01 - 19. Additional Techniques

19. Additional Techniques

W e’ve already covered many basic CBT techniques in this book, among them, psychoeducation, focusing on aspirations, values, and strengths; monitoring mood and behavior; cognitive restructuring; worksheets; behavioral experiments; and mindfulness. These techniques may influence clients’ thinking, behavior, and/or physiological arousal, in addition to their mood. Some increase positive affect, some decrease negative affect, and some do both. As described in Chapter 9, you collaboratively choose techniques using your conceptualization of the client as a guide. As described in Chapter 2, CBT adapts techniques from many evidence-­based psychotherapeutic modalities: acceptance and commitment therapy, compassion-­focused therapy, dialectical behavior therapy, emotion-­focused therapy, Gestalt therapy, interpersonal psychotherapy, meta-­cognitive therapy, mindfulness-­based cognitive therapy, motivational interviewing, psychodynamic psychotherapy, schema therapy, solution-­focused brief therapy, well-being therapy, and others, within the context of a cognitive conceptualization. You will also invent your own techniques as you become more proficient as a CBT therapist. This chapter answers the following questions: How do you help clients regulate their emotions (e.g., through refocusing, distraction, self-­soothing, and relaxation exercises)? How do you know when to do skills training? How do you help clients become better problem solvers? ADDITIONAL TECHNIQUES

How do you help clients make decisions? How do you create graded task assignments? How do you do exposure? When might you use role playing? When are “pie” techniques useful? How can you change unfavorable self-­comparisons? EMOTION REGULATION TECHNIQUES The goal of CBT is not to eliminate negative emotion. All emotions are important. Negative emotions frequently point to a problem that needs to be solved (which may or may not include changing one’s thinking)—or, if it can’t be solved, accepted. The goal of CBT is to reduce the degree and duration of negative emotion that doesn’t seem to be proportionate to the situation (given the client’s culture and circumstances), usually related to distorted or unhelpful perceptions. Acceptance of negative emotion (instead of avoidance) is key for some clients (Linehan, 2015; Segal et al., 2018). Acceptance and commitment therapy (Hayes et al., 1999) describes useful metaphors for accepting negative emotion and turning one’s attention to valued action. You’ve read about emotion regulation techniques throughout this book, especially modifying dysfunctional cognitions and maladaptive behavior; engaging mindfully in social, pleasurable, productive, and self-care activities; exercising; focusing on one’s strengths and positive qualities; and cultivating positive cognitions and adaptive behavior. Below are some additional techniques. Refocusing, Engaging in Valued Behavior, and Self‑Soothing Most of the time when I feel distressed, I check the accuracy of my thinking and do problem solving. But occasionally I get stuck thinking in an unhelpful way. For example, this sometimes happens to me when I have a problem I can’t fix, at least at the moment, or when I’m feeling irritated by something I can’t change. If examining my thinking doesn’t help, I change my focus. I tell myself, “Thinking about this right now isn’t helpful. It’s okay that I’m feeling             (nervous, irritated, etc.). I should just refocus on what I’m doing (or engage in a valued action).” I assume you do this too, and you can teach your clients to do the same. Help them monitor their negative affective

Additional Techniques

responses, noticing where their attention is, and then shift their focus to something else. Multiple websites list pleasant, self-­soothing activities, relaxation, or mindfulness exercises. To name just a few, clients can refocus on the task at hand, their immediate experience (using all their senses, especially if they’re ruminating about past events or obsessing about future events), their bodies or their breath, or their aspirations and a plan to work toward those aspirations. They can engage in various activities: valued action, talking to other people, surfing the net, playing a video game, posting or viewing posts on social media, doing chores, exercising, taking a bath or shower, interacting with children or pets, or practicing gratitude. Abe often ruminated and became quite self-­critical about perceived mistakes he had made in the past, and he worried about finances and his future. I taught him mindfulness of the breath and helped him compose a written list of things he could do to engage his attention elsewhere since we determined that rumination and self-­ criticism caused more harm than good. Relaxation Many clients, especially those who experience bodily tension, benefit from learning relaxation techniques, described in detail elsewhere (Benson, 1975; Davis et al., 2008; Jacobson, 1974). There are several kinds of relaxation exercises, including progressive muscle relaxation (PMR), imagery, and slow and/or deep breathing. PMR teaches clients to alternately tense and then relax muscle groups in a systematic way. Imagery involves having clients create a vision in their minds of feeling relaxed, calm, and safe in a particular environment, such as lying on a beach. There are several breathing exercises you can teach clients too. Search online for scripts, and have clients try one or more of these exercises in session, while you make an audio recording on the client’s phone, followed by daily home practice. CLINICAL TIPS Some clients experience a paradoxical arousal effect from relaxation exercises; they actually become more tense and anxious (­Barlow, 2002; Clark, 1989). You can use this as a learning experience. Ask clients, “What are you most afraid could happen if you continue with this exercise?” Then encourage them to continue the relaxation techniques to find out to what degree, if at all, their fears come true. Cognitive Behavior Therapy: Basics and Beyond

SKILLS TRAINING Many depressed clients show deficits in certain skills, including communication, effective parenting, job interviewing, budgeting, household or time management, organization, and relationships. When you uncover a skill deficit, give a rationale for working on it and then make a collaborative decision to do so. Describe the skill and demonstrate it during the session. CBT self-help books and workbooks can also be useful in teaching clients some skills; you can find a list at www.abct. org/SHBooks. When you uncover an obstacle or problem, however, you’ll need to see whether clients have an actual skill deficit or whether they have cognitions that interfere with their using a skill they already possess. You can ask them, “If you were sure that you’d get a good outcome, then what would you do or say?” If they give you a reasonable response, they may not need skills training, just cognitive restructuring. For example, the thought “What if I make a mistake?” might lead clients to avoid doing a task they know how to do. “If I put limits on my child, he won’t listen to me anyway” might lead to overly permissive parenting. Yet these clients may have adequate skills. CLINICAL TIPS When clients are unsure about what to say to another person, give them the choice of whether to play themselves or the other person in a role play. If they play themselves, and do a good job, give them positive feedback and ask them if they want to record what they said, to remember it better. If they don’t do a good job, ask them if they’d like you to demonstrate another approach. If so, you’ll play the client but then switch roles so the client gets a chance to practice. If needed, interrupt the role play to give feedback and have the client practice again. Collaboratively set an Action Plan to use the communication skill in particular circumstances or with specific people. PROBLEM SOLVING Associated with or in addition to their psychological disorders, clients face real-life obstacles to taking steps toward valued action or fulfilling their aspirations. At every session, you’ll encourage clients to look ahead to the coming week or weeks, think about what they can do to improve their experience, and identify potential obstacles or problems. There are several approaches you can take, depending on the nature of the predicted difficulties.

Additional Techniques

Difficulty Solving Problems You can focus on encouraging clients to devise solutions to the problem, in accordance with their values and aspirations. When clients are deficient in problem-­solving skills, they may benefit from direct instruction in problem solving, where they learn to specify a problem, devise solutions, select a solution, implement it, and evaluate its effectiveness (see, e.g., D’Zurilla & Nezu, 2006). You can also ask clients how they’ve solved similar problems in the past, or how they might advise a close friend or family member to solve the same kind of problem. Or you can offer potential solutions yourself. You can also use judicious self-­disclosure, when relevant. Some problems are facilitated by a change in the environment. Maria realized that her overconsumption of high-­calorie junk food was related to not having enough healthy food around. She decided to make it a priority to go to the supermarket twice a week. This change helped significantly. Some problem solving may involve significant life changes. After careful evaluation of a situation, you might encourage battered spouses to seek refuge or take legal action. If you have clients who are chronically dissatisfied with their jobs, you might guide them in analyzing the advantages and disadvantages of staying in their current job versus looking for another job. When dysfunctional cognitions interfere with problem solving, you’ll help clients identify and respond to interfering cognitions and then return to problem solving. Abe, for example, wanted to buy clothes for a special event. He knew how to ask his cousin to go with him, but his belief that he shouldn’t ask for help inhibited him. After evaluating his cognitions about this specific situation, Abe implemented the solution he himself had initially conceived. When Problems Can’t Be Solved Not all problems, of course, can be solved. When problems aren’t leading to much distress, clients may be able to accept them without much help from you. You might teach them the “Oh, well” technique (J. S. Beck, 2007). “Oh, well” is shorthand for “I don’t like this situation or problem. But there’s nothing I can do to change it, not if I want to reach my goal. So, I might as well stop struggling, accept it, and change my attention to something else.” Abe found this technique useful when he didn’t get a job he had interviewed for. When clients have unhelpful cognitions associated with an unsolvable problem, cognitive restructuring is often called for (see pp. 258– 259). Abe had a problem with his ex-wife. She was highly critical of him. Cognitive Behavior Therapy: Basics and Beyond

He had tried to talk to her several times about having more productive conversations, but she just criticized him more. It seemed unlikely that she would change. What made the problem worse though were Abe’s cognitions when he was depressed. He often thought, “She’s right. I am good for nothing.” Evaluating and responding to that cognition made it easier for Abe to accept her behavior, to turn his attention elsewhere, and to work toward increasing life satisfaction in other ways. Although he couldn’t fix the problem, he was able to change his response to the problem. When Problems Have a Low Probability of Occurrence When problems are unlikely to occur, you might help clients • assess the probability that the problem will occur, • look for best and most realistic outcomes, • discuss how to cope if the problem does arise, • distinguish between reasonable and unreasonable precautions, • accept uncertainty, • decrease an overinflated sense of responsibility, • recognize and expand their personal and external resources, and/or • increase their sense of self-­efficacy. MAKING DECISIONS Many clients, especially those who are depressed, have difficulty making decisions. When clients want your help in this area, ask them to list the advantages and disadvantages of each option and then help them devise a system for weighing each item and drawing a conclusion about which option seems best (see Figure 19.1). Judith: You mentioned that you wanted help in deciding whether to volunteer at the homeless shelter? Abe: Yes. Judith: Okay. (Pulls out a piece of paper.) If it’s okay, I’d like to show you how to weigh advantages and disadvantages. Have you ever done that? Abe: No. At least not in writing. I’ve been going over some of the pros and cons in my head.

Additional Techniques

Judith: Good. That’ll help us get started. I think you’ll find that writing them down will make the decision clearer. Which one do you want to start with, volunteering or not volunteering? Abe: Volunteering, I guess. Judith: Okay. Write “Advantages of Volunteering” at the top left of this paper and “Disadvantages of Volunteering” on the top right, and “Advantages of Not Volunteering” and “Disadvantages of Not Volunteering” at the bottom. Abe: (Does so.) Okay. Judith: What have you been thinking? Could you jot down some advantages and disadvantages of volunteering there? (Abe writes down the ideas he has had so far. I ask some questions to guide him.) How about the fact that you’d be getting out of your apartment—­is that an advantage too? Abe: Yeah. (Writes it down.) Abe and I continue this process until he feels he has recorded both sides fairly and thoroughly. We repeat the process with the second option. Examining advantages and disadvantages of one option reminds Abe of additional items to add to the other option. Next, I help Abe evaluate the items: Advantages of Volunteering 1.  Get me out of the apartment 2.  Make me feel useful, productive 3.  Help people 4.  Good step before I get a paying job 5.  Learn new skills? Disadvantages of Volunteering 1.  Might be too tired 2.  Might not like it 3.  Thinking about it makes me anxious Advantages of Not Volunteering 1.  Don’t have to feel anxious about it 2.  Can save my energy for other things 3.  Don’t have to face potential failure Disadvantages of Not Volunteering 1.  Doesn’t help my depression 2.  Doesn’t get me out of the house 3.  Doesn’t give me potential opportunity to feel useful and productive 4.  Doesn’t help me practice for a paying job 5.  Doesn’t increase my skill set FIGURE 19.1.  Abe’s advantages–­disadvantages analysis. Cognitive Behavior Therapy: Basics and Beyond

Judith: Okay, this looks pretty complete. Now you need to weigh the items in some way. Do you want to circle the most important items—or rate the importance of each one on a 1–10 scale? Abe: Circle the items, I guess. Judith: Okay, let’s look at each list now. Which items feel the most important to you? (Abe circles items in each column in Figure 19.1.) Just looking over what you’ve circled, what do you think? Abe: I’d like to volunteer because I’d be helping people and I think I’d feel productive, and it would be good to get out. But I don’t think I’d know what to do. Judith: Do you think everyone who volunteers there knows what to do beforehand? Can you find out if there’s an orientation? And  who is the person you should find if you have questions? Maybe you need a little more information before you make the decision. At the end of the discussion, I increase the probability that Abe will use this technique again: “Did you find this [process of listing and weighing advantages and disadvantages] useful? Can you think of any other decisions you might have to make where it would be good to do the same thing? How can you remember to do it this way?” GRADED TASK ASSIGNMENTS AND THE STAIRCASE ANALOGY Depressed clients get easily overwhelmed by tasks they need to accomplish. It’s important to break down larger tasks into manageable parts (Beck et al., 1979). To reach a goal, you usually need to accomplish a number of tasks or take a number of steps along the way. Clients tend to become overwhelmed when they focus on how far they are from a goal, instead of focusing on their current step. A graphic depiction of the steps is often reassuring (Figure 19.2). Judith: Maria, it sounds like you get nervous just thinking about moving, though it’s something you really want to do. Maria: Yeah. Judith: I wonder how we could break it down into steps; for example, could you start by deciding which neighborhoods you might want to move to?

Additional Techniques

Maria: Yeah. I was thinking of asking my new neighbor for advice. She did a lot of investigating before she moved next door. Judith: What could the next step be? (Guides Maria in identifying several additional steps.) Are you still anxious about moving? Maria: Yeah, some. Judith: (Draws a staircase.) Okay, here’s what I want you to remember. You’re going to go step by step, like going up a staircase. You’re not going to move right away. You’ll start here (pointing to the bottom), talking to your neighbor. Then you’ll figure out how much you can afford in rent. Then you’ll start looking online for apartments. Then you can make an appointment to visit the first apartment. Then you’ll visit the first potential apartment. And then the Visit another potential apartment Visit one potential apartment Call to make appointment to visit Look online for apartments Figure out how much rent I can afford Talk to my neighbor about moving FIGURE 19.2.  Using a staircase metaphor. Cognitive Behavior Therapy: Basics and Beyond

second one. You’ll start here (pointing to bottom step) and just move up one step at a time (drawing arrow from bottom step to next step). You’ll feel more comfortable at each step before you take another one. You won’t jump from here (pointing to bottom step) all the way up to here (pointing to the top step). Okay? Maria: Uh-huh. Judith: So every time you start thinking about the final goal, how about reminding yourself of this staircase, especially of the step you’re now on, and how you’re going to take just one step at a time. Do you think that’ll help bring down the anxiety? EXPOSURE Depressed and anxious clients often engage in avoidance, a coping strategy. They may feel hopeless about engaging in certain activities (“It won’t do any good to call my friends. They won’t want to see me”) or fearful (“If I [do this activity], something bad will happen”). The avoidance may be quite apparent (e.g., clients who spend a great deal of time in bed, avoiding self-care activities, household tasks, socializing, and errands). Or the avoidance may be more subtle (e.g., socially anxious clients who avoid making eye contact, smiling at others, making small talk, and volunteering their opinions). These latter avoidances are safety behaviors (Salkovskis, 1996). Clients believe that these behaviors will ward off anxiety or feared outcomes. While avoidance tends to bring immediate relief (and so is quite reinforcing), it perpetuates the problem. Clients don’t get the opportunity to test their automatic thoughts and receive disconfirmatory evidence. When clients are anxious and significantly avoidant, you’ll provide a strong rationale for exposure. Here’s what you’d say using a traditional CBT approach: Therapist: Can we talk now about decreasing your avoidance of               [the feared situation]? Research has shown us that the way to get over a fear of             is to expose yourself to it, either in gradual steps or all at once, whichever you’d like to do. For example, I know you have cats, so you must not have a fear of them. But if you did, how would you get over it? We could start by having you look at pictures or videos of cats and do that until you realized your predictions weren’t accurate, and it’s likely that your anxiety would decrease. (pause) Do you follow me so far? Client: Yes. Therapist: Then maybe you’d visit someone you know who has a cat

Additional Techniques

and is willing to put it in a carrier bag. Then maybe we’d have you get close to a kitten and work up to petting it, and so on. The idea is to reduce avoidance so you can learn whether your beliefs and predictions about cats are accurate. And you can also learn if you’re able to tolerate anxiety. As noted above, you’ll create a hierarchy of avoided situations with clients. Have them rate how anxious they believe they would be in each situation, 0–100 (or 0–10), and write down the list, with the less anxiety-­provoking activities first; and the most, last. Then find out which activity clients want to work on in the coming week. Clients usually want to start with less anxiety-­provoking exposures. We usually look for situations in which they predict they’ll be about 30% anxious. But occasionally a client chooses to engage in the most anxiety-­ provoking activity. When they successfully expose themselves to this situation, it usually speeds up treatment. In a recovery orientation, you would link exposures to the client’s values and aspirations. Here’s what you might say: “I know it’s important to you to be able to visit your grandmother, but it sounds like your coping strategy of avoidance is getting in the way. Do you want to take a step toward taking long car rides this week? You could go somewhere that you think will raise your anxiety only a little or you can really go for it and choose a place that could lead to much more anxiety.” Whether you formally or informally identify an exposure, ask clients to engage in the activity every day (if feasible) and stay in the situation until they find out that the feared outcome doesn’t happen (Craske et al., 2014). We want clients to believe, “This activity isn’t dangerous. I don’t need to avoid it. Even if there’s a bad outcome, I can still handle it.” If at all possible, have clients engage in an exposure right in your office or accompany them to another place. It’s important for you and clients to be alert for their use of safety behaviors. We don’t want them to think, “It’s good I [used that safety behavior] or something bad really might have happened.” Suggest that they ask themselves during exposures, “Am I doing anything to try to avert [the feared consequence] or to make [the feared outcome] less likely?” Also ask them to monitor their automatic thoughts after each exposure. They need to be alert for unhelpful cognitions such as “I was able to tolerate the anxiety this time but next time, I won’t be able to.” At the following session, if clients have successfully exposed themselves to the activity and drawn helpful conclusions, they can choose a new exposure for the coming week. Cognitive Behavior Therapy: Basics and Beyond

Imaginal exposure is often helpful. You can ask clients to imagine entering a situation or engaging in an activity, especially in two conditions:

1. When clients are too fearful to do even mild exposures.
2. When it’s impractical to do regular exposures. You can also have clients do virtual reality exposures in which they enter a “virtual” scenario to test their fears. Clients are more likely to do daily work on a graded exposure hierarchy if you ask them to fill out a daily monitor (Figure 19.3). It can be simple, listing just the date, activity, and level of anxiety. You can also ask clients to record and then cross off predictions that didn’t come true, which further reminds them of the inaccuracy of many of their thoughts. Clients may also fear, and then avoid, internal stimuli: • Experiencing strong emotion • Thinking about upsetting or feared situations • Having painful memories • Becoming physiologically aroused • Facing physical pain These clients usually benefit from mindfulness exercises (see Chapter

16. in which they do behavioral experiments to expose themselves to these stimuli and test their fears.

CLINICAL TIPS When clients are quite fearful of doing exposures, you may need to allow them to use safety behaviors at first, for example, having someone in the car with them when they drive across a bridge. But the next step should be entering the situation without using the safety behavior. I’ve given you a broad outline of exposure, but you’ll need additional instruction. Detailed descriptions of the process used to develop agoraphobic hierarchies can be found in various sources (e.g., Goldstein & Stainback, 1987). Dobson and Dobson (2018) describe plans for effective exposure sessions, possible targets, and factors that decrease the effectiveness of exposure.

Additional Techniques

ROLE PLAYING Role playing is a technique that can be used for a wide variety of purposes. Descriptions of role plays can be found throughout this book, including ones to uncover automatic thoughts, develop an adaptive response, and modify intermediate and core beliefs. Role plays are also useful in learning and practicing social skills. Some clients have weak social skills in general. Others have good social skills for one kind of communication (e.g., at work but not at home—or vice versa) but lack skills to adapt their style when needed. Abe, for example, is reasonably good at normal social conversation and situations that call for a caring, empathic stance. I asked him, “If you were sure that your cousin would react well, what would you say to her about canceling plans at the last minute?” Abe wasn’t sure. He had a skill deficit. So we did a couple of role plays. First I played Abe. Next he played himself. Then I asked him whether anything might get in the way of his having a similar conversation with his cousin. He replied, “She might think I was being critical of her.” In this instance, Abe had both a skill deficit and an interfering cognition that we needed to address. USING THE “PIE” TECHNIQUE It’s often helpful to clients to see their ideas in graphic form. A pie chart can be used in many ways, for instance, helping clients set goals. A pie chart can indicate how much time they’re currently devoting to fulfilling their aspirations or values (Figure 19.4). Another use of the pie chart is determining relative responsibility for a given outcome (Figure 19.5). Judith: Abe, how much do you believe it’s your fault that your ex-wife is so mad at you? Abe: 100%. If I hadn’t lost my job, we’d probably still be married. FIGURE 19.3.  Exposure monitor. Date Activity Predicted level of anxiety (1–100) Actual level of anxiety (1–100) Predictions 12/12 Going to church services 90% 60% I won’t be able to stand the anxiety. I’ll have to leave services early. Cognitive Behavior Therapy: Basics and Beyond

FIGURE 19.4.  Pie charts in goal setting. Work/School/ Intellectual Side Friends Fun Other Interests Spiritual Household Physical IDEAL EXPENDITURE OF TIME Work/School/Intellectual Side Friends Fun Other Interests Spiritual Household Physical ACTUAL EXPENDITURE OF TIME

Additional Techniques

Judith: I wonder if there might be any other explanations? Abe: (Thinks.) Sometimes I wonder if she’s really mad at herself. She thought she’d be happier if we got divorced, but she doesn’t seem to be. Judith: Anything else? Abe: I don’t know. Judith: Did she get mad even when the marriage was going well? Abe: Yeah, she tended to be on my back about every little thing. Judith: Did she only get mad at you? Abe: No, she’d get mad at the kids. She’d get mad at her friends sometimes. Oh, and at her sisters and her parents. Judith: So getting mad seemed to be part of her personality? Abe: Yeah. I guess so. Judith: Would you say she has a hair trigger for getting mad? Abe: Yeah. That describes her exactly. Judith: And you obviously didn’t lose your job to make her mad. Abe: No, of course not. Judith: Could we draw a pie chart? (Draws circle in Figure 19.5.) I’d like to see how much it’s really your fault that she’s still mad at you. Okay? FIGURE 19.5.  Pie chart for causality. Personality 25% Hair Trigger 25% Divorce Hasn’t Made Her Happier 30% Losing My Job 20% REASONS WHY MY EX-WIFE IS MAD Cognitive Behavior Therapy: Basics and Beyond

Abe: Sure. Judith: How much of her anger do you think is due to her personality? Abe: (Thinks.) At least 25%. Judith: (Sections off 25% of the circle and labels it “her personality.”) And to her hair trigger? Abe: Maybe another 25%. Judith: (Sections off an additional 25% of the circle and labels it.) And how much is she really mad at herself because the divorce hasn’t made her happier? Abe: 30%? Judith: (Sections off 30% and labels it.) And how much is due to your losing your job? Abe: Well, there’s not much left, is there? 20%, I guess. Judith: (Labels the remaining 20% of the circle.) And obviously, you didn’t lose your job to deliberately make her mad. So now how much do you believe that it’s your fault that your ex-wife is so mad? Abe: Not as much. I guess I didn’t think of all those other reasons. CLINICAL TIPS When investigating the contribution of alternative explanations, ask clients to estimate the dysfunctional attribution (in this case, “It’s my fault”) last so they will more fully consider all explanations. SELF‑COMPARISONS Clients often have automatic thoughts in the form of unhelpful comparisons. They compare themselves at present with how they were before the onset of their disorder, or with how they would like to be, or they compare themselves with others who don’t have a psychiatric disorder. Doing so helps to maintain or increase their dysphoria, as it does with Maria. I help her see that her comparisons are unhelpful. I then teach her to make more functional comparisons (with herself at her worst point). Judith: Maria, it sounds as if you were comparing yourself to other people quite a lot this week. Maria: Yeah, I guess I was. Judith: And it sounds as if that always made your mood worse. Maria: Yeah. I mean, look at me. It was so hard just to do basic stuff, like organizing the living room, paying bills . . .

Additional Techniques

Judith: Would you be as hard on yourself, for example, if you had to push yourself because you had pneumonia? Maria: No, but then I’d have a legitimate reason to be tired. Judith: Isn’t depression a legitimate reason to be tired? Maybe it’s not fair to compare yourself to people who aren’t depressed. Do you remember at the first session when we talked about some of the symptoms of depression: tiredness, low energy, trouble concentrating, low motivation, and so on? Maria: Uh-huh. Judith: So maybe there’s a legitimate reason that you have to push yourself, even though other people don’t, or don’t have to as much? Maria: (Sighs.) I guess so . . . Judith: Okay, can we go over what you can do when you compare yourself with others? Maria: (Nods.) Judith: What would happen if you said to yourself, “Now wait a minute. That’s not a reasonable comparison. Let me compare myself to me at my worst point, before I started therapy, when my whole apartment was a mess, and I spent all day in bed or on the couch.” Maria: Well, I’d realize that I’m doing more now. Judith: And would your mood get worse? Maria: No, probably better. Judith: Would you like to try this comparison as part of your Action Plan? Maria: Uh-huh. Judith: What do you want to write down? Maria: I guess that it’s not helpful to compare myself to other people. Judith: Especially people who aren’t depressed. And what can you do instead? Maria: I could think of what I’m doing now that I wasn’t doing before we started working together. Judith: Great—do you want to write those two things down? Clients may also have automatic thoughts in which they compare themselves at present to where they would like to be. For example, they might say, “I should be able to [work full time].” Or they may compare themselves to where they were before they became depressed (“This used to be so easy for me”). Again, have them focus on how far they’ve progressed. Cognitive Behavior Therapy: Basics and Beyond

CLINICAL TIPS When clients are at their lowest point, you’ll need to modify the approach: “It sounds as if you feel pretty down when you compare yourself with other people, or with how you wish you were. I wonder if it might be helpful at these times to remind yourself that you have a goal list, and that together we’re working on a plan to help you make changes. If you reminded yourself that you and I are a team working to get you to where you want to be, what could happen to your mood?” SUMMARY In summary, there are a great variety of techniques used in CBT. Some apply across conditions; some are specific to a particular disorder. Many are adapted from other modalities. These techniques may influence clients’ thinking, behavior, and/or physiological arousal, in addition to their mood. Some increase positive affect, some decease negative affect, and some do both. Some techniques help clients regulate their emotions; others teach them skills. You will select techniques, provide a rationale, elicit the client’s agreement, and then employ them. Use your conceptualization of the client as a guide. REFLECTION QUES TIONS There are so many techniques you can use in CBT. What advice would you give to a friend who feels overwhelmed at the prospect of how much there is to learn? Which techniques in this chapter might help? PRACTICE EXERCISES What is a decision you need to make or can imagine needing to make? Write out the advantages and disadvantages of one option versus another option. Also, make a pie diagram showing your aspirational use of time versus your actual expenditure of time.

Additional Techniques