, sleep), (e) Recreation/relaxation, (f) Domestic responsibilities. Basic human needs: "Autonomy: the ability to decide for ourselves what we do, without being overly controlled by others. Relatedness: meaningful and satisfying connections to other people. Competence: feeling like we’re good at what we do and able to put our talents to use.
What are your goals?
Homework: For next week record how you're spending your days (Daily Activities form): (a) each hour write what you did, (b) each hour write how much you enjoyed each activity and how important it was for you, (c) rate your overall mood for each day (0-10, 0 is very bad and 10 is very good)
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Week 2: Getting back to life
Review Daily Activities Form, note how often your doing activities that are enjoyable and important? Are there certain times when you're not doing such activities? (Begin every session with homework review.)
Behavioral activation: generally a treatment for depression but can lower anxiety also. Once we get depressed, we tend to stop doing things that make us feel good.
Behavioral activation: generally a treatment for depression but can lower anxiety also. Once we get depressed, we tend to stop doing things that make us feel good.
Start by "getting ourselves to do more of the things we find rewarding--part 'B' of CBT." CBT usually starts with behavior because (a) it's simple (we can easily identify the things that we enjoy) and doing these behaviors can quickly make a big different. These activities often hurt in the short-term but have long-term benefits (e.g., I'm depressed and don't want to go to my friends, but this will help me in the long-run).
Homework. To pick activities: decide what you value in areas discussed last week; these will be values that are high in terms of both enjoyment and importance. Come up with activities that fall under each of those values; choose three specific activities; rank activities in terms of easiest to do (1) and hardest (3); start by working through the 1s. Maybe start by picking three 1s, determine day you'll do them.
You're more likely to do these activities if when: (a) Activities are specific and manageable, (b) Activities are enjoyable and/or important, (c) Plan to do each activity at a specific time, (d) You build accountability into your plan.
Exercise has be shown to help with both anxiety and depression; "[t]he effect is about the same size as that of antidepressant medication." Some reasons: exercise improves sleep, distracts us from negative thinking, can lead to positive social contact, can give us sense of satisfaction.
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Week 3: Identifying your thought patterns
Homework review. Review how your three activities went.
Think about recent situation in which you felt unpleasant emotion. Picture situation as vividly as possible. Describe event, including emotions. Can you identify any specific thoughts you had at the time. (Not all thoughts in the form of words.)
Homework. (a) This week pick four activities; it's okay to repeat an activity from last week, "but try to add some new ones." Stick with activities rated 1, add a 2 if you'd like. (b) Use Identifying Thoughts form: record three times in which your mood dipped; note what was happening, what you felt, what your thoughts were.
See if you notice recurring themes. "It's like our mind is a jukebox and only has a few 'hits' to play over and over when a triggering event 'pushes the button.'"
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Week 4: Breaking negative thought patterns
Review homework.
CBT. Use Challenging Your Thoughts form, evaluate evidence for/against your thought. Also ask how you could modify thought to make it better align with reality.
Some tips. (a) Ask how likely it is that you're seeing things as worse than they really are. (b) Ask if you're ignoring evidence that would contradict your thought. (c) Ask what you would tell someone you loved.
Use Identify Core Beliefs to brainstorm, notice trends, and get identify core beliefs.
Homework. (a) Choose 5 activities from list; choose some 2s and 3s if they seem doable. Schedule these activities. (b) Choose 3 triggering events and complete Challenging Your Thoughts form for each one.
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Week 5: Time and task management
Review homework.
Both anxiety and depression make it hard to concentrate and be effective problem solvers and to complete tasks. Principles of time and task management: (a) Identify your tasks. (2) Prioritize your tasks. (3) Plan when to complete tasks. (4) Follow through on completing tasks.
Strategies: (a) Break down tasks into manageable pieces. (b) Set alarms and reminders (don't count on yourself to "just remember"). (c) Build in accountability. (d) Reward yourself (e.g., pause to read two news articles after you do 45 minutes of homework). (e) Remove distractions (e.g., in your work space).
CBT for insomnia: see bookmark.
Homework. (a) Choose 5 more activities. (b) Complete at least one Challenging Your Thoughts form. (c) Schedule some tasks to complete, tasks you've delayed completing in the past. (d)Choose 2-3 strategies to implement.
See if you notice recurring themes. "It's like our mind is a jukebox and only has a few 'hits' to play over and over when a triggering event 'pushes the button.'"
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Week 4: Breaking negative thought patterns
Review homework.
CBT. Use Challenging Your Thoughts form, evaluate evidence for/against your thought. Also ask how you could modify thought to make it better align with reality.
Some tips. (a) Ask how likely it is that you're seeing things as worse than they really are. (b) Ask if you're ignoring evidence that would contradict your thought. (c) Ask what you would tell someone you loved.
Use Identify Core Beliefs to brainstorm, notice trends, and get identify core beliefs.
Homework. (a) Choose 5 activities from list; choose some 2s and 3s if they seem doable. Schedule these activities. (b) Choose 3 triggering events and complete Challenging Your Thoughts form for each one.
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Week 5: Time and task management
Review homework.
Both anxiety and depression make it hard to concentrate and be effective problem solvers and to complete tasks. Principles of time and task management: (a) Identify your tasks. (2) Prioritize your tasks. (3) Plan when to complete tasks. (4) Follow through on completing tasks.
Strategies: (a) Break down tasks into manageable pieces. (b) Set alarms and reminders (don't count on yourself to "just remember"). (c) Build in accountability. (d) Reward yourself (e.g., pause to read two news articles after you do 45 minutes of homework). (e) Remove distractions (e.g., in your work space).
CBT for insomnia: see bookmark.
Homework. (a) Choose 5 more activities. (b) Complete at least one Challenging Your Thoughts form. (c) Schedule some tasks to complete, tasks you've delayed completing in the past. (d)Choose 2-3 strategies to implement.
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Week 6: Facing your fears
Review homework.
It's usually helpful to have something to say to our thoughts -- e.g., "Okay, back to reality," "Thank goodness that's not true," "Not everything you think is true."
Write down your biggest fears. Do these fears get in the way of living to the fullest? What are some activities that would allow you to face your fears incrementally?
Exposure must be intentional to work. Exposure isn't something that can be done to us. "Intentionally defying our desire to avoid our fears sends a powerful message to our brains: Maybe we don't have to be so afraid."
To overcome a fear, you must repeatedly face it. "Our nervous systems usually don't stop being afraid of a situation after facing it one time." Also, our repeated exposures must be relatively close together in time: e.g., flying once a year if you're afraid of flying won't be sufficient.
We have to stay in the situation long enough to feel discomfort. "If we run away at the first feeling of discomfort, we'll be reinforcing our avoidance behavior and the belief that had we stayed, things could have been really bad." Encourage yourself to face your fears by reminding yourself that it will be hard and that you're going to do it anyway; foster an attitude of curiosity; remember what motivated you to face your fears in the first place; remember the discomfort won't last forever; reminder yourself that few great things are achieved through avoidance.
Eliminate unnecessary props or safety behaviors.
Tailoring exposure for different fears (specific phobias, panic disorder, social anxiety, generalized anxiety disorder) -- excellent discussion, pp. 171-181.
Homework: (a) Continue completing scheduled activities from Getting Back to Life list, (b) Monitor activities for three days using Daily Activities form, (c) Complete Challenging Your Thoughts form as needed, (d) Continue completing tasks from week 5, (e) Create your exposure hierarchy and complete first few items.
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