Coping with the Seasons: A Cognitive Behavioral Approach to Seasonal Affective Disorder, Workbook (Treatments That Work)

Coping With the Seasons

EDITOR-IN-CHIEF

David H. Barlow, PhD SCIENTIFIC ADVISORY BOARD

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

Coping With the Seasons A COGNITIVE-BEHAVIORAL APPROACH TO SEASONAL AFFECTIVE DISORDER

W o r k b o o k Kelly J. Rohan

1 2009

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

c 2009 by Oxford University Press, Inc. Copyright
Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. ISBN 978-0-19-534137-9

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

About TreatmentsThatWork TM

One of the most difficult problems confronting patients with various disorders and diseases is finding the best help available. Everyone is aware of friends or family who have sought treatment from a seemingly reputable practitioner, only to find out later from another doctor that the original diagnosis was wrong or the treatments recommended were inappropriate or perhaps even harmful. Most patients, or family members, address this problem by reading everything they can about their symptoms, seeking out information on the Internet, or aggressively “asking around” to tap knowledge from friends and acquaintances. Governments and healthcare policymakers are also aware that people in need do not always get the best treatments—something they refer to as “variability in healthcare practices.” Now healthcare systems around the world are attempting to correct this variability by introducing “evidence-based practice.” This simply means that it is in everyone’s interest that patients get the most up-to-date and effective care for a particular problem. Healthcare policymakers have also recognized that it is very useful to give consumers of healthcare as much information as possible, so that they can make intelligent decisions in a collaborative effort to improve health and mental health. This series, TreatmentsThatWorkTM , is designed to accomplish just that. Only the latest and most effective interventions for particular problems are described in user-friendly language. To be included in this series, each treatment program must pass the highest standards of evidence available, as determined by a scientific advisory board. Thus, when individuals suffering from these problems or their family members seek out an expert clinician who is familiar with these interventions and decides that they are appropriate, they will have confidence that they are receiving the best care available. Of course, only your healthcare professional can decide on the right mix of treatments for you. This workbook follows a 12-session treatment program for seasonal affective disorder (SAD). The program is most effective when carried out in collaboration with a trained facilitator. Each session will help you learn skills to overcome the “winter blues” and start enjoying your life again. Scheduling pleasant activities every week will help you become more active and less depressed. Replacing

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negative thoughts and beliefs with more positive ones will also improve your mood. This workbook includes forms and tips for applying your new skills. With continued practice, you can reduce your SAD symptoms this winter and keep them at bay next winter. David H. Barlow, Editor-in-Chief, TreatmentsThatWorkTM Boston, MA

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Contents

Welcome!

ix

Session 1

Introduction to the Group

1

Session 2

Symptoms, Prevalence, and Causes of SAD

Session 3

How Activities Relate to Mood and Thoughts

Session 4

Doing More to Feel Better

Session 5

What You Think Influences How You Feel

Session 6

Cognitive Distortions

Session 7

Evaluating Your Automatic Thoughts

Session 8

Rational Responses

Session 9

Core Beliefs

Session 10

Evaluating Your Core Beliefs

Session 11

Maintaining Your Gains and Relapse Prevention

Session 12

Review and Farewell

7 17

23 31

39 47

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59 65

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Weekly Pleasant Activities Plans Thought Diaries

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Automatic Thought Questioning Forms Core Belief Worksheets

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Welcome!

Congratulations on your decision to join this group! By participating in this program, you are taking a step toward overcoming your seasonal affective disorder (SAD). SAD is a type of depression related to the winter season and is common, affecting 1–9% of the U.S. population, depending on latitude. The way you experience SAD is unique to you. You may feel tired, depressed, or irritable. You may experience changes in appetite or aches and pains. You may have difficulty concentrating or trouble sleeping. Whatever your symptoms, SAD can greatly affect your quality of life, making it difficult to enjoy things the way you used to. Over the next 6 weeks, you will learn skills to cope with your SAD this winter season and ways to prevent future episodes of SAD. You will work together with the other members of your group, providing each other with support and encouragement. Your group leaders will help you understand your SAD symptoms and how your thoughts and behaviors maintain your SAD. Because SAD is often associated with decreased activity level, throughout the program you will make an effort to become more active. By planning more pleasant activities into your schedule, you will begin to feel better. You will also learn how to evaluate your negative thoughts and beliefs that can make your SAD worse. You will begin to replace these with more positive thoughts and beliefs that help you to cope. You do not have to keep suffering from your SAD every winter. By practicing your new skills and staying aware of the warning signs of your SAD, you can stop a SAD episode before it starts or gets worse. Your participation in this program will help you take control of your SAD and your life.

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My Group Information My Group Leaders:

Contact information:

Other Group Members (first names):

Group Meetings: Days: Time: Place: End date:

Notes:

x

Session 1

Introduction to the Group

Goals ■

To learn about the group

■

To learn about cognitive-behavioral therapy (CBT)

■

To learn about what changes you can expect to make

■

To identify your seasonal affective disorder (SAD) symptoms

Overview Session 1 begins with an introduction to the group. Your group leaders will give an overview of the group, its goals, and what you will be working on over the next 12 sessions. You will also learn about the kind of treatment to be used—CBT. To prepare for the next session, you will identify your SAD signs and symptoms for homework.

Introduction to the Group This group is designed to teach you how to manage your SAD. In this group, you will 1. Increase knowledge and understanding of SAD. It is important to understand what the signs and symptoms of SAD are so you can recognize them when they occur. If you recognize symptoms early on, you can do something to interrupt them and prevent them from getting a lot worse. 2. Learn how common SAD symptoms are. Most people experience some changes in their mood or behavior with the changing seasons, although the severity of these symptoms differs from

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person to person. SAD and SAD-like symptoms are more common in higher latitudes, where the days are shorter and winter weather lasts longer. 3. Learn skills to help you cope better with seasonal changes. You cannot change the fact that winter will arrive every year, but you can work to change the way you cope with it. You will learn and practice skills to help you manage, reduce, or eliminate seasonal symptoms. 4. Learn skills to help you prepare for SAD symptoms before they start. You will develop a long-term plan to cope with SAD so you will be ready for it next year and every year after that. Having a plan in place will help you prevent symptoms or do something about early symptoms before they get worse. Skill-Based Treatment

Unlike other groups you may have been in, this is a skill-based treatment group. The focus is on learning skills that you can apply to your everyday life. You will be asked to be an active participant in your treatment by completing in-session and homework activities. Like learning any other skill, you may first need a lot of guidance. Think about the experience of learning to drive. You probably had an instructor sitting next to you, telling you what to do, and even hitting the brakes if needed. Eventually, you had enough knowledge and experience to drive on your own. You can think of this group as your driving instructor. By the end of the group program, you will have learned how to be your own therapist. Importance of Confidentiality

In the group, you will be asked to share your experience with SAD related to the skill you will be learning that day. Confidentiality is required for membership in the group. That is, please do not share personal information about other group members with those outside the group. That way, everyone in the group can feel comfortable speaking freely.

What Is Cognitive-Behavioral Therapy (CBT)? CBT is an effective, nondrug treatment for depression. Studies show that CBT is a promising new treatment for SAD. “Cognitive” refers to thinking and

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“behavioral” refers to behavior or things you do. It makes sense then that cognitive-behavioral therapy (CBT) focuses on changing your thinking and your behavior to help you feel better emotionally. Based on three decades of research, all of the following statements are true of CBT: 1. CBT is effective in treating both mild and more severe depression. 2. Most comparisons have shown CBT to be as effective as medications in treating depression. 3. CBT has no known adverse physical side effects. 4. CBT may prevent or help delay relapse (or return) of depressive symptoms in the future better than other forms of treatment for depression. 5. Preliminary studies suggest that CBT may be as effective as light therapy (LT) in treating SAD and that prior treatment with CBT may prevent the return of SAD in the next winter season better than prior treatment with LT.

What to Expect The benefits you will receive from this program depend on your willingness to keep an open mind and try new things. How much effort you put into your homework assignments and the frequency with which you attend the group sessions will also determine how much you get out of this group. Some changes you may make through this group include 1. Becoming more active. This group will help you do things that are fun and enjoyable instead of withdrawing or “hibernating” during the fall and winter months. If you can push yourself to be more active even when you don’t feel like it, you should begin to feel a little bit better. When your mood improves, you should have even more energy to do fun things. 2. Thinking more positively. The way you think about things influences the way you feel. Learning to think less negatively about things during the fall and winter will help improve your mood. In this group, you will learn to identify and challenge negative thoughts that contribute to feeling down.

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The Importance of Homework Homework is an important part of this program. At the end of each session, you will be assigned an activity designed to help you get better. This workbook includes all the instructions and forms you will need to do the homework. You will be expected to complete the homework and bring your workbook to every session for review. You will not be graded or evaluated on the homework, but you should try your best. Like taking up a new sport, practice is key to learning new skills. The more effort you put into this program, the more you will get out of it and the better you will begin to feel.

Homework

✎ Complete the Identifying SAD Symptoms form.

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Identifying SAD Symptoms For this exercise, try to think back to last winter and also think about how you are feeling now. In the space below, please write down some of the changes you notice in yourself during fall and winter. In other words, what’s different about you in the fall/winter versus the spring/summer? Think about changes in how you feel emotionally, how you feel physically, things you do, and what you think about. I can tell that my SAD symptoms are starting when I notice:

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Session 2

Symptoms, Prevalence, and Causes of SAD

Goals ■

To learn about SAD and its symptoms

■

To become aware of the vicious cycle of SAD symptoms

■

To learn about how common SAD is

■

To learn about possible causes of SAD

■

To begin to understand how thoughts and behaviors influence SAD

Overview In this session, you will learn more about SAD and how it may affect you. You will identify the different types of symptoms and their varying degrees. The vicious cycle of SAD symptoms and how to break it will be explained. This session also covers how common SAD is and the theories about why people experience SAD. In addition, you will begin to understand how your thoughts and behaviors keep you feeling down. To prepare for the next session, your homework will be to identify activities you typically like to do.

SAD and Its Symptoms You may not be aware of all the symptoms of SAD. By recognizing the different types of symptoms, you may better understand the way SAD affects you. Paying attention to when symptoms increase and decrease can help you track your progress. Early intervention in symptoms can prevent your SAD from becoming full-blown.

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What Is SAD?

SAD is a form of clinical depression. SAD is different from nonseasonal depression in that it tends to recur every year and follows a seasonal pattern of onset in the fall or winter and remission in the spring or summer. Symptoms of SAD

The symptoms of SAD fall into four general categories in terms of how they affect someone: 1. Physical symptoms (how SAD affects your health and body): Low energy, appetite changes (craving starches or sugars), increase in appetite, loss of appetite, weight gain or loss, muscle tension, pain, stomachache, headache, sensations of being weighted down or walking through water. 2. Emotional symptoms (how SAD affects how you feel emotionally): Depressed or anxious mood, sadness, feeling blue, decreased enjoyment or interest in things previously liked, irritable mood. 3. Cognitive symptoms (how SAD affects what you think about): Trouble concentrating, forgetfulness, thoughts about being worthless or a failure, negative thoughts about winter (e.g., “I can’t cope with this,” “I hate winter,” and “Winter is never going to end”), thoughts about death or suicide. 4. Behavioral symptoms (how SAD affects what you do): Less active, withdrawing from others, crying, sleep problems (oversleeping, napping, insomnia, or restless sleep), changes in eating (overeating, excessive carbohydrate consumption, or eating less). Notice that these categories cover a variety of symptoms and include some that are even polar opposites (e.g., increase in appetite and loss of appetite). Any two people with SAD can have different symptoms. Review the Identifying SAD Symptoms form from Session 1 for your personal symptoms. Degree of Emotional Symptoms

Emotions are not all or nothing—they have various degrees. Rather than an on– off light switch, our emotions are more like a dimmer switch. Think of how sad you felt when you were feeling at your worst today and use a 0–10 scale (where

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10 is the highest and 0 is the lowest) to rate the degree of emotion. Do the same for when you were feeling at your best today and also give yourself a mood rating for how you felt, on average, throughout the day today. Today I felt

Degree of sadness (0–10)

at my worst: at my best: on average: As your emotional symptoms get more intense, this may be a sign that your SAD is getting worse. As your emotional symptoms lessen, this may be a sign that your SAD is improving. Actually, any one of the symptoms on your list can be thought of on a scale like this. By paying attention to the degree of your symptoms, you can not only notice when your SAD is getting better or worse but also catch your SAD early on.

The Vicious SAD Cycle All of the different types of SAD symptoms can interact or influence each other. Often a vicious SAD cycle starts with one or two symptoms and then other symptoms build on those. A snowball effect is created in which SAD symptoms gradually get worse and you end up in a rut and having a lot of pretty intense SAD symptoms. For example, if you are feeling especially fatigued, you could end up sleeping too much. Your tiredness and oversleeping might make you feel less like doing things that you would normally enjoy or being around other people. This could then make you feel sad, which may actually make you have even less energy and want to sleep even more, etc. Think about the following questions: ■

Have you ever noticed which SAD symptom starts your cycle?

■

What symptoms follow along behind?

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■

What is your pattern of symptoms?

To help you stop the SAD cycle, this group will teach you how to intervene at the cognitive and behavioral levels of the cycle. That is, you will ■

learn to view things in a less negative light and

■

increase the number of pleasant activities you regularly do.

How Common Is SAD? In general, SAD prevalence increases with latitude in the United States with the lowest rates (about 1.4%) in Florida and the highest rates (more than 9%) in Northern states such as Alaska. At Northern latitudes, the majority of people experience SAD symptoms to a certain extent and very few people do not experience any changes in their behavior during fall and winter. People who experience moderate changes with the seasons are said to have subsyndromal SAD (S-SAD). The bottom line is that SAD symptoms are very common and get more common as distance from the equator increases.

Causes of SAD After more than two decades of research, we still do not know why people experience SAD. Below are some hypotheses (or educated guesses), but none of these has been definitively proven. Phase-Shift Hypothesis

Your body has a kind of internal clock that regulates your body’s daily rhythms (called circadian rhythms) in things such as the release of the hormone melatonin by the pituitary gland, rapid eye movement (REM) sleep, core body temperature, and alertness. This model suggests that owing to later dawns in the winter, circadian rhythms in individuals with SAD may get shifted later than normal, leading to difficulty waking up in the morning and feeling out-of-sync with the natural day–night cycle.

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Photoperiodic Hypothesis

The human pineal gland produces melatonin during the dark hours from dusk to dawn. People without SAD do not differ across the seasons in how long their bodies are releasing melatonin each night, but people with SAD do. This model suggests that SAD may be due to a longer period of nighttime melatonin release when days are shorter during winter than when the days are longer during summer. Photon-Count Hypothesis

Based on this hypothesis, SAD may result when the amount of light a person receives in a day (the total number of light particles or photons received by the eye’s retina) comes up short. According to this model, any decrease in environmental lighting (e.g., cloudy weather) regardless of season will produce SAD symptoms. The Serotonin Hypothesis

Serotonin is a neurotransmitter or chemical messenger in the brain and is involved in regulating sleep and appetite. Humans differ across the seasons in their serotonin levels with the most serotonin in the summer and the least in the winter. Because SAD tends to be related to sleep and appetite changes, according to this model, SAD-prone individuals may be especially sensitive to these seasonal changes in serotonin level and/or may show an even larger wintertime decrease in serotonin than people without SAD.

Influence of Thoughts and Behaviors on SAD Even if there are biological causes for SAD, what you think and do can help keep your SAD going. SAD is associated with a negative thinking style and reduced activity level that can also make SAD symptoms worse, make them start earlier, or make them last longer. Think about whether you have negative thoughts and become less active when you start to notice winter arriving. How does this affect your SAD? A biological cause for depression does not mean that CBT will not be helpful. In fact, people with biological depression that occurs out-of-the-blue, without any life event bringing it on, benefit as much from CBT as those who become

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depressed in reaction to life circumstances. Regardless of the cause of your depression, this program will help you change your thoughts and your behavior to begin to feel better.

Homework

✎ Complete the Pleasant Activities Rating Scale. This will help you identify activities that you enjoy doing and that could be mood-boosting during the fall and winter months.

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Pleasant Activities Rating Scale For each activity listed below, circle how often each event has occurred in the past month and how pleasant it was for you. If you have not done the activity in the past month, circle how pleasant you think it would have been for you. How much does it occur?

How pleasant is it for you?

1.

Doing a hobby

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

2.

Doing winter sports (skiing, snowshoeing, ice skating, snowmobiling, etc.)

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

3.

Relaxing

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

4.

Exercising

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

5.

Reading

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

6.

Sightseeing

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

7.

Listening to music

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

8.

Spending time with friends

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

9.

Playing or watching sports

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

10.

Cleaning

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

11.

Going on a date

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

12.

Traveling

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

13.

Cooking and baking

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

14.

Enjoying nature

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

15.

Playing games

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

16.

Repairing things

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

17.

Spending time with family

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

18.

Writing

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

19.

Going to a play, concert, or performance

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

20.

Learning something new

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

21.

Taking care of yourself

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

22.

Shopping or buying things

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

23.

Spending time with animals

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

continued

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Pleasant Activities Rating Scale continued How much does it occur?

How pleasant is it for you?

24.

Taking a class

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

25.

Pampering yourself

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

26.

Going to a museum or exhibit

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

27.

Talking on the phone

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

28.

Being part of a team

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

29.

Entertaining

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

30.

Collecting things

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

31.

Going for a walk

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

32.

Having positive thoughts or memories

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

33.

Spending time with children

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

34.

Singing or playing music

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

35.

Organizing

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

36.

Being sexual

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

37.

Going to a party, event, or gathering

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

38.

Planning for the future

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

39.

Participating in a club or group

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

40.

Going out to eat

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

41.

Dressing up

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

42.

Daydreaming

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

43.

Taking or looking at pictures

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

44.

Doing crafts, knitting, or sewing

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

45.

Teaching

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

46.

Solving a problem, puzzle, or crossword

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

continued

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Pleasant Activities Rating Scale continued How much does it occur?

How pleasant is it for you?

47.

Volunteering

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

48.

Practicing religion

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

49.

Having a discussion

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

50.

Going to a bar or club

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

51.

Helping others

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

52.

Dancing

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

53.

Watching television or movies

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

54.

Decorating

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

55.

Going to a lecture or presentation

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

56.

Laughing or telling jokes

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

57.

Working on a project

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

58.

Using the Internet

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

59.

Spending time alone

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

60.

Seeing or caring for plants

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

61.

Doing outside activities

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

62.

Creating artwork (painting, drawing, sculpture, etc.)

Not at all or rarely

Sometimes

Often

Not

Somewhat

Very

Note: Adapted from “The Pleasant Events Schedule: Studies on Reliability, Validity, and Scale Intercorrelation,” by D. J. MacPhillamy and P. M. Lewinsohn, 1982, Journal of Consulting and Clinical Psychology, 50, pp. 363–380.

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Session 3

How Activities Relate to Mood and Thoughts

Goals ■

To understand how pleasant activities relate to mood and thoughts

■

To increase your activity level to improve your mood

■

To use positive self-statements to help motivate you to do activities

Overview This session focuses on the relationship between pleasant activities and mood. It also looks at how your activity level and thoughts influence each other. Decreased activity level and negative thoughts can contribute to depressed mood. To improve your mood, it is important for you to do more pleasant activities. Saying positive statements to yourself can help motivate you to follow through on activities.

What Is a Pleasant Activity? A pleasant activity is something you enjoy doing for fun. Every person has different pleasant activities because of different interests. For homework last session, you completed the Pleasant Activities Rating Scale to rate your frequency of and enjoyment in specific activities. If you engage in pleasant activities often, it is more likely that you are satisfied and happy. If you do not do very many pleasant activities, you probably have a depressed mood. During winter, people with SAD commonly do not engage in many pleasant activities. People with SAD typically have little energy, and their bodies seem to be telling them to sleep, sleep, sleep. You may find that in winter you do a lot of sleeping and sitting around instead of doing things you enjoy. As spring arrives, you begin to be more active.

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How Activities Relate to Mood What comes first—decreased activity or depressed mood? This is like the famous chicken and egg question! Decreased activity may come before or after depressed mood. When you are experiencing depressed mood with a SAD episode, you are less motivated to do things. You begin to be less active because you are feeling depressed. On the other hand, if for some reason or another, you are not able to be as active as usual, you may begin to feel depressed. Your decreased activity level causes your depressed mood. Whatever comes first, depressed mood or decreased activity level, a vicious cycle is often created (see Figure 3.1).

Depressed Mood

Do Even Less Things You Enjoy

Figure 3.1 The Negative Mood–Activity Level Cycle

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Do Less Activities

Depressed Mood Intensifies

How Activities Relate to Thoughts When you are suffering from your SAD symptoms, you may end sitting around thinking about how bad and tired you feel instead of doing a pleasant activity. At these times you may feel worthless, pessimistic about your life, and blame yourself for your own inactivity and fatigue. You may say to yourself something like “I’m so useless I can’t even get off the couch and do something.” These types of thoughts are common among people with SAD. They tend to make people feel even worse and even less likely to do pleasant activities.

Reversing the Depressed Mood–Activity Level Cycle The good news is that it is possible to reverse the cycle of depressed mood and activity level! You may have tried to just feel better or snap out of your sad mood, but your emotions are the hardest part to change. It is easier to change how you behave, which will then affect how you feel. Increasing your number of pleasant activities is one way to improve your mood. See Figure 3.2 that shows the cycle of doing more activities and feeling better.

Changing Thoughts to Increase Activity Level People with SAD often have negative thoughts that make them feel worse. These types of thoughts may also keep them from trying the activities that just might make them feel better. Think about the kinds of thoughts that you have when you are considering whether or not to do an activity. If you have negative thoughts such as, “I’m so tired” or, “I won’t enjoy it anyway,” you are less likely to engage in the activity. To become more active, you need to say positive statements to yourself. Statements such as “I can do it” or “I’ll feel better if I do it” can help motivate you to do an activity. On the Positive Self-Statement Cards write down statements that seem helpful to you. Make sure you believe these statements in order for them to be effective motivation. Keep these cards somewhere handy and review them before doing the pleasant activity you chose to do this week.

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Do More Activities Depressed Mood

Do Even More Things You Enjoy Depressed Mood Lessens

And so on. . . Feel Even Better

To Even Better Activity Level and Better Mood!

Figure 3.2 The Positive Mood–Activity Level Cycle

Homework

✎ Choose and complete a pleasant activity from the Pleasant Activities Rating Scale. Pick something that you can easily do before the next session. You should be prepared to tell the group about how your pleasant activity went and how you felt afterward. If you want, you may choose to involve a friend, family member, or significant other in the activity to help you get started this first time.

✎ Use the Positive Self-Statement Cards for motivation to complete activities.

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Positive Self-Statement Cards Copy and paste the following instructions to the front of an index card. Generate positive self-statements and list on the reverse side.

When you are thinking about doing a pleasant activity and trying to motivate yourself to actually do it, here are some things to remind yourself about . . .

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Session 4

Doing More to Feel Better

Goals ■

To learn about important mood-related activities

■

To solve possible problems in doing pleasant activities

■

To create a balanced activity level

■

To choose and plan pleasant activities

Overview This session introduces different types of pleasant activities that can help improve your mood. It also addresses potential obstacles to doing pleasant activities. You will learn about the importance of balancing responsibilities with pleasant activities and strategies for creating balance. You will make a list of activities that you enjoy and schedule these activities into your week.

Mood-Related Activities There are several kinds of pleasant activities that are especially important in keeping your mood positive: Positive social interactions—pleasurable interactions with other people (e.g., conversations or activities with friends or family) Competency experiences—doing things that make you feel skilled and competent (e.g., performing a task well or learning to do something new) Incompatible responses—doing things that are not compatible with feeling depressed (e.g., enjoying the company of a good friend, laughing or smiling, feeling truly relaxed, or getting a good night’s sleep)

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Physical activities and exercise—as little as 10 min of doing something physical can boost mood. Regular, consistent aerobic exercise is even better (e.g., walking, swimming, biking, snow shoeing, or cross-country skiing).

Problems in Doing Pleasant Activities There are some common problems among people with SAD that may get in the way of doing pleasant activities: Fatigue

Problem: You have a hard time getting motivated to do a pleasant activity because you feel so tired. Solution: Push yourself to do it anyway and watch how the activity affects your mood. Remind yourself that activities will make you feel a bit better. Use positive self-statements to help with your motivation. Problem: You feel tired after doing a pleasant activity. Solution: Start with a small activity and gradually build up to bigger, longer ones so as not to tire yourself too much. Your fatigue should reduce over time as activities gradually improve your mood. Loss of Enjoyment or Pleasure in Activities

Problem: During a SAD episode, you may experience a loss of pleasure in activities you normally enjoy. Solution: Fake it until you make it. Studies show that the sense of enjoyment or pleasure comes back gradually with repetition over time. Pressure From Necessary Activities That Are Neutral or Unpleasant

Problem: Responsibilities such as work and household duties can often get in the way of doing fun things. Solution: Use time management to complete your responsibilities, but also schedule time for pleasant activities.

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Lack of Care in Selecting Activities

Problem: Not selecting activities carefully can result in a mismatch between what you like to do and what you actually do (e.g., spending the weekend working around the house instead of going shopping or to a movie). Solution: Think about the things you like to do and make time for them.

Change in the Availability of a Pleasant Activity

Problem: Sometimes something happens that removes the possibility of doing something you enjoy (e.g., death of a loved one, moving, end of a relationship, or getting a divorce). Winter weather also makes some outdoor activities difficult (e.g., going to the beach). Solution: Work on finding substitute pleasant activities or activity partners. Develop a new “winter interest.”

Emotional Interference

Problem: Emotions such as anxiety, discomfort, and irritability can interfere with your enjoyment of otherwise pleasant activities (e.g., being nervous or irritable in social situations makes it difficult to enjoy them). Solution: Identify the source of the emotional discomfort and work on removing it. Find ways to relax and practice doing things that make you anxious until they get easier.

Getting Started on a Balanced Activity Plan Before you get started on pleasant activities, you must first commit yourself to putting the plan into effect. You must be willing to make choices, establish priorities, and rearrange your life a bit. The goal is to achieve a balance between the things you have to do and the things you want to do. It will involve planning and you should try to anticipate any problems that might interfere with carrying out your plan. You will achieve a sense of self-control to the extent that you stick to your plan. By controlling your time, you are taking a step toward controlling your life and your mood.

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Creating Balanced Activity Level

While making a plan, it is important to achieve a balance between: 1. Neutral or unpleasant activities—things you have to do (e.g., housework, work, or errands) 2. Pleasant activities—things you enjoy doing The difference between these activities is very individual. What someone considers a chore, someone else may consider a pleasant activity (e.g., cooking or shopping). A balanced activity level allows you to accomplish the things you need to do while ensuring that you set aside time to do the things you enjoy and that you have some energy left over to do them. Strategies for Balance Use Your Time Efficiently

1. Set aside blocks of time for neutral or unpleasant activities. 2. Create a “to do” list. 3. Consider whether those things really need to get done today. 4. Ask other people to help in getting necessary activities done. 5. Use a timer to stick to the amount of time designated for a neutral or unpleasant activity or for a pleasant activity. Plan Ahead

1. Schedule pleasant activities at least 1 day in advance. 2. Designate a time and place for each pleasant activity. 3. Do not allow yourself to make excuses or back out. Anticipate and Prevent Problems

1. Avoid distractions and focus only on the pleasant activity at hand (e.g., unplug the phone). 2. Make the necessary arrangements ahead of time (e.g., make reservations, buy tickets, get supplies, or arrange for a babysitter). 3. Be prepared to substitute activities when unexpected problems arise. Have a backup plan.

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Steps to Activity Scheduling The steps to activity scheduling are (1) set a specific goal; (2) plan, schedule, and record; and (3) reward yourself. Step 1: Set a Specific Goal

Consider your current activity level and decide what would be a modest increase in activity. You should make sure the goal is reasonable and attainable. Remember that your negative mood or activity level cycle came on gradually over time. Reversing it will also be a gradual process that will take some time. Select activities that are potentially pleasant, but also available to you. You may even want to incorporate some local events, take a class, join a club, develop a new interest, or learn about something new. The leisure section of the newspaper is full of ideas. Step 2: Plan, Schedule, and Record

You will be using a weekly planner to plan out your activity levels. You will also record whether or not you followed through and how enjoyable each activity was. Scheduling activities in advance increases the likelihood that you will actually do a given activity. It also makes it more likely that you will regularly engage in pleasant activities over time. Step 3: Reward Yourself

Use small daily rewards and/or larger rewards for being active all week. Rewards may include other pleasant activities such as calling a good friend, eating out, making a small purchase, or seeing a movie.

Weekly Pleasant Activities Plan In order to increase your activity levels, you need to come up with a specific plan. First, decide on a realistic weekly goal for the number of pleasant activities you want to do and the amount of time you want to spend on pleasant activities. Write down ideas for pleasant activities on the Menu of Pleasant Activities. These should be activities that you enjoy and that are available to you. Use the Pleasant Activities Rating Scale from Session 2 as a guide. Include some activities that you currently do rarely, but highly enjoy.

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Pick from your menu some activities to try in the coming week. It is best to start off with activities that are relatively easy to do. Next schedule an appointment with yourself to do them using the Weekly Pleasant Activities Plan. Each day’s planned activity should be scheduled at least 1 day in advance and should be set for a specific time of day. Every day, you should record whether or not you followed through and rate how enjoyable the activity was on the form. If you stick to your plan, you should begin to see an improvement in your mood.

Homework

✎ Develop your Menu of Pleasant Activities. ✎ Schedule and complete at least one pleasant activity everyday for at least 10 min per activity. Record activity appointments, follow through, and enjoyment ratings on the Weekly Pleasant Activities Plan.

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Menu of Pleasant Activities In the space below, list some of your pleasant activities or things you highly enjoy doing. You will use this “menu” to plan your pleasant activities for the week. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

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Weekly Pleasant Activities Plan Directions: Use this plan to schedule a time to do at least one pleasant activity every day for at least 10 minutes. Record whether or not you did the activity and how long you did the activity in minutes. Finally, rate how enjoyable the activity was for you where 0 = completely unenjoyable and 10 = completely enjoyable. Try to stick to your plan!

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Session 5

What You Think Influences How You Feel

Goals ■

To understand the relationship between thoughts and mood

■

To learn about the concept of automatic thoughts

■

To become more aware of your thoughts and their connection to how you feel

Overview This session discusses the relationship between what we think and how we feel. You will learn about how negative thoughts can make your SAD worse. You will become more aware of the thoughts you have in reaction to daily situations by using a Thought Diary. You will begin to see how these thoughts influence the way you feel.

Relationship Between Thoughts and Mood We will now focus on the cognitive symptoms of SAD. “Cognitive” refers to your thinking. What you think can affect how you feel. Note how different people often have different reactions to the same situation. Unpleasant or frustrating things happen to everyone, but not everyone feels negative emotions such as sadness or frustration in reaction to them. How can this be? Something comes between the event that is happening and what the person feels. That something is what the person is thinking (what he says to himself ). See Figure 5.1 of the A-B-C model. Consider the following example: George and Bill are both on the dating scene. Both men ask the object of their affection out on a date and get shot down. George thinks to himself, “I’ll never get a date again. I’m going to be single for the rest of my life. I’m a total failure at love and sure to be unloved forever.” Bill

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A

B

C

A = Antecedent event Any event that happens

B = Belief What you think about A

C = Consequence An emotional reaction

Examples:

Examples:

Examples:

Being rejected by someone

“I’m worthless.”

Sad or depressed

Being criticized

“I always mess up.”

Nervous

Feeling unappreciated

“I’ll never get it right.”

Angry

Failing at something

“I’m stupid.”

Frustrated

Making a mistake

Figure 5.1 The A-B-C Model

says to himself, “Well, this is disappointing. I really liked this person, but I guess we weren’t meant to be. If I continue to be myself, I’m bound to find someone I can have fun with.” George’s thoughts are likely to lead to depressed feelings. Bill, on the other hand, might feel appropriately sad, but he would not be overwhelmed by his emotions. On the basis of their thoughts and feelings, George and Bill are likely to act differently from each other in the future. Bill is more likely to keep on searching for a dating partner, whereas George is more likely to give up.

Negative Thinking Some events that might put you at risk for negative thinking at the B (Belief ) stage include: ■

Getting rejected by someone

■

Being criticized or disapproved of

■

Feeling under-appreciated

■

Doing more than your share of work without receiving credit

■

Performing poorly, failing, or making a mistake

Once you are in the habit of negative thinking, you may start to see events that are not really all that bad in a negative light. For example, you are at the store and you see a friend. You wave, but the friend does not wave back. If you are already in the swing of negative thinking, you are likely to have negative thoughts such as, “He doesn’t like me. He is trying to avoid me because I’m miserable with my SAD.” This thinking leads to negative emotions such as sadness. However, it could really be that the friend was distracted and did not even see you. In Session 6, you will learn more about different types of negative thinking and their effects.

Automatic Thoughts We call the thoughts or things we say to ourselves at stage B automatic thoughts. We call them “automatic” because they happen very quickly. They are an automatic “knee jerk” response to things that happen. They pop up

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spontaneously. Occasionally, automatic thoughts are not preceded by an actual event or situation, but rather by a stream of thoughts, a daydream, or thinking about events in the past. Everyone has automatic thoughts. Most of the time, we are barely aware of our automatic thoughts because they tend to be very brief. Usually, we are just aware of the emotion that follows the thought rather than the thought itself. For example, you recognize feeling sad, embarrassed, angry, anxious, or irritated, but do not tie these feelings to what you are thinking at the time. With training, you can become aware of your automatic thoughts and how they are related to your feelings. Automatic thoughts can be either negative or positive. In individuals with SAD, automatic thoughts are frequently negative during the winter and become part of the SAD cycle keeping them down. In the summer, their automatic thoughts tend to be more positive, which is part of the reason they feel good during this time of year. Using a Thought Diary Using a Thought Diary can help make you more aware of your automatic thoughts (See Figure 5.2 for an example). You should try to make at least one recording each day. When you notice a negative change in how you are feeling, that should be a cue for you to complete a Thought Diary because you are probably having some negative automatic thoughts. Be prepared to share your automatic thoughts with the group next meeting. The following questions can help you complete the Thought Diary form: 1. Can you think of some time today when you felt sad, down, or upset in some way? What was happening then? 2. What was going through your mind? While this was happening, how much did you believe that thought from 0 (not at all) to 100% (completely, totally believed it to be true)? 3. What else went through your mind? How much did you believe it? (Make sure to get all the thoughts. Do not stop with just one.) 4. After these thoughts, how did you feel? Sad, anxious, angry? How much did you feel that way? Give each emotion a rating from 0 (not at all) to 100% (the most intense I have ever felt this).

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Date

1/24

Situation

Automatic Thought(s)

Emotions

Briefly describe situation (antecedent event), stream of thoughts, daydream, or image.

1) Write the automatic thoughts that accompany the emotions. 2) Rate belief in automatic thought (0–100%).

1) Specify sad, anxious, angry, etc. 2) Rate degree of emotion (0–100%).

I was looking over a report I submitted to my boss and found a typo.

I am such a dope. (90%)

Sad (95%)

I messed up again. (90%)

Frustrated (85%)

He will think I am careless and not a good worker. (80%) I should do a better job. (95%)

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Figure 5.2 Example of Completed Thought Diary—4 Column

Homework

✎ Continue scheduling activities using the Weekly Pleasant Activities Plan and modify it as needed to make it work for you. Copies of the form can be found at the end of the book.

✎ Try to add some new pleasant activities to challenge yourself. ✎ Strive for increasing your time for a pleasant activity to more than 10 min per day.

✎ Complete at least one entry on the Thought Diary—4 Column form each day.

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Thought Diary—4 Column Date

Situation

Automatic Thought(s)

Emotion(s)

Briefly describe situation (antecedent event), stream of thoughts, daydream, or image.

1) Write the automatic thoughts that accompany the emotions. 2) Rate belief in automatic thought (0–100%).

1) Specify sad, anxious, angry, etc. 2) Rate degree of emotion (0–100%).

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Cognitive Distortions

Session 6

Goals ■

To become aware of your SAD-specific thoughts

■

To learn about cognitive distortions

■

To practice identifying cognitive distortions

Overview This session begins by examining the kinds of automatic thoughts that people with SAD tend to have. The rest of this session focuses on extreme or inaccurate negative thinking called cognitive distortions. You will learn about the different categories of cognitive distortions and how they can make you feel worse. You will then practice identifying cognitive distortions so you can begin to recognize them in your own thinking.

SAD-Specific Automatic Thoughts People with SAD tend to have negative thoughts about the winter season, signs that the seasons are changing, weather, and lack of light. Think about the kinds of thoughts you have in the following scenarios and how you would feel. Try to make the connection between your thoughts and feelings. Scenario 1: You are watching the local weather forecast, and it shows that the sunrise is taking place a minute later every day and that the sunset is taking place a minute earlier every day. Your Thoughts:

Your Feelings:

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Scenario 2: Summer is drawing to a close with the arrival of September. You notice the leaves gradually changing from green to shades of yellow, red, and orange. Your Thoughts:

Your Feelings:

Scenario 3: You are just getting out of bed, you feel groggy and tired, and you look out the window. The sky is dark and overcast, and there is a dusting of snow on the ground. You can feel the cold air coming in through your window. Your Thoughts:

Your Feelings:

Cognitive Distortions Recall the A-B-C model introduced in Session 5. The negative automatic thoughts at stage B tend to fall into certain categories. We call these cognitive distortions because these thoughts are distorted or extreme in their interpretation of reality. These occur in everyone to some extent, but people with SAD think this way more than those without SAD, especially during the winter. It is useful to be familiar with the specific cognitive distortions so you can recognize when your thinking is unhelpful. There is a lot of overlap between the specific types of cognitive distortions, and some automatic thoughts fit into more than one category. The following definitions are adapted from Feeling Good: The New Mood Therapy (Burns, 1999) and illustrated with SAD-specific examples.

All-or-Nothing Thinking (Black-and-White Thinking)

You think in black-and-white terms; there are no gray areas. This type of thinking is unrealistic because things are seldom all or nothing, all good or all bad.

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Example: A woman with SAD thinks, “Winter is totally bad and summer is totally good.” In reality, some days are better than others in summer and winter alike. Some winter days may be more enjoyable and associated with more cheer than some summer days.

Overgeneralization

You assume that a one-time negative occurrence will happen again and again. You use words such as “always” or “never” to make generalizations. Example: A man with SAD may have a tough day, when he is suffering from a lot of pretty severe symptoms (e.g., fatigue, depressed mood, oversleeping, overeating, and loss of interest in activities). He may say to himself, “Because this particular day was so bad for me, every day for the rest of winter until spring arrives will surely be this terrible.”

Mental Filter

You focus exclusively on negative details and ignore anything positive. As a result of filtering out the positives, you see the entire situation as negative. Example: A woman with SAD hears about possible snow for 1 day in the week’s forecast. She thinks, “The weather for the whole week is shot.”

Disqualifying the Positive

You turn positives into negatives by insisting they “don’t count.” This allows you to maintain your negative outlook despite positive experiences. Example: A woman with SAD is at a cocktail party. She appears to be having a good time, smiling, talking, and laughing. Afterward, she tells herself that she was just faking this because she had to look like she was having fun or the host would be insulted. A man with SAD spends an afternoon with his buddies and has such a good time, he forgets about his SAD. Afterward, he thinks, “That was a fluke. It doesn’t really count. I still have SAD.”

Jumping to Conclusions

In the absence of solid evidence, you jump to a negative conclusion. There are two types of this: “mind reading” and the “fortune teller error.”

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Mind Reading

You assume that you know what someone else is thinking. You are so convinced that the person is having a negative reaction to you; you do not even take the time to confirm your guess. Example: A woman with SAD is at a holiday party with her family. Her grandchildren interact very little with her and she thinks, “They don’t want to talk with me because I am so miserable with my SAD.” Actually, they are so distracted by their new toys that the children barely talk at all to anyone.

The Fortune Teller Error

You act as a fortune teller who predicts only the worst for you. You then treat your unrealistic prediction as if it were a proven fact. Example: A man with SAD thinks, “I will suffer from SAD symptoms repeatedly every single fall and winter for the rest of my life.”

Magnification (Catastrophizing) or Minimization

You magnify negative things, blowing their importance out of proportion. The outcome of an event appears catastrophic to you. Example: A man with SAD thinks, “Winter is horrible! This cold, dark weather will never go away, and I’ll feel badly forever.” You minimize positive things, shrinking down their significance. You make good experiences out to be smaller than they are. Example: The sun shines brilliantly on a cold December day and a woman with SAD thinks, “What use is this? It’ll just be dark and dreary again tomorrow.”

Emotional Reasoning

You take your emotions as proof of the way things really are. You assume something is true because you feel it is. Example: Someone with SAD thinks, “I feel overwhelmed and hopeless during winter, therefore my problems must be unsolvable.”

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“Should” Statements

You build your expectations with “shoulds,” “musts,” and “oughts.” When you do not follow through, you feel guilty. When others disappoint you, you feel angry and resentful. Example: A person with SAD thinks “I should be able to cope with the winter season.” Labeling and Mislabeling

You label yourself or someone else, rather than just identifying the behavior. Example: A person with SAD thinks “I’m a loser for sleeping so much.” You mislabel an event by using inaccurate and emotionally extreme language. Example: A person with SAD sees gray skies and thinks “The weather is the pits; it’s impossible to do anything on a totally depressing day like this.” Personalization

You take responsibility for things that you do not have control over. You feel guilty because you assume a negative event is your fault. Example: A man with SAD thinks, “There’s something wrong with me. It’s my fault I have SAD.” Practicing Identifying Cognitive Distortions Identifying cognitive distortions takes a lot of practice. Can you identify the distortions in this example? Scenario: The weather forecast is predicting a major winter storm. You think, “This is going to be terrible! I can’t stand winter! Winter is the worst! I’ll never be able to get out of the house.” You feel sad and angry. Cognitive Distortions:

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Homework

✎ Continue your Weekly Pleasant Activities Plan. Copies of the form can be found at the end of the book. Remember it may be time to change your activities a bit. Pick some new ones to add for variety. Challenge yourself with an activity you did not feel like trying during the previous weeks. Your energy and motivation for activities should be improving a bit by now so you may feel like trying even more activities or doing an activity for longer than 10 min.

✎ Complete the Thought Diary—5 Column form. Again, try to record at least one example every day. Make an attempt to classify thoughts as specific cognitive distortions from the list. Some thoughts may have more than one distortion because the categories overlap so much.

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Thought Diary—5 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions

Emotion(s)

Briefly describe situation (antecedent event), stream of thoughts, daydream, or image.

1) Write the automatic thoughts that accompany the emotions. 2) Rate belief in automatic thought (0–100%).

Identify the types of cognitive distortions.

1) Specify sad, anxious, angry, etc. 2) Rate degree of emotion (0–100%).

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Session 7

Evaluating Your Automatic Thoughts

Goals ■

To learn the Socratic method for evaluating thoughts

■

To evaluate your automatic thoughts

Overview In this session you will learn to evaluate your automatic thoughts by asking yourself a series of questions. This is the first step toward changing your negative thinking.

Evaluating Your Automatic Thoughts Now that you have had some practice identifying your automatic thoughts, the next step is learning to evaluate and question those automatic thoughts. In honor of the Greek philosopher Socrates, who had a style of asking his students a lot of questions in order to evaluate their thinking, we call this “the Socratic method.” Once you have identified an automatic thought that is both important and distressing, you can practice the Socratic method by using the Automatic Thought Questioning Form to evaluate it.

Automatic Thought Questioning Form Pick out an automatic thought from your Thought Diary and use the Automatic Thought Questioning Form to question it. Try to pick a thought that seems important and had a big impact on your mood—a thought that had particularly high ratings for degree of belief and degree of negative emotional consequences. To start, imagine that you are both a witness for the defense and an attorney for the plaintiff at a trial. First you are the witness, and your automatic thoughts are

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your “testimony.” Then you step out of the witness role and act as the attorney doing a cross-examination of that testimony. Go through the following steps. 1. Review the evidence. Ask yourself: ■ ■

What is the evidence for this thought? What is the evidence against this thought?

2. Review possible outcomes. Ask yourself: ■ ■ ■

What is the worst thing that could happen? Could I survive it? What is the best thing that could happen? What realistically is most likely to happen?

3. Consider the impact of your automatic thought. Ask yourself: ■

What are the results of my belief in this automatic thought? ◦ How do I feel and act in response to this automatic thought?

■

What could be the results of changing my thinking? ◦ Would I feel any differently? ◦ Would I do anything differently if I could change the thought?

4. Problem-solve the situation that brought on your negative thinking. Ask yourself: ■

■

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What could I do about it? Brainstorm possible solutions and consider the pros and cons of all options. What would I tell someone else to do? What if a friend of mine was faced with the same situation?

Automatic Thought Questioning Form This form will help you evaluate and question your automatic thoughts. Using your Thought Diary, select an unhelpful automatic thought or a series of automatic thoughts that contributed to negative mood. Write this automatic thought or thoughts in the space below.

Now, follow steps 1 through 4 and ask yourself the following questions. Write your responses in the space provided. (1) Review the evidence. What is the evidence for this thought?

What is the evidence against this thought?

(2) Review possible outcomes. What is the worst thing that could happen? Could I survive it?

What is the best thing that could happen?

What realistically is most likely to happen?

(3) Consider the impact of your automatic thought. What are the results of my belief in the automatic thought? That is, how do I feel and act in response to this automatic thought?

What could be the results of changing my thinking? That is, would I feel any differently or do anything differently if I could change the thought?

(4) Problem-solve about the situation that brought on your negative thinking. What could I do about it?

What would I tell

(a friend) if he or she were in the same situation?

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Example of Questioning Thoughts Recall the example of George and Bill from last week (the two guys who asked someone out and got shot down). George said, “I’ll never get a date again. I’m going to be single for the rest of my life. I’m a total failure at love and sure to be unloved forever.” How could George evaluate these automatic thoughts using the questions on the Automatic Thought Questioning Form?

Homework Remember the more effort you put into your homework, the more benefit you will get from this group!!!

✎ Continue with your Weekly Pleasant Activities Plan. Copies of the form can be found at the end of the book.

✎ Continue to keep a Thought Diary on a daily basis using the 5-column form.

✎ Use the Automatic Thought Questioning Form to evaluate and question at least one important, distressing automatic thought. Copies of the form can be found at the end of the book.

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Thought Diary—5 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions

Emotion(s)

Briefly describe situation (antecedent event), stream of thoughts, daydream, or image.

1) Write the automatic thoughts that accompany the emotions. 2) Rate belief in automatic thought (0–100%).

Identify the types of cognitive distortions.

1) Specify sad, anxious, angry, etc. 2) Rate degree of emotion (0–100%).

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Session 8

Rational Responses

Goals ■

To learn how to generate rational responses

■

To understand the importance of believing your rational responses

■

To evaluate the impact of your rational responses

Overview In this session you will begin to develop new, more accurate, and helpful thoughts to replace your distressing and unhelpful automatic thoughts. These new thoughts are called “rational responses.” You will learn why your rational responses need to be believable. Finally, you will evaluate how your rational responses affect your belief in the original automatic thought and your emotions.

Generating Rational Responses to Your Automatic Thoughts So far, you have been practicing identifying your negative automatic thoughts and then questioning and evaluating them using the Automatic Thoughts Questioning Form. You are now ready for the most important part of cognitive therapy: changing your negative automatic thoughts to make them more realistic and helpful, as well as less negative in tone. We will be adding stage “D” to the A-B-C model (See Figure 8.1).

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A

B

C

A = Antecedent event Any event that happens

B = Belief What you think about A

C = Consequence An emotional reaction

This is the new part!!! After using the Automatic Thoughts Questioning Form to evaluate your automatic thought, try to actually change your automatic thought to something more helpful.

D D = Dispute Change your automatic thought from B to a rational response Is there any other way to view this situation? Is there another way I can think about this situation? What would be a more realistic thought to have? What would be a more helpful thought to have?

Figure 8.1 The A-B-C-D Model

D == Disptue

At stage “D,” you try to change your problematic automatic thought to a substitute thought that is more realistic and helpful. The following questions can help you to do this: ■

Is there any other way to view or to think about this situation?

■

What would be a more accurate and realistic thought to have?

■

What would be a more helpful thought to have?

If you see words like the following in your automatic thoughts, question them: ■

“Should”—Why should I?

■

“Terrible, awful, etc.”—Is it really that bad? What is the worst thing that could happen? Could I survive it?

■

“Always”—Is it really always or just this time or some of the time?

These questions lead you to form a new substitute thought called a “rational response.” A rational response is like a rebuttal to your automatic thought. It is very important that you practice with the Thought Diary, so that you can improve at coming up with rational responses to your automatic thoughts. Over time, this should help you to think more positively and, therefore, feel emotionally better.

Importance of Believing in Your Rational Response In your Thought Diary, under “Rational Responses,” record each rational response and rate how much you believe it on a scale of 0–100%, where 0% is you do not believe it at all and 100% is you completely, totally believe it. It is very important that you believe your rational response. You do not want to come up with something that is overly positive and rosy because such thoughts are generally not very realistic in the same way that extremely negative thoughts tend not to be highly accurate. Instead, your rational response should be something that is more realistic, more helpful, and less negative in tone than your original automatic thought and also something that you can accept as believable. If you end up with a statement you do not have any faith in, keep on questioning your automatic thoughts until you arrive at a rational response you highly believe. For

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each automatic thought, it is recommended that you generate several rational responses that you highly believe in order to have a strong, convincing rebuttal to your original automatic thought.

Evaluating the Impact of Rational Responses The next step is to evaluate the impact of your rational response on your original automatic thought and on your emotions. If you have generated a good, helpful rational response, it should reduce your belief in your original negative automatic thoughts and make you feel better. Indicate the impact on your original automatic thought in the last column of the Thought Diary. In the “Outcome” column, re-rate your belief in the original automatic thought under number 1. In other words, now that you have evaluated the automatic thought and generated a rational response, how much do you believe that automatic thought you had in the first place? 0% is you do not believe it all, and 100% is you still totally, completely believe it. If you have generated a good, helpful rational response, your degree of belief in the original automatic thought should go down. Also indicate the impact on your emotions in the “Outcome” column. Under number 2, list any emotions you feel now. In other words, what was the impact of coming up with a rational response to your automatic thought on your emotional state? You may still have some of those same emotions you had in the original “Emotion(s)” column. However, they should now be less in degree. You may also experience new emotions after generating a rational response, maybe even some positive emotions such as hopefulness or happiness.

Example of Rational Responses Recall the example of George and Bill from last week (the two guys who asked someone out and got shot down). George’s A, B, and C are shown below. Come up with some rational responses for George and write these in at stage D. A = the person he asked out declined his invitation B = “I’ll never get a date again. I’m going to be single for the rest of my life. I’m a total failure at love and sure to be unloved forever.”

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C = felt depressed D=

Homework

✎ Continue with your Weekly Pleasant Activities Plan. Copies of the form can be found at the end of the book.

✎ Continue to keep a Thought Diary on a daily basis, now using the 7-column form. Copies of the form can be found at the end of the book.

✎ Try to look for patterns in your automatic thoughts as you complete the Thought Diary. Do any automatic thoughts occur again and again? Does there seem to be any common themes among your automatic thoughts? This will prepare you for some of the skills to be discussed next week.

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Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive

Emotion(s)

Rational Responses

Outcome

1. Specify sad, anxious, angry, etc. 2. Rate degree of emotion (0–100%).

1. Write a rational response to the automatic thoughts. 2. Rate belief in rational response (0–100%).

1. Re-rate belief in automatic thought (0–100%). 2. Specify and rate degree of emotion (0–100%).

Distortions Briefly describe 1. Write the automatic situation (antecedent thoughts that event), stream of accompany the thoughts, daydream, emotions. or image. 2. Rate belief in automatic thought (0–100%).

Identify the types of cognitive distortions.

Session 9

Core Beliefs

Goals ■

To learn about core beliefs

■

To understand the difference between automatic thoughts and core beliefs

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To identify your core beliefs

Overview This session introduces the concept of core beliefs. You will learn how core beliefs develop and how they affect your automatic thoughts. You will begin to identify your own core beliefs.

What Are Core Beliefs? We have already talked about automatic thoughts and how they affect the way we feel. Automatic thoughts are the words that actually go through our minds and are very close to our conscious awareness. There is, however, a deeper, less conscious level to our thinking that influences what we think about, what we do, and how we feel. This level is made up of our core beliefs. Core beliefs are our most central, fundamental, important beliefs about ourselves, other people, and the world. We learn most of our core beliefs during childhood. Most people have positive core beliefs for most of their lives (e.g., “I am likeable,” “I am competent,” “I am in control,” “Other people are trustworthy,” “The world is a good place,” and so on). When people feel depressed, however, their negative core beliefs tend to surface (e.g., “I am a failure,” “I am unlovable,” “Other people are critical,” or “The world is a dangerous place”). This would apply to SAD in the following

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way: During winter, when people with SAD feel their worst, their negative core beliefs are activated and wreak havoc on their thinking, helping to maintain the symptoms of SAD. In contrast, during summer, when people with SAD feel their best, their positive core beliefs are activated and help contribute to good mood and a sense of well-being. Once a negative core belief is activated, you easily notice any evidence that seems to support it, but ignore or discount any evidence that contradicts it. It is like having a screen around your head that allows anything that fits with the negative core belief through and stops anything that does not fit. For example, a college student who is depressed may have the core belief, “I’m inadequate.” He would, therefore, ignore that he got an A on a recent biology exam (maybe saying, “The test was easy”). Instead, he would pay special attention to getting a C on an economics exam because this would confirm his negative core belief of inadequacy.

Core Beliefs Versus Automatic Thoughts Core beliefs are different from your automatic thoughts. Your core beliefs influence the way you view daily situations and, therefore, influence the way you think, feel, and behave. Core beliefs actually are what drive your automatic thoughts; they are like the root of your automatic thoughts. Core beliefs are the reason why different people have different automatic thoughts in reaction to the same situation. Core beliefs fit into the A-B-C model as shown in Figure 9.1. Core beliefs can be difficult to understand at first. To practice, recall the example of George and Bill. Both men ask the object of their affection out on a date and get shot down. Based on what we know about their automatic thoughts, we can assume the following core beliefs. George’s Core Beliefs Core beliefs about self:

Core beliefs about others:

Core beliefs about the world:

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CORE BELIEFS (Self, Others, World)

A

B

C

A = Antecedent event

B = Belief

C = Consequence

(Situation, stream of thoughts, or daydream)

(Automatic thoughts)

(Emotional reaction)

Figure 9.1 Core Beliefs 61

Bill’s Core Beliefs Core beliefs about self:

Core beliefs about others:

Core beliefs about the world:

How Can You Identify Your Core Beliefs? To learn what your own core beliefs are, look for patterns or themes in the automatic thoughts that you recorded in your Thought Diaries: 1. Do any of your automatic thoughts occur again and again?

2. Does there seem to be any common themes among your automatic thoughts?

3. Do your automatic thoughts suggest any ideas about how you think about yourself, other people, and the world?

Homework

✎ Continue with your Weekly Pleasant Activities Plan. Copies of the form can be found at the end of the book.

✎ Continue to keep a Thought Diary on a daily basis. Copies of the 7-column form can be found at the end of the book.

✎ Keep looking for themes and patterns in your automatic thoughts so you can begin to learn what your core beliefs are.

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Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive

Emotion(s)

Rational Responses

Outcome

1. Specify sad, anxious, angry, etc. 2. Rate degree of emotion (0–100%).

1. Write a rational response to the automatic thoughts. 2. Rate belief in rational response (0–100%).

1. Re-rate belief in automatic thought (0–100%). 2. Specify and rate degree of emotion (0–100%).

Distortions Briefly describe situation (antecedent event), stream of thoughts, daydream, or image.

1. Write the automatic thoughts that accompany the emotions. 2. Rate belief in automatic thought (0–100%).

Identify the types of cognitive distortions.

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Session 10

Evaluating Your Core Beliefs

Goals ■

To identify your core beliefs

■

To review common core beliefs

■

To begin evaluating your core beliefs

Overview In this session, we will discuss patterns in your automatic thoughts from your Thought Diaries as a means of identifying your core beliefs. You will also review common core beliefs to see which ones you may hold. You will then begin evaluating your core beliefs by using the Core Beliefs Worksheet.

Common Core Beliefs Refer back to the patterns you noticed in your Thought Diaries. Common core beliefs include being helpless or unlovable. Do you have any core beliefs that fall into these categories? Write them down in the space provided. I am . . .

I am . . .

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Core Belief

Strength (0–100%)

Evidence for with BUT statements

Evidence against

New Belief

Strength (0–100%)

I am a failure.

Current: 80%

Growing up, my mother often made statements comparing me to my sister, suggesting that I was not as good as my sister (not as smart, not as likeable, not as pretty, etc.) BUT that was only her opinion and today I understand that nurturing parents do not say such things to their kids.

I maintained excellent grades throughout my education and received lots of praise from my instructors.

I perform most things I do very well, but, like most people, I do not reach my top goal all of the time.

New Belief: 95%

Most (past week): 90% Least (past week): 70%

During my senior year of high school, I did not make a sports team that I really wanted to be part of BUT I did make this team every other year of high school and more students tried out at that year than ever before. I did not get into the top college of my choice BUT that was a highly selective school and I ended up attending an excellent college. During college, I really struggled to pass my biology courses BUT many students struggled with biology and I earned high grades in all of my other courses.

Most things I wrote under “evidence for” are specific times when I did not reach some top goal. I do reach my desired goal the vast majority of the time. Even when I do not reach my top goal, things work out for me and I do not end up as a total failure. I at least partially succeed. I obtained a very good job that I perform well and continue to enjoy. Achieving things is not the only way to define success or failure—having good relationships is important, too. I have good relationships with my family and friends.

Figure 10.1 Example of Completed Core Belief Worksheet Source: Adapted from Judith S. Beck (1995). Cognitive therapy: Basics and beyond. New York: The Guilford Press.

Old Belief: 60%

Evaluating and Changing Your Core Beliefs Just like with negative automatic thoughts, it is important to evaluate and change any negative core beliefs you have to make them less negative and more positive. The process of evaluating and changing your core beliefs is difficult because core beliefs are a lot more important to you and more believed by you than your automatic thoughts. It can help to think of your core beliefs as an iceberg that you will need to gradually chip away at. Use the Core Belief Worksheet to help you with this. Core Belief Worksheet

The Core Belief Worksheet is similar to a Thought Diary, but it helps organize core beliefs instead of automatic thoughts. It combines the steps of evaluating core beliefs and generating new, more helpful core beliefs. Be sure to state your core belief in sentence form, so that it will be easier to evaluate. See Figure 10.1 for an example of how to complete the Core Belief Worksheet. Notice a unique feature of the Core Belief Worksheet, the “BUT” statements. In reviewing evidence in support of a core belief, generate BUT statements to offer one or more other explanations for that piece of evidence (other than the core belief being true).

Homework

✎ Continue with your Weekly Pleasant Activities Plan. Copies of the form can be found at the end of the book.

✎ Continue to keep a Thought Diary on a daily basis. Copies of the 7-column form can be found at the end of the book.

✎ Keep looking for themes and patterns in your automatic thoughts to give you more ideas about what your core beliefs are.

✎ Complete the Core Belief Worksheet and be prepared to talk about this process with the group in the next session. Copies of this form can be found at the end of the book.

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Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive

Emotion(s)

Rational Responses

Outcome

1. Specify sad, anxious, angry, etc. 2. Rate degree of emotion (0–100%).

1. Write a rational response to the automatic thoughts. 2. Rate belief in rational response (0–100%).

1. Re-rate belief in automatic thought (0–100%). 2. Specify and rate degree of emotion (0–100%).

Distortions Briefly describe 1. Write the automatic situation (antecedent thoughts that event), stream of accompany the thoughts, daydream, emotions. or image. 2. Rate belief in automatic thought (0–100%).

Identify the types of cognitive distortions.

Core Belief Worksheet Core Belief

Strength (0–100%)

Evidence for with BUT statements

Evidence against

New Belief

Strength (0–100%)

Current:

New Belief:

Most (past week):

Old Belief:

Least (past week):

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Note: Adapted from Cognitive Therapy: Basics and Beyond, by J. S. Beck, 1995, New York: The Guilford Press.

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Session 11

Maintaining Your Gains and Relapse Prevention

Goals ■

To maintain the gains you have made in group

■

To make a relapse prevention plan

■

To set new personal goals

Overview This session will help you prepare for the end of group meetings. You will think about how you can maintain any gains you have made in this group and continue to improve over the rest of this winter. You will also make a relapse prevention plan to prepare for future winters. Finally, you will consider what new goals you may want to set in other areas of your life.

Maintaining Your Gains We hope that you have experienced some improvements in your SAD symptoms and in your quality of life since you started attending this group 5 weeks ago. However, winter is not over yet! It is best to think about how to maintain any gains you have made now so you will have a plan in place to use after the last group session. If you do not plan ahead, you may fall back into your old habits that contributed to making your SAD worse. Just like a driving instructor teaches you the basic skills necessary to be a good driver, this group was meant to teach you some basic skills to cope with winter more effectively. Although it is true that the group is not going to meet anymore after this week, you do not need to stop “driving.” You are now in the driver’s seat, so to speak, for coping with your SAD.

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Relapse Prevention You will need to watch out for future SAD episodes next winter and every winter from now on. Compare yourself to a forest ranger firefighter whose job is to identify fires quickly, have a plan, and put the fire out. This is called relapse prevention. A good relapse prevention plan will help you be ready for winter next time it rolls around. You cannot prevent winter from happening, but you can be prepared to cope with it. It is important to keep practicing the skills learned in group all year round to prevent SAD and depression in general. Review the following tips for relapse prevention. 1. Be alert to signs and symptoms of SAD. Monitor your mood on a regular basis and notice whether you are falling back into the same old negative patterns. Ask yourself, “How have I been feeling over the past week? How have I been handling things lately?” If you notice that you are falling back into some of the same old negative patterns (e.g., low energy, sleep problems, negative thinking, do not feel like doing anything, appetite changes), this should alert you. 2. Take early action. Identify any changes in your mood and behaviors, have a plan in place, and take action before you are feeling so badly that you cannot get motivated to do anything about it. Try to identify early signs of SAD and depression because prevention is easier than treatment for a full-blown SAD episode. 3. Be aware that major life events can set you up for depression. Try to think ahead about ways stressful events may affect you. Monitor your mood more closely when you are under stress. Prepare for these events with a plan. Some examples of life events associated with depression include: ■

■ ■

■ ■

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Social separations: moving away from loved ones or loved ones relocating, divorce or separation or end of a relationship, death of a loved one, etc. Health-related problems: injury or illness, a new medical problem, etc. New responsibilities and adjustments: change in career, becoming a caretaker for someone, going back to school, etc. Work-related changes: promotion, getting laid off, etc. Financial and material changes: decrease in income, cutting back on spending, etc.

4. Have a relapse prevention plan in place. Develop a prevention plan and be ready to use your plan when you need it! Remind yourself of the skills you have learned in group and other things that can help you cope with winter. 5. Remember that your thoughts play a role in relapse and relapse prevention. Be careful of negative thoughts that can get in the way—for example, “I must be a failure. I went through this SAD treatment program and I’m depressed in the winter again.” Replace these with positive, empowering thoughts—for example, “I can do something to help myself feel better.”

Setting New Goals Now that you have worked hard to improve your SAD, you may want to generate new goals for yourself. Sometimes making one positive life change can lead to other positive life changes in other areas. Keep the positive momentum going! Broaden your perspective and think about other areas in your life you would like to change for the better. Such goals can include: ■

Individual Goals: educational plans, vocational choices, exercise and physical activity level, economic pursuits, recreational and creative activities

■

Interpersonal Goals: goals related to family, friends, and romantic relationships; joining a group; becoming a leader

Homework Your last homework assignment is perhaps your most important one!

✎ Use the Personal Goal Planning Sheet to come up with a personal plan for how you will maintain any gains you have made in this group and for how you plan to cope with future fall or winter seasons.

✎ Set new goals for other areas in your life and record these on the Personal Goal Planning Sheet. Be prepared to share your goals with the group at the last meeting.

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Personal Goal Planning Sheet (1) Plan for Maintaining Your Gains What can you do to maintain the gains you have made in this group? What can you do to make sure you continue to improve even more after the group stops meeting? Is this as good as it is going to get for you during the winter with your SAD or do you want to try and make it even better? If you want it to be even better, what can you do to try and make this happen?

(2) Plan for Relapse Prevention Say that you have a relapse (next fall or winter, you begin to experience SAD symptoms again), what would you do to improve your mood? How can you remind yourself to use what you have learned in this group if you start feeling down again? Are there other things you know can help you cope with winter (other than things you have learned in this group?)

(3) Broadening Your Perspective: Other Life Goals Now that you have worked hard to improve your SAD, you may want to generate new goals for yourself. Do you have any other areas of your life you would like to improve upon? What are some short- and long-term goals that will help you make these improvements?

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Session 12

Review and Farewell

Goals ■

To review what you have learned in group

■

To continue improving on your own

Overview This is the last session of the group. Key points from the last 11 sessions will be covered. You will share the goals and plans you developed on the Personal Goal Planning Sheet. You will also have the opportunity to share your thoughts about the group with the other group members. Finally, you will say good-bye to the group. Remember, even though the group is ending, you should keep working to improve your SAD symptoms and to make future winters even better for you.

The Most Important Things You Have Learned in This Group 1. SAD and SAD symptoms are a very common experience, especially at higher latitudes. 2. SAD symptoms fall into four main categories—physical, emotional, cognitive, and behavioral. All of these types of symptoms interact with each other, as in a domino effect, to create the “vicious SAD cycle.” 3. Your frequency of pleasant activities relates to how you feel. Becoming inactive can make your SAD worse, but doing more pleasant activities can make you feel better. 4. What you think about relates to how you feel. Negative automatic thoughts tend to contain cognitive distortions that make your SAD worse.

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5. Evaluating your negative automatic thoughts and coming up with more positive and realistic thoughts called “rational responses” can help you feel better. 6. Core beliefs are basic ideas we have about ourselves, other people, and the world in general. When your negative core beliefs are activated during a SAD episode, they can cause negative automatic thoughts. Identifying and replacing negative core beliefs can improve your mood. 7. After group, it is important to maintain gains and prevent relapse by continuing to practice your skills.

Reflecting on Your Progress Answer the following questions to review how far you have come since the beginning of group: 1. Out of the skills that you have learned, which have been most helpful to you?

2. What do you see as the biggest change you have made from this group?

3. What do you think is left to improve upon?

Taking Credit

Do not forget that you are responsible for any improvements you have made in this group! You did not just sit here passively and listen to the material. You interacted with the group, asked questions, thought about the material between sessions, and did a homework assignment after every session. You deserve the majority of the credit. Do not discount your own contribution to your feeling better.

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Suggested Readings If you would like to learn more about CBT, here are a few suggested books, available in paperback at most public libraries and book stores: Burns, D. D. (1999). Feeling good: The new mood therapy: The clinically proven drug-free treatment for depression (Revised and Updated ed.). New York: Avon Books. This book, revised in 1999, is one of the most highly recommended self-help books ever. It focuses on the principals of cognitive therapy. Greenberger, D., & Padesky, C. A. (1995). Mind over mood: Change how you feel by changing the way you think. New York: The Guilford Press. This is a hands-on self-help book using cognitive therapy techniques. It contains many worksheets and practice exercises. Lewinsohn, P. M., Munoz, R., Youngren, M. A., & Zeiss, A. M. (1992). Control your depression (Rev. ed.) (Paperback). New York: Fireside. This book focuses on the principals of behavior therapy for depression, including pleasant activities, relaxation, and social skills. Westermeyer, R. (2004). Kicking depression’s ugly butt: Tried and true methods for outsmarting depression. St. Louis, MO: Quick Publishing, LC. This book focuses on the principals of cognitive therapy and has sections on social skills and anxiety. Young, J. E., & Klosko, J. S. (1994). Reinventing your life: The breakthrough program to end negative behavior . . . and feel great again. New York: Plume. This cognitive therapy self-help book focuses more on core beliefs.

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Weekly Pleasant Activities Plans

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Weekly Pleasant Activities Plan Directions: Use this plan to schedule a time to do at least one pleasant activity every day for at least 10 minutes. Record whether or not you did the activity and how long you did the activity in minutes. Finally, rate how enjoyable the activity was for you, where 0 = completely unenjoyable and 10 = completely enjoyable. Try to stick to your plan!

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Weekly Pleasant Activities Plan Directions: Use this plan to schedule a time to do at least one pleasant activity every day for at least 10 minutes. Record whether or not you did the activity and how long you did the activity in minutes. Finally, rate how enjoyable the activity was for you, where 0 = completely unenjoyable and 10 = completely enjoyable. Try to stick to your plan!

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Weekly Pleasant Activities Plan Directions: Use this plan to schedule a time to do at least one pleasant activity every day for at least 10 minutes. Record whether or not you did the activity and how long you did the activity in minutes. Finally, rate how enjoyable the activity was for you, where 0 = completely unenjoyable and 10 = completely enjoyable. Try to stick to your plan!

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Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Weekly Pleasant Activities Plan Directions: Use this plan to schedule a time to do at least one pleasant activity every day for at least 10 minutes. Record whether or not you did the activity and how long you did the activity in minutes. Finally, rate how enjoyable the activity was for you, where 0 = completely unenjoyable and 10 = completely enjoyable. Try to stick to your plan!

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

83

84

Weekly Pleasant Activities Plan Directions: Use this plan to schedule a time to do at least one pleasant activity every day for at least 10 minutes. Record whether or not you did the activity and how long you did the activity in minutes. Finally, rate how enjoyable the activity was for you, where 0 = completely unenjoyable and 10 = completely enjoyable. Try to stick to your plan!

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Planned Activity:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Scheduled Time:

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

Did you do it? Y N

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

For how long?

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Enjoyment Rating (0–10):

Thought Diaries

85

86

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

87

88

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

89

90

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

91

92

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

93

94

Thought Diary—7 Column Date

Situation

Automatic Thought(s)

Cognitive Distortions Emotion(s)

Briefly describe 1) Write the automatic Identify the types of situation (antecedent thoughts that cognitive distortions. event), stream of accompany the thoughts, daydream, emotions. or image. 2) Rate belief in automatic thought (0–100%).

Rational Responses

Outcome

1) Specify sad, 1) Write a rational 1) Re-rate belief in anxious, angry, etc. response to the automatic thought 2) Rate degree of automatic thoughts. (0–100%). emotion 2) Rate belief in rational 2) Specify and rate (0–100%). response (0–100%). degree of emotion (0–100%).

Automatic Thought Questioning Forms

95

Automatic Thought Questioning Form This form will help you evaluate and question your automatic thoughts. Using your Thought Diary, select an unhelpful automatic thought or a series of automatic thoughts that contributed to negative mood. Write this automatic thought or thoughts in the space below.

Now, follow steps 1 through 4 and ask yourself the following questions. Write your responses in the space provided. (1) Review the evidence. What is the evidence for this thought?

What is the evidence against this thought?

(2) Review possible outcomes. What is the worst thing that could happen? Could I survive it?

What is the best thing that could happen?

What realistically is most likely to happen?

(3) Consider the impact of your automatic thought. What are the results of my belief in the automatic thought? That is, how do I feel and act in response to this automatic thought?

What could be the results of changing my thinking? That is, would I feel any differently or do anything differently if I could change the thought?

(4) Problem-solve about the situation that brought on your negative thinking. What could I do about it?

What would I tell

96

(a friend) if he or she were in the same situation?

Automatic Thought Questioning Form This form will help you evaluate and question your automatic thoughts. Using your Thought Diary, select an unhelpful automatic thought or a series of automatic thoughts that contributed to negative mood. Write this automatic thought or thoughts in the space below.

Now, follow steps 1 through 4 and ask yourself the following questions. Write your responses in the space provided. (1) Review the evidence. What is the evidence for this thought?

What is the evidence against this thought?

(2) Review possible outcomes. What is the worst thing that could happen? Could I survive it?

What is the best thing that could happen?

What realistically is most likely to happen?

(3) Consider the impact of your automatic thought. What are the results of my belief in the automatic thought? That is, how do I feel and act in response to this automatic thought?

What could be the results of changing my thinking? That is, would I feel any differently or do anything differently if I could change the thought?

(4) Problem-solve about the situation that brought on your negative thinking. What could I do about it?

What would I tell

(a friend) if he or she were in the same situation?

97

Automatic Thought Questioning Form This form will help you evaluate and question your automatic thoughts. Using your Thought Diary, select an unhelpful automatic thought or a series of automatic thoughts that contributed to negative mood. Write this automatic thought or thoughts in the space below.

Now, follow steps 1 through 4 and ask yourself the following questions. Write your responses in the space provided. (1) Review the evidence. What is the evidence for this thought?

What is the evidence against this thought?

(2) Review possible outcomes. What is the worst thing that could happen? Could I survive it?

What is the best thing that could happen?

What realistically is most likely to happen?

(3) Consider the impact of your automatic thought. What are the results of my belief in the automatic thought? That is, how do I feel and act in response to this automatic thought?

What could be the results of changing my thinking? That is, would I feel any differently or do anything differently if I could change the thought?

(4) Problem-solve about the situation that brought on your negative thinking. What could I do about it?

What would I tell

98

(a friend) if he or she were in the same situation?

Core Belief Worksheets

99

100

Core Belief Worksheet Core Belief

Strength (0–100%)

Evidence for with BUT statements

Evidence against

New Belief

Strength (0–100%)

Current:

New Belief:

Most (past week):

Old Belief:

Least (past week):

Note: Adapted from Cognitive Therapy: Basics and Beyond, by J. S. Beck, 1995 New York: The Guilford Press.

Core Belief Worksheet Core Belief

Strength (0–100%)

Evidence for with BUT statements

Evidence against

New Belief

Strength (0–100%)

Current:

New Belief:

Most (past week):

Old Belief:

Least (past week):

101

Note: Adapted from Cognitive Therapy: Basics and Beyond, by J. S. Beck, 1995 New York: The Guilford Press.

102

Core Belief Worksheet Core Belief

Strength (0–100%)

Evidence for with BUT statements

Evidence against

New Belief

Strength (0–100%)

Current:

New Belief:

Most (past week):

Old Belief:

Least (past week):

Note: Adapted from Cognitive Therapy: Basics and Beyond, by J. S. Beck, 1995 New York: The Guilford Press.