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SELF-HELP COGNITIVEBEHAVIOURAL THERAPY (CBT) WORKBOOK FOR DEPRESSION, ANXIETY AND ANGER Stress Management Clinic Self-Help CBT Course

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Table of Contents Setting a Goal ............................................................................................................................4 Activity: Establishing SMART Goals for self-help .....................................................5

What is Cognitive-Behavioural Therapy? ......................................................................7 CBT Model in Anxiety ........................................................................................................8 CBT Model in Depression ...................................................................................................9

Activity: Identifying thoughts, feelings, and behaviours ..........................................10

“Five Aspects” Sheet .............................................................................................................12 Understanding the Links between Thoughts, Feelings & Behaviours .................13 Low Mood or Depression ..................................................................................................13 Anxiety ..............................................................................................................................15 Anger .................................................................................................................................18

A Vicious Cycle of Depression ..........................................................................................20 A Vicious Cycle of Anxiety ..................................................................................................21 A Vicious Cycle of Anger .....................................................................................................22 Making Changes in Behaviour ...........................................................................................23 Activity ............................................................................................................................23

Four Steps to Increasing Activity Levels .............................................................................. 25 Activity ....................................................................................................................................... 25 Step 1 – Activities List ..........................................................................................26 Step 2 – Activities Hierarchy ................................................................................27 Step 3 – Activity Dairy ..........................................................................................28 Step 4 – Review the Week .....................................................................................29

Anxiety - Facing Your Fears ..............................................................................................30 Activity: Anxiety Ladder ...............................................................................................31 Activity: Steps for Exposure .........................................................................................32 Activity: Anxiety Diary .................................................................................................33

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Changing Thoughts ...............................................................................................................34 Activity: Three Stages of Challenging Thoughts .......................................................35 Stage 1 – Catching Thoughts .................................................................................35

Activity: Thought Diary ................................................................................................41 Stage 2 – Looking for the Evidence ......................................................................42

Activity: Thought Challenging Diary ..........................................................................43 Stage 3 – Finding an Evidence Based Thought ......................................................6

Activity: Thought Diary ................................................................................................46

Problem-Solving Approach ................................................................................................47 Activity: Solving-Problem Sheet ..................................................................................47

Bibliography ............................................................................................................................49

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Stress can affect many people at different times in their lives. Sometimes life can be very difficult. We might feel stressed due to having money problems, or having to attend a job interview. Although we often cannot change the life experiences we go through, we can change how we react to these experiences and we can learn how to manage our mood. Stress Management Clinic provides support for people who are experiencing difficulties with depression, anxiety, and anger. This workbook has been designed to be used as self-help. The aim of this workbook is to introduce you a number of tools that will help you build up your own “tool bag” which will give you some skills to manage your mood. The tools covered in this book are based on the principles of Cognitive-Behavioural Therapy. Going through this workbook, you will have to complete worksheets which might be helpful for you to learn and to apply these CBT tools. Try and work through the exercises and perhaps spend more time on those that seem more useful to you and your problems and remember that as with any skills, the tools may need some time to learn and practice!

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Setting a Goal In order to make self-help to be effective, it is important to set SMART goals.

Specific Measurable Achievable Relevant Time Limited

Self-Help is Like a Road Map Imagine you’re planning a journey and you are looking for directions. Is it possible to get directions to a destination that you do not know yet? If you do not have any goals, how do we know what techniques to use to help you reach your goals? Not having goals is like trying to find directions to a destination when you have not decided where you would like to go.

Examples of SMART goal 1. I would like to meet people of the same interests once a week and spend and hour talking to them. I would like to achieve this within the next 2 months.

2. Whilst I am looking for a job, I would like to approach 4 prospective employers each week and ask them about any vacancies. I would like to be able to do this within the next 3 weeks.

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3. I would like to learn how to challenge my negative thinking. Instead of worrying about things all day, I’ll dedicate 20 minutes a day to writing down all my worries and do my best to manage them. I would like to achieve this by the end of the following month.

Examples of goals which are NOT SMART 1. I would like to feel get rid of depression. 2. I would like to stop being anxious. 3. I would like to do the things I used to do.

Activity: Establishing SMART Goals for self-help Please take a few minutes to identify your goals and triggers. Triggers refer to the situations that normally cause you any anxiety or low mood that you may be experiencing. Identify what triggers your anxiety or depression.

Triggers: ______________________________________________________________________________ ______________________________________________________________________________

Goals Spend a few minutes thinking about your own goals and write them down using the principles of the SMART goals mentioned above (i.e., being specific, measurable, achievable and so forth).

NB! Remember that there is not one ‘correct’ way to complete tasks. Remind yourself that improvement can be gradual, which is normal and to be expected. Prioritise time to practice the techniques and complete tasks so that you can get as much benefit as possible. Discuss any concerns with a qualified professional if you are receiving help and support from one. Self-Help CBT Workbook

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What do you hope to gain? ______________________________________________________________________________ ______________________________________________________________________________

What do you hope to have achieved? ______________________________________________________________________________ ______________________________________________________________________________

What will be different for you? ______________________________________________________________________________ ______________________________________________________________________________

What do you think could prevent you from being able to achieve these goals? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

What could you do to ensure that these obstacles do not prevent you from achieving your goals and overcoming your problems? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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What is Cognitive-Behavioural Therapy? Cognitive-Behavioural Therapy (CBT) is a form of psychotherapy that talks about 

How you think about yourself, the world and other people



How what you do affects your thoughts and feelings

This approach can help people look at the different situations that they find themselves in, and to understand their thoughts, emotions and behaviours. The idea is that our thoughts, emotions, physical symptoms and behaviour can all influence one another and therefore help to maintain unhelpful moods such as depression and anxiety.

Situation Thoughts Behaviour

Emotions

Physical The CBT model emphasises that it is not the situation that causes the emotional distress but instead the event an individual is experiencing through his or her interpretation or view of that event or situation. CBT works by focussing on the negative thoughts and learning how to challenge them, as well as learning how to change unhelpful behaviours such as avoidance. Example: If someone you know passes you by in the street without acknowledging you, you can interpret it in different ways. Firstly, you could think that that person didn't want to know you, because no one likes you (which may lead you to feel depressed). Secondly, you could think that that person didn't stop to talk to you, because you didn't know what to say and that person could think you're boring and stupid (may lead to anxiety). And thirdly, you could

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think that person was deliberately snotty (leading to anger). A healthier response might be that that person just didn't see you.

Now, let us look at the examples which can explain in what the CBT model can work in a real situation.

Anxiety: Mary was chairing a meeting at work. Her thoughts, emotions, physical symptoms and behaviours were all influenced by each other. She thought that “everyone will think that I am stupid,” which contributed to her feeling embarrassed, as well as making her heart beat faster and becoming sweaty. As a result of this, she now actively avoids going to any meetings. This can cause Mary to feel even more anxious and embarrassed and strengthens her negative thoughts. If Mary thought she was able to chair the meeting, and did not avoid future meetings, this can then help create a more balanced emotion and to manage anxiety.

Linda chaired a meeting “Everyone thinks I’m stupid” Avoids going to meeting

Distressed, embarrassed Heart being faster, sweaty, dizzy

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Depression: Peter has been having problems at work and over the last few months has been feeling very low. His situation is that he has been asked to go to a party by an old friend. Again, notice how his thoughts, emotions, behaviour and physical sensations are all influenced by each other. He thinks negatively about the invitation and thinks that “no-one will talk to me”. As a result, he decides not to go to the party and feels even lower. If Peter had gone to the party and found that people did talk to him this may have helped him feel better and improved his low mood.

Peter is being invited to a party “I won’t enjoy it. Nobody will talk to me there.” Make excuse not to go

Low, unhappy

Lethargic, fatigue

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Activity: Identifying thoughts, feelings, and behaviours What is your situation? ____________________________________________ What has happened? ______________________________________________ What else was going on? ____________________________________________ Who were you with? ________________________________________________ Was it a situation that you often find yourself in? __________________________

What thought or images went through your mind just before or during that time?___________________________________________________________ What disturbed you? _______________________________________________ If you had that thought, what did that mean to you?________________________ Or what did that say about you or the situation? __________________________ If your thought was a question, try to answer it. ___________________________

What distressing emotion(s) did you feel? ____________________________ What else? _______________________________________________________ (E.g., anger, anxiety, terror, rage, depression, frustration, guilt, shame, irritation and so forth)

What did you notice in your body? __________________________________ In anxiety and anger (and excitement) the body's adrenaline can result in us feeling physical sensations which can include: heart pounding or racing, palpitations, rapid breathing, difficulty breathing, light-headed, dizzy, shaky, sweaty, hot, red, pins & needles, tense or sore muscles, urge to go to the toilet, butterflies in the tummy, warm uncomfortable feeling in the abdomen or chest, difficulty concentrating, lump in throat. In depression, we can feel tired, lethargic, exhausted, experience appetite and sleep changes, aches and pains, headaches, digestive changes (e.g. constipation), agitation and feel unable to settle, experience lack of interest in sex, and have slow movement or speech.

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What did you do? _________________________________________________ What didn’t you do? ________________________________________________ How did you cope? ________________________________________________ Anxiety: Stayed home, left wherever you were or felt the urge to leave, didn’t talk to anyone, avoided eye contact, fiddled with a pen, sat in a corner, didn’t go out, chose to shop at less busy times, went to local corner shop instead of the big supermarket, distracted yourself (TV, radio, kept busy, etc.), urge to go (or went) to toilet, looked for reassurance, drank more, smoked more, ate more (or less), disturbed sleep. Depression: Stayed in bed, pulled covers over your head, didn't go out, sat and stared, watched television, didn't answer the phone, turned down an invite from a friend, didn't go to work, ate more (or less), slept more (or less), paced around, kept starting to do things but couldn't finish, no interest in others, no interest in sex, no interest in anything. Anger: shouted at someone, hit out, screamed, had a go at someone, sulked, criticised others (or had urge to do those things), used put-downs and threats, bottled it up, lost control.

Now you need to fill out the form provided below.

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“Five Aspects” Sheet Your Situation

Your Thoughts & Images

Body / Physical Sensations

Moods / Emotions

Behaviours / What I did or didn’t do

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Understanding the Links between Thoughts, Feelings & Behaviours

Low Mood or Depression Low mood or depression is an emotion which can cause emotional distress. People can often experience a number of different symptoms that can affect the way that we think, the things that we do, as well as the physical symptoms that we can experience. This can then impact people further by causing their mood to deteriorate even more. Depression can happen to anyone - and does happen to one in four of us over our lifetimes. Different factors that make it more likely to happen, include biological make-up, upbringing, or reaction to life events. What keeps it going though, is how we deal with those things. The way we think and what we do affects the way we feel.

Thoughts that occur in depression People who are depressed tend to think very negatively about themselves, the future and the world around them. It can be like seeing life through "gloomy specs". 

Everything is hopeless - nothing can change



I'm useless, worthless



It's all my fault



The world is a terrible place - everything goes wrong



I’m a failure



People think I’m stupid



Nobody likes me



There’s no point, I won’t enjoy it

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I might as well not be here Self-Help CBT Workbook

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Physical sensations in depression 

Tiredness, fatigue, lethargy



Difficulty concentrating or remembering



Difficulties sleeping



Poor appetite or over eating



Lose interest in hobbies, activities, sex



Tearful



Loss of sex drive

Behaviours in depression Because of the tiredness, difficulty sleeping and eating, and negative style of thinking, we tend to do less and less. We stop doing the things we used to do and enjoy. It could get so bad that we can't even go to work, or do things at home. We want to stay in bed, or stay at home doing very little. We might isolate ourselves from friends and family. 

Social withdrawal



Increased smoking or drinking



Decrease in activities



Sleeping during the day

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Anxiety Anxiety is an emotion which usually involves an element of worry and fear. It is a state of mind but can also affect our thoughts, behaviours and physical reactions in our body. Although anxiety can be unpleasant, it is actually an evolutionary survival mechanism. When we find ourselves in dangerous or stressful situations, anxiety helps us by preparing our body to either run away or fight back. This is known as the “fight versus flight” response. Although anxiety can help us survive, it can start to become a problem when we use the fight versus flight response when there is no need. Anxiety is natural and helpful in dangerous or stressful situations but becomes a problem when we experience anxiety when we are not in a dangerous or stressful situation or long after a dangerous or stressful situation has passed.

Thoughts that often occur in anxiety The thoughts include our overestimating or exaggerating the actual threat, and underestimating or minimising our ability to cope: 

I'm in danger right now



The worst possible scenario is going to happen



I won't be able to cope with it



Something awful is going to happen



I will not be able to cope



What if I don’t do it right



What will people think of me



I need to escape

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Physical sensations in anxiety 

Faster heart beat. This helps to take the blood to where it is most needed. At the same time blood is taken from the places it is not needed for example fingers, toes and skin. These changes cause tingling coldness and numbness.



Breathing gets faster. This helps the bloodstream to carry oxygen to the arms, legs and lungs. This will give him more power. The side effects may include chest pain, breathlessness and a choking feeling. As there is a slight drop in the blood and oxygen being sent to the brain he may feel dizzy or light headed, he may experience blurred vision.



Physical tension. The large skeletal muscles tense and create power, this may cause pain, aching and shaking.



Sweating. This sensation helps cool the muscles and the body and prevent the body from overheating.



Digestive system slows down. This physical reaction helps save energy. Side effects may include nausea and a dry mouth.

Behaviours in anxiety 

Avoiding people or places



Not going out



Going to certain places at certain times, e.g. shopping at smaller shops, at less busy times



Arguing



Escape, leave early



Talking or doing things faster



Under or over eating



Go to the feared situation, but use coping behaviours to get you through: examples include: self talk, holding a drink, smoking more, fiddling with clothes or handbag, avoiding eye contact with others, having an escape plan, medication. These are called 'safety behaviours'.

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‘Safety behaviours’ can also help to keep your anxiety going. Whilst you depend on them to help you cope, you don't get to find out that without them, the anxiety would reduce and go away on it's own. Whilst avoiding people or situations might help you feel better at that time, it doesn't make your anxiety any better over a longer period. If you're frightened that your anxiety will make you pass out or vomit in the supermarket aisle, you won't find out that won't actually happen, because you don't go. So the belief that it will happen remains, along with the anxiety.

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Anger Anger is a result of thinking that we have been unfairly treated or disrespected, or that others have broken or fallen short of our rules, standards or expectations, and we won't stand for it. Thinking this way leads us to feel angry. We respond to those thoughts and feelings, by acting, or feeling an urge to act, in threatening or aggressive ways.

Thoughts that often occur in anger 

I'm being treated unfairly



I'm being disrespected



They're breaking a rule or standard



I won't stand for it

Physical sensations in anger When there is real, or we believe there is a real, threat or danger, or we believe we need to defend or stand up for what we believe, our bodies' automatic survival mechanism kicks in very quickly. We will notice lots of physical sensations, which might include: 

heart racing or pounding - enabling good blood supply around our bodies



breathing quickly - allowing more oxygen around the body



tense muscles - a state of readiness to fight or flee



shaking



hot, sweating



light-headed Self-Help CBT Workbook

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stomach churning or butterflies



fist or teeth clenching

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Behaviours in anger 

staring & angry facial expression



aggressive body posture



attacking



hitting out (or urge to hit out)



arguing



shouting or snapping at others



running or storming away



staying silent (maybe inwardly seething)



sulking

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A Vicious Cycle of Depression

There is no point? Wake up in the morning

Thoughts:

Feelings:

I’ll only mess up again

Behaviours: Stay in bed

Depressed Pull covers over head Fatigue

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A Vicious Cycle of Anxiety

Something terrible is going to happen I feel bad. So, it must be bad. Real or perceived danger

Thoughts:

Feelings:

I can’t cope

Behaviours: Avoid, escape or freeze

Physical sensations of anxiety

Try to cope by doing things that help feel better or keep safe Anxious, fearful

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A Vicious Cycle of Anger

That idiot’s deliberately cut me up!

E.g., driving a car & being cut up by another driver

Thoughts:

Feelings:

I’ll teach this driver

Behaviours: Shout, stare, make rude gesture

Fired up, tense, heart racing

Clench wheel, drive up closer to that vehicle Angry

NB! In Cognitive-Behavioural Therapy, we aim to break those cycles by changing something - what we think or what we do.

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Making Changes in Behaviour Changing what we normally do can greatly affect the way we feel and think. When you look at your “Five Aspects” Sheet where you wrote down your thoughts, emotions, behaviours and physical sensations, notice particularly what you wrote for behaviours. Very often we react automatically, without considering our actions or the consequences.

Activity What helped you cope and get through it? ______________________________________________________________________________ ______________________________________________________________________________ What didn’t I do or what did I avoid doing? ______________________________________________________________________________ ______________________________________________________________________________ What automatic reactions did I have? ______________________________________________________________________________ ______________________________________________________________________________ What would other people have seen me doing? ______________________________________________________________________________ ______________________________________________________________________________ What were the consequences of what I did? ______________________________________________________________________________ ______________________________________________________________________________ What happened later because of it? ______________________________________________________________________________ ______________________________________________________________________________ Did it affect the way I felt later? ______________________________________________________________________________ ______________________________________________________________________________

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What could I have done differently? ______________________________________________________________________________ ______________________________________________________________________________ What would someone else have done in that situation? (it might help to think about particular people that you know, and what they might have done differently) ______________________________________________________________________________ ______________________________________________________________________________ Have there been times in the past when I would have done something else? ______________________________________________________________________________ ______________________________________________________________________________ If I had paused, and taken a breath, what would I have done? ______________________________________________________________________________ ______________________________________________________________________________ If I had tried that, how would the situation have been different? ______________________________________________________________________________ ______________________________________________________________________________ How would it have affected what I felt? ______________________________________________________________________________ ______________________________________________________________________________ How would it have affected what I thought? ______________________________________________________________________________ ______________________________________________________________________________ Would it have been more helpful or effective for me, another person or for the situation? ______________________________________________________________________________ ______________________________________________________________________________ What would the consequences have been of doing something differently? ______________________________________________________________________________ ______________________________________________________________________________

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Four Steps to Increasing Activity Levels Activity Now have a go at filling in the following forms to start to work through the 5 steps.

NB! Remember that it may be quite difficult at first to increase your activity levels and there’s no such thing as failure. Every ‘failed’ task is actually an opportunity to learn from mistakes in order to improve the next time.

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Step 1 – Activities List Create a list of Routine, Necessary and Pleasurable activities – things you would like to do, but have stopped doing since you felt distressed. Routine (the things that are done normally on a daily basis; e.g. waking up, showering, watching TV and so forth) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Necessary (the things that we may not want to do but need to be done otherwise there will be adverse consequences; e.g. paying the bills, going to work or cleaning the house and so forth) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Pleasurable (the things that we enjoy doing such as our hobbies. Examples include swimming, visiting friends, playing tennis and so forth) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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Step 2 – Activities Hierarchy Create a hierarchy of the list you just made in step one – make sure you include each type of activity – routine, necessary and pleasurable. Use mixture of routine, necessary and pleasurable activities.

___________________________________ ___________________________________

Hard

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Medium

___________________________________ ___________________________________ ___________________________________ ___________________________________

Easy

___________________________________

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Step 3 – Activity Dairy Schedule the tasks using a blank Activity Diary (below) – put in a mixture of activities. Try some easier activities first. Small and regular activities are best to start with and then you can build in other activities over time. Activities need to be very detailed, for instance, to go for a 10-minute walk with the dog every morning around 10 a.m.

Activity Dairy for week commencing ____________________ Monday Morning

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What Where When Who

Afternoon

What Where When Who

Evening

What Where When Who

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Step 4 – Review the Week Review the week – review what activities you managed to include during the week. What activities have you completed? Activities List

Yes

No

Activities Hierarchy

Yes

No

Activity Dairy

Yes

No

What impact did increased activity have on your mood? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Were any activities more helpful in making you feel better? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What will you include in next week’s activity schedule? (you may want to add some new more difficult activities, or you may want to increase some of the existing activities) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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Anxiety - Facing Your Fears People are experiencing the “fight” versus “flight” response when feeling anxious. The “flight” response is quite important in anxiety, as refers to avoiding or escaping the situation that causes this emotional state. Avoiding or escaping the situation could make you feel better in a short term, but in the long run the avoidance is actually reinforcing your anxiety. As a result, you learn that avoiding or escaping a stressful event does reduce your anxiety and in this way, this perception is encouraging you to be afraid of the situation. Anxiety levels drop significantly, when the situation is avoided or escaped. However, the next time the individual faces the same situation, the feeling of anxiety returns and continues up to the moment the individual escapes and avoids it. The only healthful solution is to actually stay in the situation which causes the anxiety and cope with its challenges. In order to overcome this, CBT uses an approach called graded exposure. This involves staying in situations that cause some anxiety and gradually working your way up an anxiety ladder until you eventually stay in the situation that causes the most anxiety.

Example: Public Speaking Fear Most Feared 6. Giving a presentation to unknown people

100%

5. Giving a presentation to friends and family

90%

4. Giving a presentation in front of a mirror

70%

3. Giving a comment on the service (e.g., at the restaurant)

60%

2. Asking about items in different shops for about 30 minutes

55%

1. Wearing clothes that stand out in a public place

40%

Least Feared

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Activity: Anxiety Ladder If you are finding that you have an irrational fear of an object or activity or are avoiding something, then complete your own anxiety ladder:

Your Fear ___________________________

Most Feared 6. 5. 4. 3. 2. 1. Least Feared

Doing Graded Exposure For graded exposure to be effective, it needs to be graded, prolonged, repeated and done without distraction. This means the following: Graded – overcoming a fear is best achieved by gradually confronting the fear. Prolonged – exposure must be for a long enough time to allow the levels of anxiety to reduce. Sessions need to last until the levels of anxiety have reduced by around 50%. Repeated – an exposure task needs to be repeated around 4 or 5 times a week. Without distraction – when doing exposure, it is important that people can experience some anxiety and see that it can reduce. Therefore, it is important that people do not do other things when doing the exposure exercises, for instance distracting themselves with music, relaxation or breathing exercises etc.

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Activity: Steps for Exposure 1. Take a step from you Anxiety Ladder. 2. Face the situation until your fear reduces by at least 50%. 3. Repeat 4 or 5 times in the week. 4. Remember: Expose without using distraction, relaxation or breathing exercises so you can feel the anxiety peak and reduce. 5. Once you have conquered the step and no longer feel anxious, move on to the next step. 6. Repeat the Steps.

When completing any exposure tasks, it may be helpful to keep an anxiety diary. This can allow you to rate your levels of anxiety before, during and after your exposure exercise. You can also make notes or write down any of your thoughts at the time. Please use the blank anxiety diary on the next page.

NB!

Exposure needs lots of practice and can be difficult at first. However, it will get easier as you practice.

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Activity: Anxiety Diary

Date and Time

No anxiety 0%

Duration

Exercise

Anxiety Rating 0 – 100% Before Exercise At Start of At End of Exercise Exercise

Moderate anxiety 50%

Thoughts and Comments

Severe anxiety 100%

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Changing Thoughts Learning how to manage negative thoughts can also help to manage your anxiety and depression. When people are feeling depressed or anxious, their thoughts can often be extreme or unrealistic. As we discussed earlier, CBT calls these types of thoughts Negative Automatic Thoughts. As thoughts can influence our emotions, behaviour and vice versa, it is important to learn how to challenge some of our Negative Automatic Thoughts. Although some people understand that their negative thoughts may not be true, it can be very difficult for people with anxiety or depression to differentiate between the two and they often take their negative thoughts as fact.

Examples of Negative Automatic Thoughts “Nobody likes me.” “Everything always goes wrong for me.” “If I am late for work, I will lose my job.” “They think I’m stupid.” “I am no good.” “Why can’t I ever succeed?” “I hate myself.” “I am a loser.” “I can finish nothing.” “I am worthless.” “I can’t stand for this anymore.” “I feel like I am up against the world.” “What’s wrong with me?” “There must be something wrong with me.” “I can’t get started.” “I can’t get things together.” “My life is mess.” “I am a failure.” “I feel so helpless.” “My future is bleak.” “Nothing feels good anymore.” Self-Help CBT Course

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Activity: Three Stages of Challenging Thoughts Stage 1 – Catching Thoughts In order to help you catch your Automated Negative Thoughts, answer the following questions:

What were you doing? ______________________________________________________________________________ ______________________________________________________________________________ Who were you with? ______________________________________________________________________________ ______________________________________________________________________________ Where were you? ______________________________________________________________________________ ______________________________________________________________________________ What were you telling yourself? ______________________________________________________________________________ ______________________________________________________________________________ What is the worst thing that went through your mind? ______________________________________________________________________________ ______________________________________________________________________________ What does it say about you if it’s true? ______________________________________________________________________________ ______________________________________________________________________________

NB!

There are also a number of points to bear in mind when you are trying to catch your Negative Automated Thoughts: 

They are short and specific;



They occur extremely quickly after the event;



They can occur as words or images; Self-Help CBT Workbook

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They do not arise from careful thought;



They do not occur in a logical series of steps;

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They seem reasonable at the time.

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Thought Traps – Unhelpful Thinking Style When catching your Negative Automated Thoughts, you may also find that there is a theme to your negative thinking. They are called thought distortions or thought traps. They are as follows: MENTAL FILTER You pick out a single negative detail and dwell on it, viewing the whole situation as negative. Refusing to notice any positives or anything that went well or you did well. ALL OR NOTHING THINKING - BLACK AND WHITE THINKING You see things in extreme or in black and white. “It is either perfect, or it is a mess”, “My friend likes me or he doesn’t.” OVERGENERALISATION You see a single negative event as proof that other similar events will turn out the same way. If one person embarrassed you, then all people will behave in this way towards you. DISQUALIFYING THE POSITIVE You reject positive experiences by insisting they ‘don’t count’ for some reason or another. In this way, you can maintain a negative belief that is contradicted by your everyday experiences. JUMPING TO CONCLUSIONS You make a negative interpretation even though there are no definite facts that support your conclusion. Mind Reading – you conclude that someone is reacting negatively to you, but you do not check this out with them. Fortune Telling – You anticipate that things will turn out badly, and you feel that your prediction is an already established fact. CATASTROPHISING You exaggerate the importance of things, such as, something you may have thought was wrong. You inappropriately shrink your achievements or desirable qualities. EMOTIONAL REASONING You assume that your negative emotions necessarily reflect the way things really are “I feel like a failure, therefore, I am one”.

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“SHOULD/MUST” STATEMENTS You set your self standards of what you perceive you “should” or “must” be doing. These standards are often too high and unrealistic. The emotional consequence is guilt. When your direct should statement towards others, you feel anger, frustration and resentment. LABELING AND MISLABELING This is an extreme form of over generalising. Instead of describing your error, you attach a negative label to yourself: “I’m a failure”. When someone else’s behaviour bothers you, you attach a general label to them “he/she is an idiot”. Mislabelling involves describing an event with language that is highly coloured and emotionally loaded. PERSONALISING Y You see yourself as the cause of some negative external event, when in fact you did not have primary or any responsibility. COMPARE AND DESPAIR Seeing only good and positive aspects in others, and comparing ourselves negatively against them.

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Different Perspectives of Thinking Just imagine a traffic accident on the road. You see that police are asking for witnesses to describe what has happened. Their aim is to collect as many as possible statements in order to draw a broader picture to obtain a more realistic vision of the event. In a traffic accident, there will be many different perspectives on what happened. For instance, the driver would have one perspective, another driver would have his/her story, and a passenger would have quite another perspective different from both drivers. Each one who witnessed the same accident would have a slightly different perspective, depending on where they were, how far away they were, how much their view or vision was restricted, how much danger they felt they were in, what else was going on, how the accident affected them, what the accident means to them. So, it is the same principle with everything – each situation, event, conversation means something different to all those involved, and to those not involved. We give different meanings, according to our belief systems, and how we are affected by the event. We all have our own realities. We look at situations, events, and interpret what other people say and do, according to our own set of past experiences, culture, faith, values, all of which help us form our beliefs about ourselves, about others, and about the world in general. The meaning we give events, the way we make sense of our world, is based upon our core belief system. Our minds are constantly trying to make sense of our world, forming judgements and opinions about every situation, event, and interaction. Those judgements and opinions will be affected by our central or Core Belief System. It is as though we are looking at the world through distorted or coloured lenses – and everyone has their own personal prescription or colour for their glasses. Our Core Belief System comprises of:  How I think about myself  How I think about others  How I think about the world Our Core Belief System is formed and influenced by:  Past experiences  Childhood upbringing  Culture and Faith  Values  Current circumstances  Character traits, including genetic influences Self-Help CBT Workbook

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Example: Childhood Experience: Bullied and hurt by others

Lens: distorted perception

Core Beliefs: Others will hurt me. The world is a dangerous place. I am useless and unlovable. I must try to please others so they like and won’t hurt me.

Situation See situations and events as threatening and dangerous Interpret others words and reactions As critical or threatening.

Behaviour: Passive, go along with what others want, don’t talk, avoid eye contact Emotions: Anxious, depressed, low self-esteem Thoughts: I am vulnerable. This is dangerous. I am going to get hurt. I am useless and stupid. No one likes me. In the example above, even situations which others find enjoyable and relaxing, this particular person will experience it very differently, and feel threatened by others.

Learning to see things differently – “The helicopter view” Sometimes it’s useful to use a metaphor to help us consider the bigger picture. When something is distressing us, we’re so close to it, involved with it, part of it – it’s really hard to stand back from what’s happening. It’s like the well-known saying “We can’t see the wood for the trees”. We can zoom out our view, and see the bigger picture. This principle is called the “Helicopter View” – as the helicopter takes off, getting higher and higher, it sees a bigger picture, and is less involved with the details at ground level. Seeing different perspectives will help to reduce distressing emotions, help us feel more confident, enable us to be more understanding and empathic, and improve communication and relationships. As we challenge our unhelpful thoughts and biased perspectives, and see things in a more balanced and realistic way, so we will discover that situations and people can be different to how we usually interpret things, which can lead us to modify our core belief system, and therefore bring about lasting positive change.

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The “Helicopter View”

SELF

OTHERS

What am I reacting to?

What would this look like to others involved?

What does this situation mean to me?

SITUATION STOP! Take a Breath What is the bigger picture?

OUTSIDER

WISE MIND

How would this seem to someone outside the situation – not emotionally involved?

What would be the best thing to do – for me, for others, for this situation?

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Activity – Thought Diary In order to combat the negative effects that these thoughts can have on our emotions and behaviours, we need to start by learning how to catch our negative automated thoughts by using a Thought Diary sheet.

Please look at the example and then try to complete your own example on the blank column.

SITUATION

EMOTIONS

THOUGHTS

What were you doing? Where was it? When did it happen?

What did you feel in one word? How intense from 0% to100%?

Example: I failed my exam today, although I have been preparing for it for the last 2 weeks.

Anxious 70% Depressed 80%

What did come through your mind? What bad think do you expect to happen? What unhelpful thinking style could this be? How intense from 0% to100%? I won’t go through this challenge. 50% I am a looser. 90% I should give up and leave the college. 60%

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Stage 2 – Looking for the Evidence In this stage, you have to challenge you Negative Automated Thoughts. This process is focused on seeking evidence for these unhelpful thoughts and against them. You might ask the question “How can this process help me?”. The research showed that more balanced thoughts could improve your mood and might enable you to function better, which will result in enjoying your life again. Opinions or thoughts are what people think. People do not need to have any scientific evidence in order to have an opinion or thought, and just because someone has a thought or opinion does not necessarily make it true. This type of evidence is subjective and therefore difficult to prove. Factual evidence is much stronger as there can not be any element of doubt. Factual evidence is objective and therefore very difficult to disprove. When challenging negative thoughts, we need to practice looking for evidence for and against the negative thought. The idea is that we work with the thought which causes the most emotional distress, usually the one with the highest belief rating. We then need to create a new alternative thought which is based on the evidence. Before to start the Activity, please answer the following questions:

How would someone else think about the situation? ______________________________________________________________________________ ______________________________________________________________________________ If I wasn’t anxious, how would I look at the situation? ______________________________________________________________________________ ______________________________________________________________________________

Is there any other way of looking at the situation? ______________________________________________________________________________ ______________________________________________________________________________

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Activity: Thought Challenging Diary Example: Negative Automated Thought: “I am a failure” - 90% Your Negative Automated Thought: _______________________

EVIDENCE FOR

I failed the exam. I received F grade.

EVIDENCE AGAINST What unhelpful thinking style are you using? I’ve got 50% mark, but I did some of it right. I’ve successfully passed all my previous exams. This is the first exam I failed. I was sick for 2 weeks prior to this exam and had less time to study.

EVIDENCE-BASED THOUGHT EMOTION What balanced thought would be How do you feel now in one more helpful to you? word? How intense? I am not a looser, I have just failed Depressed 70% only one exam. Anxious 60% 60% Hot, sweating 50% This means that I have to focus now and study for the retake of it.

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Stage 3 – Finding an Evidence Based Thought In this stage, you will have to create an alternative thought to Your Negative Automated Thought, which is more realistic rather than the original one. However, it does not mean that you simply develop a new thought, which is the opposite to your negative thought. CBT is not aimed at developing positive thinking; instead it helps create more balanced or realistic thoughts. Schematically, it can be presented as following:

Balanced Thought (CBT aims here!) Negative Automated Thoughts E.g., “Everyone hates me.” “I think that Mike doesn’t like me, but many others have admired me many times.”

Positive Thinking “Everyone loves me.”

So, once you have a negative thought, decide what the other extreme would be (going from a negative thought to a positive one) and then using the evidence for and against try to create a balanced evidence based thought.

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In the next Activity, you will need to apply the “Helicopter View” principle. In order to make it easy to feel out the column “STOP! Take a breath…”, you need answer the following questions:

What would someone else say about this situation? ______________________________________________________________________________ ______________________________________________________________________________ What’s the bigger picture? ______________________________________________________________________________ ______________________________________________________________________________

Is there another way of seeing it? ______________________________________________________________________________ ______________________________________________________________________________

What advice would I give someone else? ______________________________________________________________________________ ______________________________________________________________________________

Is my reaction in proportion to the actual event? ______________________________________________________________________________ ______________________________________________________________________________

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Activity: Thought Diary NB!

Spend some time completing the first 3 columns only and then when you feel more confident about catching your thoughts. Try to complete more of the diary, starting to consider the evidence for and against and thinking about an alternative thought. This needs a lot of practice! Situation

Emotion

Automatic Thought

How did you feel? Rate it (0 – 100%)

What is going through my mind? What is the worst thing might happen to me?

Evidence For

Evidence Against Am I jumping to any conclusions without justification by the evidence?

Alternative Thought STOP! Take a breath... Use the Helicopter View

Emotion Rate Again (0 – 100%)

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Problem-Solving Approach Although people who experience low mood or anxiety may worry about things in general, sometimes there may actually be a need to deal with problems and difficulties in a practical way. A problem solving approach can be used to help identify the problem and then try to find a way to manage it.

Activity: Problem-Solving Sheet Identify problem to be solved ______________________________________________________________________________ ______________________________________________________________________________

Examine costs and benefits of solving problem: Costs ___________________________________________________________________ Benefits ________________________________________________________________

List all resources and information available ______________________________________________________________________________ ______________________________________________________________________________

Use brainstorming to generate as many solutions and possible, without evaluating them ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Rank these solutions from the most desired to least desired ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Self-Help CBT Course

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Develop a plan of action based on suggested solutions ______________________________________________________________________________ ______________________________________________________________________________

Schedule the first step(s) ______________________________________________________________________________ ______________________________________________________________________________

Evaluate the outcome ______________________________________________________________________________ ______________________________________________________________________________

Revise the plan, if needed ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Reward yourself for carrying out the steps!

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Bibliography Drozdek, B. & Wilson, J.P. (2007). Voices of trauma: Treating survivors across cultures. Springer: New York. Leahy, R.L. (2003). Cognitive therapy techniques. The Guilford Press: New York. Leahy, R.L. & Holland, S.J. (2000). Treatment plans and interventions for depression and anxiety disorders. The Guilford Press: New York. Marra, T. (2004). The dialectical behaviour therapy workbook for overcoming depression and anxiety. New Harbinger Publications: Oakland, CA. Nezu, A.M., Nezu, C.M., & D’Zurilla, T.J. (2007). Solving life’s problems. Springer: New York.

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