Home » Positive CBT » 25 CBT Techniques and Worksheets for Cognitive Behavioral Therapy
You have definitely heard about CBT.
You may not know it, or you may not immediately assign meaning to those three letters placed side by side, but there’s almost no doubt that you have at least a passing familiarity with CBT.
If you’ve ever interacted with a therapist, a counselor, or a clinician in a professional setting, you have likely participated in CBT. If you’ve ever heard friends or loved ones talk about how a mental health professional helped them recognize their fears or sources of distress and aided them in altering their behavior to more effectively work towards their goals, you’ve heard about the impacts of CBT.
CBT, or cognitive behavioral therapy, is one of the most used tools in the psychologist’s toolbox. It’s based on a fairly simple idea which, when put into practice, can have wildly positive outcomes.
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What is CBT?
This simple idea is that our unique patterns of thinking, feeling, and behaving are significant factors in our experiences, both good and bad. Since these patterns have such a significant impact on our experiences, it follows that altering these patterns can change our experiences (Martin, 2016).
CBT aims to change our thought patterns, the beliefs we may or may not know we hold, our attitudes, and ultimately our behavior in order to help us face our difficulties and more effectively strive towards our goals.
The founder of CBT is a psychiatrist named Aaron Beck, a man who practiced psychoanalysis until he noticed the prevalence of internal dialogues in his clients, and realized how strong the link between thoughts and feelings can be. He altered the therapy he practiced in order to help his clients identify, understand, and deal with the automatic, emotion-filled thoughts that arise throughout the day.
Beck found that a combination of cognitive therapy and behavioral techniques produced the best results for his clients. In describing and honing this new therapy, Beck laid the foundations of the most popular and influential form of therapy of the last 50 years.
This form of therapy is not designed for lifelong participation, but focuses more on helping clients meet their goals in the near future. Most CBT treatment regimens last from five to ten months, with one 50 to 60 minute session per week.
CBT is a hands-on approach that requires both the therapist and the client to be invested in the process and willing to actively participate. The therapist and client work together as a team to identify the problems the client is facing, come up with new strategies for addressing them, and thinking up positive solutions (Martin, 2016).
Many of the most popular and effective CBT techniques are applied to what psychologists call “cognitive distortions” (Grohol, 2016).
Cognitive distortions: inaccurate thoughts that reinforce negative thought patterns or emotions.
Cognitive distortions are faulty ways of thinking that convince us of a reality that is simply not true.
There are 15 main cognitive distortions that can plague even the most balanced thinkers at times:
Filtering refers to the way many of us can somehow ignore all of the positive and good things in our day to focus solely on the negative. It can be far too easy to dwell on a single negative aspect, even when surrounded by an abundance of good things.
Polarized Thinking / “Black and White” Thinking
This cognitive distortion is all about seeing black and white only, with no shades of grey. This is all-or-nothing thinking, with no room for complexity or nuance. If you don’t perform perfectly in some area, then you may see yourself as a total failure instead of simply unskilled in one area.
Overgeneralization is taking a single incident or point in time and using it as the sole piece of evidence for a broad general conclusion. For example, a person may be on the lookout for a job but have a bad interview experience, but instead of brushing it off as one bad interview and trying again, they conclude that they are terrible at interviewing and will never get a job offer.
Jumping to Conclusions
Similar to overgeneralization, this distortion involves faulty reasoning in how we make conclusions. Instead of overgeneralizing one incident, however, jumping to conclusions refers to the tendency to be sure of something without any evidence at all. We may be convinced that someone dislikes us with only the flimsiest of proof, or we may be convinced that our fears will come true before we have a chance to find out.
Catastrophizing / Magnifying or Minimizing
This distortion involves expectations that the worst will happen or has happened, based on a slight incident that is nowhere near the tragedy that it is made out to be. For example, you may make a small mistake at work and be convinced that it will ruin the project you are working on, your boss will be furious, and you will lose your job. Alternatively, we may minimize the importance of positive things, such as an accomplishment at work or a desirable personal characteristic.
This is a distortion where an individual believes that everything they do has an impact on external events or other people, no matter how irrational the link between. The person suffering from this distortion will feel that they have an unreasonably important role in the bad things that happen around them. For instance, a person may believe that the meeting they were a few minutes late in getting to was derailed because of them, and that everything would have been fine if they were on time.
Another distortion involves feeling that everything that happens to you is a result of external forces or due to your own actions. Sometimes what happens to us is due to forces we can’t control, and sometimes what happens is due to our actions, but the false thinking is in assuming that it is always one or the other. We may assume that the quality of our work is due to working with difficult people, or alternatively that every mistake someone else makes is due to something we did.
Fallacy of Fairness
We are often concerned about fairness, but this concern can be taken to extremes. As we know, life is not always fair. The person who goes through life looking for fairness in all their experiences will end up resentful and unhappy. Sometimes things will go our way, and sometimes they will not, regardless of how fair it may seem.
When things don’t go our way, there are many ways we can explain or assign responsibility for the outcome. One method of assigning responsibility is blaming others for what goes wrong. Sometimes we may blame others for making us feel or act a certain way, but this is a cognitive distortion because we are the only ones responsible for the way we feel or act.
“Shoulds” refer to the implicit or explicit rules we have about how we and others should behave. When others break our rules, we are upset. When we break our own rules, we feel guilty. For example, we may have an unofficial rule that customer service representatives should always be accommodating to the customer. When we interact with a customer service representative that is not immediately accommodating, we might get angry. If we have an implicit rule that we are irresponsible if we spend money on unnecessary things, we may feel exceedingly guilty when we spend even a small amount of money on something we don’t need.
This distortion involves thinking that if we feel a certain way, it must be true. For example, if we feel unattractive or uninteresting in the current moment, we must be unattractive or uninteresting. This cognitive distortion boils down to:
“I feel it, therefore it must be true.”
Clearly our emotions are not always indicative of the objective truth, but it can be difficult to look past how we feel.
Fallacy of Change
The fallacy of change lies in expecting other people to change as it suits us. This ties into the feeling that our happinessdepends on other people, and their unwillingness or inability to change, even if we push and press and demand it, keeps us from being happy. This is clearly a damaging way to think, since no one is responsible for our happiness except for us.
Global Labeling / Mislabeling
This cognitive distortion is an extreme form of generalizing, in which we generalize one or two instances or qualities into a global judgment. For example, if we fail at a specific task, we may conclude that we are a total failure in not only this area, but all areas. Alternatively, when a stranger says something a bit rude, we may conclude that he or she is an unfriendly person in general. Mislabeling is specific to using exaggerated and emotionally loaded language, such as saying a woman has abandoned her children when she leaves her children with a babysitter to enjoy a night out.
Always Being Right
While we all enjoy being right, this distortion makes us think we must be right, that being wrong is unacceptable. We may believe that being right is more important than the feelings of others, being able to admit when we’ve made a mistake, or being fair and objective.
Heaven’s Reward Fallacy
This distortion involves expecting that any sacrifice or self-denial on our part will pay off. We may consider this karma, and expect that karma will always immediately reward us for our good deeds. Of course, this results in feelings of bitterness when we do not receive our reward (Grohol, 2016).
Many tools and techniques found in CBT are intended to address or reverse these cognitive distortions.
You can download the printable version of the infographic here.
9 Essential CBT Techniques and Tools
There are many tools and techniques used in CBT, many of which have spread from the therapy context to everyday life. The nine techniques and tools listed below are some of the most common and effective CBT practices.
This technique is a way of “gathering data” about our moods and our thoughts. This journal can include the time of the mood or thought, the source of it, the extent or intensity, and how we responded to it, among other factors. This technique can help us to identify our thought patterns and emotional tendencies, describe them, and find out how to change, adapt, or cope with them.
Unraveling Cognitive Distortions
This is a main goal of CBT, and can be practiced with or without the help of a therapist. In order to unravel the cognitive distortions you hold, you must first become aware of which distortions you are most vulnerable to. Part of this involves identifying and challenging our harmful automatic thoughts, which frequently fall into one of the categories listed earlier.
Once you identify the distortions or inaccurate views on the world you hold, you can begin to learn about how this distortion took root and why you came to believe it. When you discover a belief that is destructive or harmful, you can begin to challenge it. For example, if you believe that you must have a high paying job to be a respectable person, but you lose your high paying job, you will begin to feel bad about yourself.
Instead of accepting this faulty belief that leads you to think unreasonably negative thoughts about yourself, you could take this opportunity to think about what makes a person “respectable,” a belief you may not have explicitly considered before.
Exposure and Response Prevention
This technique is specifically effective for those who suffer from obsessive compulsive disorder (OCD). You can practice this technique by exposing yourself to whatever it is that normally elicits a compulsive behavior, but doing your best to refrain from the behavior and writing about it. You can combine journaling with this technique, or use journaling to understand how this technique makes you feel.
This technique is intended to treat panic and anxiety. It involves exposure to feared bodily sensations in order to elicit the response, activate any unhelpful beliefs associated with the sensations, maintain the sensations without distraction or avoidance, and allow new learning about the sensations to take place. It is intended to help the sufferer see that symptoms of panic are not dangerous, although they may be uncomfortable.
Nightmare Exposure and Rescripting
Nightmare exposure and rescripting is intended specifically for those suffering from nightmares. This technique is similar to interoceptive exposure, in that the nightmare is elicited, which brings up the relevant emotion. Once the emotion has arisen, the client and therapist work together to identify the desired emotion and develop a new image to accompany the desired emotion.
Play the Script Until the End
This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment, where they imagine the outcome of the worst case scenario. Letting this scenario play out can help the individual to recognize that even if everything they fear comes to pass, it will likely turn out okay.
Progressive Muscle Relaxation (PMR)
This is a familiar technique to those who practice mindfulness. Similar to the body scan, this technique instructs you to relax one muscle group at a time until your whole body is in a state of relaxation. You can use audio guidance, a YouTube video, or simply your own mind to practice this technique, and it can be especially helpful for calming nerves and soothing a busy and unfocused mind.
This is another technique that is not specific to CBT, but will be familiar to practitioners of mindfulness. There are many ways to relax and bring regularity to your breath, including guided and unguided imagery, audio recordings, YouTube videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your problems from a place of balance, facilitating more effective and rational decision making (Megan, 2016).
These techniques can help those suffering from a range of mental illnesses and afflictions, including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without the guidance of a therapist. To try some of these techniques without the help of a therapist, see the next section for worksheets and handouts to assist with your practice.
You can download the printable version of the infographichere.
Cognitive Behavioral Therapy Worksheets (PDF) To Print and Use
If you’re a therapist looking for ways to guide your client through treatment or a hands-on person who loves to learn by doing, there are many CBT worksheets that can help.
Alternative Action Formulation
This worksheet instructs the user to first list any problems or difficulties you are having. Next, you list your vulnerabilities (i.e., why you are more likely to experience these problems than someone else) and triggers (i.e., the stimulus or source of these problems).
Once you have defined the problems and understand why you are struggling with them, you go on to list coping strategies. These are not solutions to problems, but ways in which you can deal with the effects of these problems that can have a temporary impact. Next, you list the effects of these coping strategies, such as how they make you feel in the short-term and long-term, and the advantages and disadvantages of each strategy.
Finally, you move on to listing alternative actions. If your coping strategies are not totally effective against the problems and difficulties that are happening, you are instructed to list other strategies that may work better.
This worksheet gets you (or your client) thinking about what you are doing now and whether it is the best way forward. You can find it here.
One popular technique in CBT is functional analysis. This technique helps you (or the client) learn about yourself, specifically what leads to specific behaviors and what consequences result from those behaviors.
In the middle of the worksheet is a box labeled “Behaviors.” In this box, you write down any potentially problematic behaviors or other behaviors you wish to analyze.
On the left side of the worksheet is a box labeled “Antecedents,” in which you or the client write down the factors that preceded a particular behavior. These are factors that led up to the behavior under consideration, either directly or indirectly.
On the right side is the final box, labeled “Consequences.” This is where you write down the consequences of the behavior, or what happened as a result of the behavior under consideration. “Consequences” may sound inherently negative, but they are not necessarily negative; some positive consequences can arise from many types of behaviors, even if more negative consequences result as well.
This worksheet can help you or your client to find out whether particular behaviors are adaptive and helpful in striving towards your goals, or destructive and self-defeating. Follow this linkto print out this worksheet and give it a try.
This worksheet helps you address what some CBT therapists call the “5 P Factors” – presenting, predisposing, precipitating, perpetuating, and positives. This formulation process can help you connect the dots between your core beliefs and thought patterns and your present behavior.
This worksheet presents five boxes at the top of the page, which should be completed before moving on to the rest of the worksheet.
- The first box is labeled “Precipitating Events / Triggers,” and corresponds with the Precipitating factor. In this box, you are instructed to write down the events or stimuli that provoke a certain behavior.
- The next box is labeled “Early Experiences” and corresponds to the Predisposing factor. This is where you list the experiences that you had early on, all the way back to childhood, that may have contributed to the behavior.
- The third box is “Core Beliefs,” which is also related to the Predisposing factor. This is where you write down some of the relevant core beliefs you have regarding this behavior. These are beliefs that may not be explicit, but that you believe deep down, such as “I’m bad” or “I’m not good enough.”
- The fourth box is “Old Rules for Living,” which is where you list the rules that you adhere to, whether consciously or subconsciously. These implicit or explicit rules can perpetuate the behavior, even if it is not helpful or adaptive. Rules are if-then statements that provide a judgment based on a set of circumstances. For instance, you may have the rule “If I do not do something perfectly, I’m a complete failure.”
- The final box is labeled “Presenting Problems / Effects of Old Rules.” This is where you write down how well these rules are working for you. Are they helping you to be the best you can be? Are they helping you to effectively strive towards your goals?
Below this box there are two flow charts that you can fill out based on how these behaviors and feelings are perpetuated. You are instructed to think of a situation that produces a negative automatic thought, and record the emotion and the behavior that this thought provokes, as well as the bodily sensations that can result. Filling out these flow charts can help you see what drives your behavior or thought and what results from it.
Below these two charts is the box “Protective Factors.” This is where you list the factors that can help you deal with the problematic behavior or thought, and perhaps help you break the perpetuating cycle. This can be things that help you cope once the thought or behavior arises or things that can disrupt the pattern once it is in motion.
Finally, the last box is “New Rules for Living.” This box relates to the Positive factor, in that it provides you with an opportunity to create new rules for yourself that will disrupt the destructive cycle and allow you to become more effective in meeting your therapeutic goals. Click here if you’d like to try this worksheet.
Dysfunctional Thought Record
This worksheet is especially helpful for people who are struggling with negative thoughts and need to figure out when and why they are most likely to pop up. By learning more about what provokes certain automatic thoughts, they become easier to address and reverse.
The worksheet is divided into seven columns:
- On the far left, there is space to write down the date and time a dysfunctional thought arose.
- The second column is where the situation is listed. The user is instructed to describe the event that led up to the dysfunctional thought in detail.
- The third column is for the automatic thought. This is where the dysfunctional automatic thought is recorded, along with a rating of belief in the thought on a scale from 0% to 100%.
- The next column is where the emotion or emotions elicited by this thought are listed, also with a rating of intensity on a scale from 0% to 100%.
- The fifth column is labeled “Distortion.” This column is where the user will identify which cognitive distortion(s) they are suffering from with regards to this specific dysfunctional thought, such as all-or-nothing thinking, filtering, jumping to conclusions, etc.
- The second to last column is for the user to write down alternative thoughts, more positive and functional thoughts that can replace the negative one.
- Finally, the last column is for the user to write down the outcome of this exercise. Were you able to confront the dysfunctional thought? Did you write down a convincing alternative thought? Did your belief in the thought and/or the intensity of your emotion(s) decrease? To give this worksheet a try, click here.
Fact or Opinion
One of my favorite CBT worksheets is the “Fact or Opinion” worksheet, because it can be extremely helpful in recognizing that your thoughts are not necessarily true.
At the top of this worksheet is an important lesson:
Thoughts are not facts.
Of course, it can be hard to accept this, especially when we are in the throes of a dysfunctional thought or intense emotion. Filling out this worksheet can help you come to this realization.
The worksheet includes 16 statements that the user must decide are either fact or opinion. These statements include:
- I’m a bad person.
- I failed the test.
- I’m selfish.
- I didn’t lend my friend money when they asked.
This is not a trick – there is a right answer for each of these statements. (In case you’re wondering, the right answers for the statements above are as follows: opinion, fact, opinion, fact.)
This simple exercise can help the user to see that while we have lots of emotionally charged thoughts, they are not all objective truths. Recognizing the difference between fact and opinion can assist us in challenging the dysfunctional or harmful opinions we have about ourselves and others.
If you’d like to print out this worksheet to give it a try, click here.
This worksheet employs the use of Socratic questioning, a technique that can help the user to challenge irrational or illogical thoughts.
The top of the worksheet describes how thoughts are a running dialogue in our minds, and they can come and go so fast that we hardly have time to address them. This worksheet aims to help us capture one or two of these thoughts and analyze them.
- The first box to be filled out is “Thoughts to be questioned.” This is where you write down a specific thought, usually one you suspect is destructive or irrational.
- Next, you write down the evidence for and against this thought. What evidence is there that this thought is accurate? What evidence exists that calls it into question?
- Once you have identified the evidence, you can make a judgment on this thought, specifically whether it is based on facts or your feelings.
- Next, you answer a question on whether this thought is truly a black and white situation, or whether reality leaves room for shades of grey. This is where you think about whether you are using all-or-nothing thinking, or making things unreasonably simple when they are truly complex.
- In the last box on this page, you consider whether you could be misinterpreting the evidence or making any unverified assumptions.
On the next page, you are instructed to think about whether other people might have different interpretations of the same situation, and what those interpretations might be.
Next, ask yourself whether you are looking at all the relevant evidence, or just the evidence that backs up the belief you already hold. Try to be as objective as possible.
The next box asks you whether your thought may an exaggeration of a truth. Some negative thoughts are based in truth, but extended past their logical boundaries.
Next, you are instructed to consider whether you are entertaining this negative thought out of habit or because the facts truly support it.
Once you have decided whether the facts support this thought, you are encouraged to think about how this thought came to you. Was it passed on from someone else? If so, are they a reliable source for truth?
Finally, you complete the worksheet by identifying how likely the scenario your thought brings up actually is, and whether it is the worst case scenario.
These “Socratic questions” encourage a deep dive into the thoughts that may plague you, and offer an opportunity to analyze and evaluate them for truth. If you are having thoughts that do not come from a place of truth, this worksheet can be an excellent tool for identifying and defusing them.
For more CBT worksheets and handouts, visit this website.
Some More CBT Interventions and Exercises
Haven’t had enough CBT toolsand techniques yet? Continue on for more useful and effective exercises!
These are related to thought experiments, in that you engage in a “what if” consideration. Behavioral experiments differ from thought experiments in that you actually test out these “what ifs” outside of your thoughts (Boyes, 2012).
In order to test a thought, you can experiment with the outcomes that different thoughts produce. For example, you can test the thought:
“If I criticize myself, I will be motivated to work harder” vs. “If I am kind to myself, I will be motivated to work harder.”
First, you would try criticizing yourself when you need motivation to work harder and record the results. Then you would try being kind to yourself and recording the results. Next, you would compare the results to see which thought was closer to the truth.
These behavioral experiments can help you learn how to best strive towards your therapeutic goals and how to be your best self.
Thought records are useful in testing the validity of your thoughts (Boyes, 2012). They involve gathering and evaluating the evidence for and against a particular thought, allowing for an evidence-based conclusion on whether the thought is valid or not.
For example, you may have the belief “My friend thinks I’m a bad friend.” You would think of all the evidence for this belief, such as “She didn’t answer the phone the last time I called” or “She cancelled our plans at the last minute”, and evidence against this belief, like “She called me back after not answering the phone” and “She invited me to her barbecue next week. If she thought I was a bad friend, she probably wouldn’t have invited me.”
Once you have evidence for and against, the goal is to come up with more balanced thoughts, such as
“My friend is busy and has other friends, so she can’t always answer the phone when I call. If I am understanding of this, I will truly be a good friend.”
Thought records apply the use of logic to ward off unreasonable negative thoughts and replace them with more balanced, rational thoughts (Boyes, 2012).
Pleasant Activity Scheduling
This technique can be especially helpful for dealing with depression (Boyes, 2012). It involves scheduling activities in the near future that you can look forward to.
For example, you may write down one activity per day that you will engage in over the next week. This can be as simple as watching a movie you are excited to see or calling a friend to chat. It can be anything that is pleasant to you, as long as it is not unhealthy (i.e., eating a whole cake in one sitting or smoking).
You can also try scheduling an activity for each day that provides you with a sense of mastery or accomplishment (Boyes, 2012). It’s great to do something pleasant, but doing something small that can make you feel accomplished may have longer lasting and farther reaching effects.
This simple technique can introduce more positivity into your day and help you make your thinking less negative.
Imagery Based Exposure
This exercise involves thinking about a recent memory that produced strong negative emotions and analyzing the situation.
For example, if you recently had a fight with your significant other and they said something hurtful, you can bring that situation to mind and try to remember it in detail. Next, you would try to label the emotions and thoughts you experienced during the situation and identify the urges you felt (e.g., to run away, to yell at your significant other, to cry).
Visualizing this negative situation, especially for a prolonged period of time, can help you to take away its ability to trigger you and reduce avoidance coping (Boyes, 2012). When you expose yourself to all of the feelings and urges you felt in the situation and survive experiencing the memory, it takes some of its power away.
Situation Exposure Hierarchies
This technique may sound complicated, but it’s relatively simple.
Situation Exposure Hierarchies involves making a list of things that you would normally avoid (Boyes, 2012). For example, someone with severe social anxiety may typically avoid making a phone call instead of emailing or asking someone on a date.
Next, you rate each item on how distressed you think you would be, on a scale from 0 to 10, if you engaged in it. For the person suffering from severe social anxiety, asking someone on a date may be rated a 10 on the scale, while making a phone call instead of emailing might be rated closer to a 3 or 4.
Once you have rated each item, you rank them according to their distress rating. This will help you recognize the biggest difficulties you face, which can help you decide which items to address and in what order. It may be best to start with the less distressing items and work your way up to the most distressing items.
A CBT Manual and Workbook for Your Own Practice + for Your Client
If you’re interested in giving CBT a try with your clients, there are many books and manuals that can help get you started. Some of these books are for the therapist only, and some are to be navigated as a team or with guidance from the therapist.
There are many manuals out there for helping therapists apply CBT in their work, but these are some of the most popular:
For clients or for therapist and client to work through together, these are some of the most popular manuals and workbooks:
There are many other manuals and workbooks out there that can help get you started with CBT, but these are a good start.
5 Last Cognitive Behavioral Activities
Before we go, there are a few more CBT activities and exercises that may be helpful for you or your clients that we’d like to cover.
As readers of this blog will likely know by now, mindfulness can have a wide range of positive impacts, including helping with depression, anxiety, addiction, and many other mental illnesses or difficulties.
Mindfulness can help those suffering from harmful automatic thoughts to disengage from rumination and obsession over these thoughts by helping them stay firmly grounded in the present.
This is a somewhat fancy name for a simple idea that you have likely already hear of: breaking up large tasks into small steps to make it easier to accomplish.
It can be overwhelming to be faced with a huge goal we would like to accomplish, like opening a business or remodeling a house. This is true in mental health treatment as well, since the goal to overcome depression or anxiety and achieve mental wellness can seem like a monumental task to those who are suffering from severe symptoms.
By breaking the large goal into small, easy to accomplish steps, we can map out the path to success and make the journey seem a little less overwhelming.
Writing Self-Statements to Counteract Negative Thoughts
This technique can be difficult for someone just beginning their CBT treatment or suffering from severe symptoms, but it can also be extremely effective (Anderson, 2014).
When you (or your client) are being plagued by negative thoughts, it can be hard to confront them, especially if your belief in these thoughts is strong. To counteract these negative thoughts, it can be helpful to write down a positive, opposite thought.
For example, if the thought that you are worthless keeps popping into your head, try writing down a statement like “I am a person with worth” or “I am person with potential.” In the beginning, it can be difficult to accept these replacement thoughts, but the more you bring out these positive thoughts to counteract the negative ones, the stronger the association will be.
Visualize the Best Parts of Your Day
When you are feeling depressed or negative, it is difficult to recognize that there is good in your life as well. This simple technique of bringing to mind the good parts of your day can be a small step in the direction of recognizing the positive (Anderson, 2014).
All you need to do is write down the things in your life that you are most thankful for or the things that are most positive in your day. The simple act of writing down these good things can forge new associations in your mind which make it easier to see the positive, even when there is plenty of negative as well.
Reframe Your Negative Thoughts
It can be all too easy to succumb to negative thoughts as a default setting. If you find yourself immediately thinking a negative thought when you see something new, such as entering an unfamiliar room and thinking “I hate the color of that wall,” give reframing a try (Anderson, 2014).
Reframing involves countering the negative thought(s) by noticing things you feel positive about as quickly as possible. For instance, in the example where you immediately think of how much you hate the color of that wall, you would push yourself to notice five things in the room that you feel positively about (e.g., the carpet looks comfortable, the lampshade is pretty, the windows let in a lot of sunshine).
You can set your phone to remind you throughout the day to stop what you are doing and think of the positive things around you. This can help you to push your thoughts back into the realm of the positive instead of the negative.
You can download the printable version of the infographic here.
A Take Home Message
As always, I hope this post has been helpful. There are a lot of great tips and techniques in here that can be extremely effective in the battle against depression, anxiety, OCD, and a host of other problems or difficulties.
However, as is the case with many treatments, they depend on you (or your client) putting in a lot of effort. I would encourage you to give these techniques a real try, and allow yourself the luxury of thinking they may actually work. When we approach a potential solution with the assumption that it will not work, then it will probably not work. When we approach a potential solution with an open mind and the thought that it just might work, it has a much better chance of succeeding.
So if you are struggling with negative automatic thoughts, please consider these tips and techniques and give them a real shot. Likewise, if your client is struggling, encourage them to make the effort, because the payoff can be better than they can imagine.
If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:
- USA: National Suicide Prevention Hotline at 1-800-273-8255
- UK: Samaritans hotline at 116 123
- The Netherlands: Netherlands Suicide Hotline at 09000767
- France: Suicide écoute at 01 45 39 40 00
- Germany: Telefonseelsorge at 0800 111 0 111 for Protestants, 0800 111 0 222 for Catholics, and 0800 111 0 333 for children and youth
For a list of other suicide prevention websites, phone numbers, and resources, see this website.
Please know that there are people out there who care and that there are treatments that can help.
Thank you for reading, and please let us know about your experiences with CBT in the comments section. Have you tried it? How did it work for you? Are there any other helpful exercises or techniques that we did not touch on in this piece?
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- Anderson, J. (2014, June 12). 5 get-positive techniques from Cognitive Behavioral Therapy. Everyday Health. Retrieved from http://www.everydayhealth.com/hs/major-depression-living-well/cognitive-behavioral-therapy-techniques/
- Boyes, A. (2012, December 6). Cognitive behavioral therapy techniques that work: Mix and match Cognitive Behavioral Therapy techniques to fit your preferences. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/in-practice/201212/cognitive-behavioral-therapy-techniques-work
- Grohol, J. (2016). 15 common cognitive distortions. Psych Central. Retrieved from https://psychcentral.com/lib/15-common-cognitive-distortions/
- Martin, B. (2016). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
- Megan, R. (2016, August 8). List of CBT techniques – cognitive behavioral therapy. Info Counselling. Retrieved from http://www.infocounselling.com/list-of-cbt-techniques/
- www.webmd.com - http://www.webmd.com/depression/guide/cognitive-behavioral-therapy-for-depression#1
About the AuthorCourtney Ackerman is a graduate of the positive organizational psychology and evaluation program at Claremont Graduate University. She is currently working as a researcher for the State of California and her professional interests include survey research, well-being in the workplace, and compassion. When she’s not gleefully crafting survey reminders, she loves spending time with her dogs, visiting wine country, and curling up in front of the fireplace with a good book or video game.
Broder, M. Making Optimal Use Of Homework To Enhance Your Therapeutic Effectiveness. Journal of Rational– Emotive & Cognitive-Behavior Therapy, Volume 17, Number 1, Spring 2000.
MAKING OPTIMAL USE OF HOMEWORK TO ENHANCE YOUR THERAPEUTIC EFFECTIVENESS
Michael S. Broder
Homework is a well-established yet extremely under-emphasized aspect of the Rational-Emotive/cognitive behavioral orientation. This article recognizes homework as being a very powerful tool that needs to be incorporated into treatment in order to make it more efficient and effective. The author presents numerous techniques that can be used with virtually any therapeutic approach to maximize the impact of therapy between sessions. They include audio and bibliotherapy, goal setting, SUD Scale, mood management, disputation, affirmations, mood diary, list making, guided imagery, visualization, relaxation and meditation techniques, exposure, and thought stopping techniques. The article concludes with a discussion of why clients display resistance to homework along with some approaches that can be taken to address this resistance.
The use of homework in psychotherapy is a well-established protocol of the Rational-Emotive/Cognitive Behavioral orientation and one of Albert Ellis’ many great contributions to the field. Trademark homework assignments include reading, forms of exposure to an anxious situation, making a decision, and taking a risk such as confronting someone or something more easily avoided (Ellis, 1962; 1996).
Homework empowers our clients to make and see progress on their own. To a great degree, homework can enable your client to become your collaborator in their treatment. Homework can also help you to assess your client’s motivation. After all, if you get an agreement to do a certain type of homework and at the next session it is not done, that can tell you much about a client’s motivation. And one area where most therapists agree is that a client’s level of motivation is one of the greatest predictors of whether treatment will be successful. Yet in most REBT and Cognitive Behavioral literature, homework remains quite underemphasized.
Homework can also be a great focusing tool. But only if it is clear, specific, measurable and doable. “Clear” means that you and your client are on the same page as to what the homework assignment involves; for example, what reading to do or whom to confront. “Specific” means that the homework assignment zeros in on your client’s problem in such a way that its relevancy is obvious to both of you. For example, if you were to assign as homework a relaxation exercise, there would be, hopefully, no question about the relationship between that assignment and the issues you are working on in therapy. “Measurable” means that both you and your client can objectively evaluate the extent to which the assignment was completed so there is no question as to what you mean when you ask if the reading was done or if the list was made. An assignment that is “doable” is one that can be completed by the client. In other words, its outcome depends only on the actions taken by the client and not necessarily on the agreement and! or cooperation of others. An example of a bad homework assignment would be to have the client agree to get a job or to get a date. Instead, you might encourage your client to send out a certain number of resumes or to approach an agreed upon number of people for a date. In these examples of homework, no one else’s agreement is necessary for your client to complete the assignment successfully. On the other hand, getting a job or a date requires the compliance of someone other than the client.
The main premise of homework is a recognition that real changes occur outside your office, not inside your office. In that spirit, I believe that work done by clients between therapy sessions is often as or more important as what is done in the session itself. The main challenge is to make homework as relevant and user-friendly as possible. Homework assignments need to be designed using the principle of successive approximation making sure that the step or steps assigned to be taken are not too large or too small, especially when you are dealing with difficult clients or AXIS II cases.
My personal preference is to have clients spend at least as much time doing homework as they spend in therapy. This is not an absolute or even an optimal amount, but a minimum guideline that I will generally discuss with each client. Another guideline is for you, the therapist, not to work harder than your client. All of us who have done therapy for any length of time know that this can be easier said than done, especially with some of Your more difficult cases. However, this is still a worthy goal.
In this article I offer a smorgasbord of ideas designed to help you do what you do more effectively by making maximum use of the 167 hours in between sessions as well as the therapy hour itself.
Here are a variety of techniques that you can use to engage your clients in between sessions. I will give a flavor for how they can be used as homework assignments with the understanding that they need to be tailored and fine-tuned to suit the Particular needs they are designed to address.
TECHNIQUES THAT CAN BE USED IN BETWEEN SESSIONS
Bibliotherapy and Audiotherapy
Bibliotherapy is assigned reading that is specific to the issue that you are working on in treatment. Few would dispute that the right reading is a great tool; provided, of course, the client does the reading. There are many sources of good and relevant reading information that is available to address virtually any issue (Ellis, 1993). The main problem with bibliotherapy is that clients are not as likely to read as they are to use approaches that require less effort. In addition, different people read and comprehend their reading with considerable variation. Another consideration is that most self-help material is oriented toward women. This is because publishers have long recognized that women out-buy men by a margin of more than four-to-one in the category of bibliotherapy_ type (self, help) materials (Holm, 1998).
One of the best ways to address these bibliotherapy problems is by using audiotherapy or assigning clients to listen to appropriate audiotapes that reinforce the material covered in your session in between sessions_ I have found that audiotherapy is more effective than its bibliotherapy counterpart simply because people are way more likely to listen than to read. If a tape is one-hour long, it will take everyone regardless of his Or her skill level one hour to listen to it_ Also, self-help audiotape publishers. have found that men are as likely some cases more likely) to listen, as are women. In addition, both men and women can listen to audiotherapy assignments while driving cars, exercising or walking, and at other times when they mao the mood to take on one more activity-such as listening not distract them from what they are doing. Proper listening as reading) provides the repetition of information that can h malize the issue(s) they are working on, as well as a reinforce of what is being said and worked on in treatment. When us assigned correctly, audio therapy goes a long way to free the hour so that you may concentrate on resistance and other issue5 more unique to your client.
Repetition is an important aspect of teaching difficult info In my experience, an overwhelming number of clients are more to listen again and again to get that needed repetition than the~ read and reread bibliotherapy material.
For example, if self-evaluation is the issue, they need to learn in the session and by virtue of the homework they are assign whenever they engage in global rating as “I am no good,” an generalization is taking place (Broder, 1995). Then your client disputation and other cognitive restructuring techniques as mo vant.
Clients who are going through major changes need to learn t. and doubt is quite normal, while generally not desirable. Client are working on relationships and sexual issues need to unde~_ that many myths can cause dysfunction. For example, the m in a good relationship orgasms are simultaneous and automatic very dysfunction-causing (Broder, 1996). Where better can a learn that these myths could explain why they may negate sex doing reading or listening to material that makes these points to force what they have learned in their therapy sessions.
Sometimes the easiest part of therapy is communicating info and misinformation about an issue, but at the same time it can one of the most time-consuming parts of treatment. Many thera have trained and supervised over the years have confided that th . tired of going over the same points with client after client after and, therefore, find that they develop a tendency to avoid doing remember the function of biblio- and audio therapy is to give that mation that you the therapist may take for granted, to encourage tition of it, and to reinforce what you are teaching and working the session. Thus, audio- and bibliotherapy can be considered a e ine form of mentoring.
There are several other audiotherapy approaches you can employ.
Many therapists make up relaxation tapes for their clients as well as tapes on other topics. Another fine technique is to encourage your clients to tape their therapy sessions for re-listening. This can be done by bringing their own tape and tape recorder to therapy sessions. They keep the tapes to listen to, perhaps, several times in between sessions. This is a practice that can be quite helpful in getting clients to hear much of the things they “know intellectually” but need to learn on an emotional level. Repetition of this type is one excellent way to achieve a breakthrough with hard-to-integrate material. An often helpful follow-up to this approach is to give your client a short (but expected) “quiz” on things that were said during the previous session, based on the tape they produced in therapy and, hopefully, listened to in between sessions. Finally, there are many audiocassette programs that can be used for audiotherapy purposes. Over the past few years I developed a series of audiotherapy programs that incorporate numerous techniques into a series of self-contained homework assignments with reproducible exercise worksheets which I call The Therapist’s Assistant (Broder, 1995; 1996). This series was edited by Albert Ellis and is one of many resources at your disposal.
Covering all the steps and ramifications of goal setting and goal prioritizing is often impossible to do within the time constraints of a therapy session. Yet, it is an extremely important step in the therapeutic process. So having your client work on goals-whether or not they were goals established during your session-is a great use of homework time. This includes identifying all the important aspects of the goals-all of the Who, What, When, Where and Why questions. A basic goal-setting homework assignment exercise will have the client come into the next session with answers to all of these questions: What is the goal? What do you want to accomplish by reaching it? Who is it that can be involved in this besides you? That is, who, if anyone, can help you achieve it? When do you want it accomplished by? Where is it to take place? And most importantly, why do you want to achieve this goal anyway? Once your client’s issue or reason for being in therapy is defined and fine-tuned, then the goal (what the situation would be if that issue were resolved) needs to be just as finely tuned.
The next step in goal setting is to think about and write out a strategy or plan which is defined as the shortest route between Point A (the issue) and Point B (the goal); and then, lining up whatever support is needed to achieve the goal becomes the next homework step. This can be done at home; and is also excellent material for your next session.
When there are many goals, prioritizing them is important; and goal prioritizing is also an excellent homework assignment. For example, consider a client who has lost his job and presents with a multitude of therapeutic issues. He may be depressed, feel a lack of direction, be experiencing a low level of self-confidence, and be nervous about a job interview. You have a litany of presenting problems: depression, the self-evaluation problem, you may have to help him deal with what his choices are with respect to which career moves are next. There might also be performance anxiety about taking the job interviews, anger at the boss who let him go, and marital problems at home as a result of all those things all triggered by this crisis. So finding out where the most energy is by having your client prioritize those issues and goals is a very important step. Doing this as homework can afford your client the quiet introspection this task deserves.
As a part of goal setting, it is also helpful to have your client break each defined goal into manageable steps or sub-goals. For example, there may be several smaller goals that are necessary to reach before taking that first job interview. After all, pushing your client to go right for something that may be perceived as extremely anxiety-producing such as (in this case) a job interview could be quite an approximation error that results in avoidance or a setup for failure. So the sub-goals are smaller steps that can be defined and attempted between sessions. They are ripe for discussion at your next session.
The SUD Scale (Wolpe, 1991) is an excellent way of teaching your client to quantify his or her feelings. SUD is an acronym that stands for Subjective Units of Distress (discomfort or disturbance). It measures the degree of intensity of a particular feeling or reaction on a scale of zero to ten. If you were measuring anxiety, for instance, “zero” would be no anxiety at all. A SUD of “one” would be a very small degree of anxiety whereas a “ten” would be an extreme amount of anxiety.
This can certainly be used for a variety of applications during your session. But an effective homework assignment is to haveyour clients create a customized anxiety barometer by having them identify on the scale of zero to ten something that would help trigger each level of anxiety they could feel. For example, a SUD barometer for anxiety could look like this:
Level One. While sunbathing a rain cloud appears
Level Two. Being a little bit late for dinner reservations Level Three. Having to send food back to a restaurant Level Four. Getting caught in traffic jam
Level Five. Having a flat tire while in a rush
Level Six. Asking someone you find attractive out for date while there is a real chance of being turned down
Level Seven. Waiting outside the boss’ office when there is a possibility of being fired
Level Eight. Speaking to a large and intimidating audience
Level Nine. Waiting to hear a medical report that is potentially life-threatening
Level Ten. Driving a car that is swerving out of control toward an embankment
This is just one example of an anxiety barometer. As a homework assignment, I routinely have clients who talk about anger, depression, anxiety or guilt start keeping track of just how angry, anxious, depressed or guilty they feel during the week by identifying what their potential range of the emotion is. You will find this particularly helpful, for instance, with depressed clients who negate their progress whenever the slightest twinge of depression appears, even though they may have been depressed at an eight or nine when they first started to see you and are now down to perhaps a three or four. This is quite a significant change, but if they have the tendency to negate their progress, it may be difficult for them to keep their own perspective on how far they have come without using something like a SUD Scale to keep track of their depression at home.
You can also determine together at which SUD level it might be most appropriate for your client to approach a threatening situation. For example, in the case of the client who has lost his job and is in the process of readying himself for another job interview, you may be able to collaborate and establish a target level for anxiety on the SUD Scale as the optimal point at which he would be ready to commit to actually start taking job interviews. This approach is especially indicated for someone who has demonstrated a tendency to be characteristically avoidant. It can also be used in conjunction with several of the homework techniques to be discussed later in this article.
Mood management is teaching a client how to anticipate and then master a mood-when it occurs-instead of becoming overwhelmed by it. This can be used for feelings of anxiety, depression or virtually any other kind of mood situation. The first step with mood management is to have clients identify their internal triggers to the mood and then learn to see beyond them. In other words, clients need to ask themselves “What would be my situation if I could truly master this mood?” Next, clients can learn to work both during the session and at home to develop some strategies that can be employed when finding themselves in circumstances that will predictably trigger the mood. Then, by using mood-changing techniques at the appropriate moment such as certain breathing and posture exercises, they can learn a degree of empowerment over their moods.
One of my favorite mood management exercises that employs numerous techniques you can use as homework is called the “emotional fire drill” (Broder, 1992), where I have clients anticipate-that is, identify and visualize a dreaded situation (e.g., a job interview, asking someone out for a date, or giving a talk to a large intimidating audience). I ask them to imagine the situation going first the best possible way; and then to imagine it going the worst possible way. In so doing, clients can come to anticipate that in between the two extremes generally lay the reality. An emotional fire drill can be done several times a day as a way of rehearsing for an adverse situation and learning how to handle the emotion or emotions so that they in and of themselves don’t become the dreaded situation. Thus, the emotional fire drill technique helps clients to acknowledge and learn at the crucial time they need to know it, the fact that quite often it is their emotional reaction-often the discomfort anxiety-that is dreaded way more than the trigger itself.
Disputation is perhaps the most well-known and widely used classic staple of REBT (Ellis, 1962). Disputations are generally questions that you can ask clients or, in the case of homework, clients can ask themselves. The task here both in therapy sessions and as homework is to teach clients to challenge their own irrational beliefs identified both in and out of the session.
I often have clients come up with and make lists at home of new disputations for material discussed at the last session. These client created disputations can be used whenever the situation calls for it. An example of a disputational question is “How does falling off the wagon mean that I can’t stay sober?” If a client believes “People who divorce are losers,” a disputation question might be: “If I heard that for the first time today, would I believe it?” For clients who believe that their childhood has doomed them to a life of unhappiness, they need to learn to ask themselves-between sessions-“If I had perfect parents and the best childhood of anyone I know, how would I handle (fill in the blank) differently?” This gets them into the habit of first examining and then cross-examining their own errant thinking. A client who believes “My situation won’t improve,” needs to ask, “How do I know that?” “Is that what I would tell someone I really care about who is in the same predicament?” “If not, what would I advise?” The answer to these disputation questions might prompt you to assign the client as homework to make a list of things they would advise their children to do in that situation; and you will often see an entirely different level of wisdom come out.
Effective affirmations are both coping statements and rational beliefs. Something that I have clients do on a routine basis at home is to make lists of their affirmations or coping statements and then look at them several times a day, even when they are not especially feeling the need to. Learning an affirmation on a deep emotional level involves not only looking at it when they are troubled by the issue, but also when they are in a more neutral or positive frame of mind. Coping statements reinforce the notion that poor self-evaluation and low frustration tolerance, and so forth are merely thinking habits. One big advantage to clients of seeing problems as thinking habits is simply that most people acknowledge that habits can be changed. This notion is a much harder sell when clients believe they are dealing with traits instead of habits.
Any time your client says something like “I never thought of it that way” as an answer to a disputation, whatever it is that they have just thought about differently is an excellent addition to their list of affirmations to be studied and reviewed at home. Some other examples of affirmations include, “I don’t have to lose my temper when I’m angry,” “I can handle this,” “I can stand it” (whatever one’s unique “it” may be), “Failing at a task does not make me a failure,” “I don’t have to give into my cravings for (fill in the blanks),” and “These cravings will pass.” It can be very helpful for your clients to put their affirmations on index cards and keep them handy for those times during the week when they are in the mood or simply ready to learn and re-learn this information.
A mood diary is a written record of moods kept by the client between sessions. It can be quite helpful in identifying triggers for anxiety, anger and depression. For example, a well-kept mood diary used for anger management might contain the following information:
What triggered the angry feelings?
What am I telling myself about the trigger?
A rating of the feeling on that SUD Scale of 0 to lO?
Was my angry response to the situation helpful or harmful?
Was it really worth all the attention or energy that I expended to become enraged?
Was there anything I really could have done to make those things that triggered my anger different?
If I had it to do all over again, how would I react now?
How would I advise someone else I really cared about to react or respond in this or another similarly upsetting situation?
What could have been a response that would have disarmed me if I had acted the way my opponent did?
I generally instruct clients that we do not have to spend a great deal of session time with the details of their mood diary, since it is the triggers and patterns that are most important for us to focus on in their sessions. Still, some clients will have a need to go over their entire diary in great detail during the sessions. This is all quite negotiable, but once they begin and continue to keep their mood diary at home, a lot of the dynamics of their moods will become obvious to them.
Making lists is really a way of self-brainstorming. As homework, you can have clients make any number of lists such as “All the people who care about me,” “Things I am proud of,” “Things I can do to feel better when I’m tense,” or “A list of everything that is bothering me” (including every problem, then rank them in order as though they were totally independent of each other), then a “List of solutions.” They can refer to these lists when they are feeling isolated, lonely or depressed. If you work with single clients who believe that they can only be happy if they are in a relationship, have them make a list entitled “Twenty things I now avoid that I would be doing if I were in an ideal relationship.” They will be surprised to see that most of them can be done in one form or another either alone or with a member of their support group right now. I like long lists better than short lists because long lists challenge clients to really think. Using the analogy of exercise, I explain that the pushups one does at the very end of the set are the most beneficial ones. Encouraging clients to get beyond the things they normally think of makes the lists most helpful. And in between sessions is when they have the time to do this activity the most justice.
Another favorite list of mine to assign is “If I could do it all over again go back to age 18 or high school or when single or when married, and so on, (or whatever the hindsight-driven case may be)-what would I now do differently?” (and list twenty or more things). They will find once again that most of the entries on their list can be done in some form now. This particular exercise often helps clients to rediscover their passion while reducing their need to obsess about the past.
Guided imagery techniques such as Rational Emotive Imagery (Ellis, 1962) can be extremely powerful tools for you to teach clients to do at home. They stimulate client’s affectivity through suggestions that create imagined situations rich in therapeutic material.
You can make an imagery tape during the session of your voice that is tailored especially to clients’ issues for them to hear in the session and then re-listen to at home during the week. For example, you can have them imagine a very safe place, or becoming some other person in an interaction where they are having difficulties. If you use behavioral contingencies, you can use imagery to help them produce a list of pleasant images, such as touch or lying on a beach or a warm water effect; or unpleasant images such as loud noise, pain, rodents, or something they identify as being more specifically unpleasant. After awhile, they will begin to use these skills with very little difficulty.
One great advantage you have with audiotherapy is that the tape can actually become the therapist. Additionally, on the tape you can change the entire approach from a didactic to an experiential one. This is ideal for guided imagery between sessions. With guided imagery, you can introduce a trigger or create any situation you would as previously described with the emotional fire drill. For example, clients can create situations that may depress them on the O-to-10-SUD Scale at a nine or ten. You can then teach them how to use various mood-changing techniques to quickly reduce their feelings of depression down to a one or two. And this can be practiced over and over again at home.
A sister technique to imagery is visualization where clients visualize going to some desirable or undesirable endpoint and in their mind’s eye and then work backwards to the present. You can help your clients create a situation that would exist on the other side of the obstacles they are now facing. For example, a client feeling a great deal of anxiety about giving a talk can visualize getting a standing ovation after a superb speech.
If you are working with someone who is ending a love relationship, you can have him or her imagine themselves five years from the present with all of the emotional and practical issues now on the table, having been resolved. You can then help them to come up with a vision of what their situation might be at that blissful time five years hence. From that endpoint, you can work backwards to where they are now. If done well, the result can be a very viable set of goals and plans to get to that visualized endpoint. That is a time projection technique that combines visualization with goal setting and can be done in your office or completed at home with the exercise on tape.
Yet another variation of this technique that can be assigned as homework is to have your clients look ahead and ask “What would I do differently in my life if I had an unlimited amount of self-confidence?” Once completed, clients would then make a list of every possible answer to that question after thoroughly seeing themselves in that much improved state. If any of these visions get too difficult to do in between sessions, chances are they bring up a lot of material that is worth revisiting in the next therapy session with your help in getting through the obstacles encountered.
Relaxation and Meditation Techniques
There are many relaxation and meditation approaches clients can use in between sessions when they are anxious or stressed (Broder, 1993). Many are even available on tape. One very simple meditation technique you can teach your clients without any external props is for them to get into a comfortable posture, and with their eyes closed to think of the word “calm” while inhaling and the phrase let go on the exhale. The purpose of this is to teach clients to bring their relaxation response under their own control. This can be done for any length of time.
A more direct relaxation homework technique is (again with eyes used) for clients to count backwards from ten to one, telling themselves that at the count of one they will feel completely at peace, totally relaxed and that this relaxed state can be maintained for as long – they choose. For clients to return to an alert state, they can be instructed to count forward from one to five. At the count of five, they will be back to the present bringing the relaxation exercise to an end.
This is practiced on a daily basis-once, twice or three times a day they will soon master their relaxation response and will be able to use – practically any time as an on-the-spot technique at the first signs of stress or anxiety.
Exposure is a well-tested procedure of choice to help clients confront an anxiety-provoking situation. By using exposure properly, clients earn to hold their own feet to the fire. To avoid an approximation error (taking steps that are too big resulting in failure), it is often wise ~o use imagery, visualization and other types of rehearsal before clients actually confront in-vivo the “dreaded” situation. Getting to this step is usually an advanced goal of therapy. By this stage, clients are ready to attempt the job interview or get into the elevator (if that is ~hat the anxiety is about) or, perhaps, to face another situation which has been long-feared. For example, if you are dealing with single clients with loneliness issues who are dreading Christmas, New Year’s eve, Valentine’s Day, their birthdays, or even a Saturday night, you can teach them to face that situation head-on with the goal of finding the formula to turn it into a positive situation, or at the very least to prove to themselves that they need not fear those occasions because they can stand (though may not like) them. Clients can benefit from assignments such as going alone to a nice restaurant, to the ballet, to a wedding or to someplace where they have repeatedly felt they could not bear to be unless they were with some special person. A good attitude to teach them is the realization that if the exposure exercise goes better than they thought, that progress has obviously been made. But if older fears are realized, it is still a no-lose situation since they have taught themselves the valuable lesson that they can handle themselves even if they did not particularly enjoy themselves. This insight greatly lessens their fear in performing the behavior again.
Thought-stopping techniques are very effective ways of reinforcing the notion that certain negative emotions may merely be unwanted thoughts that you can learn to control (Beck et aI., 1979). A thought stopping technique is anything that interrupts the pattern or intensity of an unwanted thought. Physical activity such as exercise is often effective. The old rubber band technique where whenever clients begin to experience an unwanted thought a rubber band around their wrist is snapped, giving them a very small amount of quite harmless pain. Thinking about yelling aloud to oneself the word “stop” at the right moment can also interrupt irrational thinking. As well, clients can make a list of things that can be distracters, such as music or anything that will interrupt their negative thought process.
HOMEWORK RESISTANCE: CAUSES, CURES
What can you do with clients who do not complete agreed-upon homework assignments? The answer often lies in the very resistance to change that could be behind practically all of their therapeutic issues. Consider some of these possibilities: Perhaps, some of your homework assignments are too difficult and need to be more carefully fine-tuned. Have your “overly compliant” clients agreed to do more than they were able? Do your clients fully understand the benefits of doing homework? For example, it is possible that the rationale and importance of working on their issues between sessions has not been fully communicated. Are your clients’ non-compliance merely examples of some of the biggest reasons they are in treatment in the first place? For instance, extreme discomfort anxiety-where the issue is short-versus long-term gain-could be the saboteur in many areas. In the short-term, it may be much easier for some of your clients to avoid the immediate pain of change than to challenge themselves with the promise of reward. Likewise, for many discomfort dodgers, it is much easier in the short run to avoid doing the homework, even though in the long run the changes they are seeking in therapy may not be forthcoming. Chances are once you have identified this strand of resistance it will be related to the cause of the presenting problem itself as well as to the resistance to doing whatever it takes to resolve it.
Extremely poor self-evaluation is another possibility for clients failing to complete homework assignments. These clients may be saying to themselves that they are so ineffectual and hopeless that no matter what they do their feelings, circumstances and life will not change anyway. The issue here is hopelessness and helplessness and all the Pandora Boxes to which those issues lead. In these cases, smaller steps resulting in some success are usually called for.
Another factor that can undermine homework compliance is that of a higher order disturbance. Some clients resist solving the presenting problem because they unconsciously anticipate that the solution of one problem will trigger even more serious problems. For example, clients who resist assignments that will help them to become emotionally free of an ended love relationship, may already be fearing and thus avoiding what they have identified as the next logical step the fear of rejection in developing a new relationship. In other words, the presenting problem could merely represent what I have long called a comfortable state of, discomfort.”
With that in mind, here are some simple strategies you can employ immediately to make homework more of a staple in your treatment protocol:
Communicate the importance of homework as early in treatment as possible with emphasis on its benefits to your client.
If your sessions are limited, space them out in such a way as to make treatment as effective as possible by giving ample time to complete homework assignments and exercises. If you do that, make it clear that if your client runs into difficulty additional sessions can be scheduled. Make sure your client understands that sessions are precious commodities.
Give lots of feedback and positive reinforcement when it becomes apparent that homework was completed.
Help your client see how therapy supplements what is being done in between sessions as well as the reverse.
Use both positive and negative contingencies to shape the completion of homework assignments.
Begin sessions by following up on homework assignments. I have found this strategy to be quite helpful in staying focused on one issue at a time. By not following up, homework may be perceived by clients as not being very important. In addition, following up gives you a built-in opportunity to reinforce whatever progress has been made in between sessions.
When you teach clients to do homework you are also teaching them relapse prevention. Those same skills they have mastered in doing homework assignments are the very skills they will need to call upon when the process of life tests them, as it will, over and over again.
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