Topic 5: Behavioral Activation & Automatic Thoughts {by 10/10}

[Behavioral Activation] – Watch MDD-8: Behavioral Activation – Reviewing Completed Daily Activity Schedule (also includes Graded Task Assignment).  Answer the following: (1) What additional questions would you ask Mark about his Daily Activity Schedule to assist you in moving forward with additional Daily Activity Schedules and future techniques with his negative automatic thoughts and maladaptive behaviors (see Table 6.5).  In other words, what additional information do you want to know? (2) What automatic thoughts (or core beliefs) do you think warrant further attention moving forward with more cognitive techniques?

 

[Automatic Thoughts] – There are multiple readings due over the past two weeks (J. Beck – 4 Chapters; Volungis – 1 Chapter).  For this discussion, share at least one main thought: (1) What are some potential challenges you may encounter as a therapist when attempting to modify a client’s negative automatic thought (consider the key components/strategies used to elicit and modify negative automatic thoughts)?  Your original post should be posted by the beginning of class 10/10.  Have your two replies posted no later than 10/12.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

23 Comments (+add yours?)

  1. Zacharie Duvarney
    Oct 06, 2019 @ 14:52:55

    Behavioral Activation
    1.
    Considering that Mark seems to internalize failures, I would ask him how failing to complete the activity schedule (partially or completely) would affect him. As is evident from his discussions regarding work, Mark seems to internalize negative events despite evidence the failures were caused by external variables. Therefore, if Mark were unable to complete certain activities, it would be advantageous for him to recognize what is and what isn’t within his locus of control. Should external variables prevent Mark from completing certain tasks, we wouldn’t want him to internalize these events.
    Before beginning the activity schedule, it would be wise to ask Mark what activities he feels he has the highest potential to complete. Essentially, we don’t want to set Mark up for failure. Also, considering Mark is depressed, he may benefit from completing activities that bring him high levels of pleasure (as opposed to high levels of accomplishment). Obviously, Mark would benefit from completing tasks that are both enjoyable and rewarding, however, pleasurable activities are better at combating depression.
    Information regarding Mark’s support networks may be useful in helping him complete his activity schedule goals. If the support of others within Mark’s life can be enlisted to help him complete tasks, this increases his chances of success. For example, Mark seems to experience some negative feelings around his inability to spend more time with his girlfriend. Perhaps discovering how his girlfriend can assist in this endeavor may improve his ability to succeed.

    2.
    Mark expresses negative automatic thoughts surrounding his responsibilities at work. He states that recruitment causes him a great deal of stress. When asked about this, Mark states he fears he isn’t performing well in his position. He internalizes much of the difficulties regarding recruitment, despite many of the difficulties resulting from external factors. These automatic thoughts may be derivative of underlying core beliefs of incompetence (e.g. “I am incompetent”). Therefore, future sessions may want to focus on possible core beliefs surrounding incompetence.
    Mark seems to express this reoccurring theme of self-doubt across multiple sessions. He experiences much anxiety around planning events (e.g. spending time with his girlfriend) and competing tasks (e.g. waking up in the morning, recruitment at work, etc.). Consequently, it may be assumed that Mark often has negative automatic thoughts due to a fear of failure. These automatic thoughts should be the focus of future sessions, as they prevent Mark from completing various tasks.

    Automatic Thoughts
    1.
    A myriad of complications can arise when attempting to modify automatic negative automatic thoughts. Challenges can present for both the client and therapist. It is imperative to recognize these potentials challenges for the sake of providing best practice.
    Volungis (2019) states that clients may struggle to identify and articulate their automatic thoughts. In this circumstance, it may be helpful to ask questions about their physiological arousal. In doing so, one can elicit responses like those felt during the triggering event. By eliciting these responses, clients may be able to make associations between their physiological arousal and the triggering event, which can help them better explain their automatic thoughts.
    Clients may also experience difficulties in recalling details about triggering events. Identifying triggering events is an essential component in labeling negative automatic thoughts. Therefore, the client and therapist can engage in role play to reenact the triggering event. Often, this can assist the client in remembering finer details.
    Another common struggle for clients is difficulty in distinguishing between thoughts and emotions. Negative automatic thoughts often go unnoticed, however, the unpleasant feelings they create are often noticed. Consequently, clients often confuse distressing emotions with negative automatic thoughts. Therapists can employ psychoeducation using the cognitive model to help clients learn to differentiate between thoughts and emotions. It is advantageous to use real life examples pertinent to the client when discussing the cognitive model. It may also be helpful to explain to clients that automatic thoughts are often described in full sentences (e.g. “My friend doesn’t really like me”), whereas emotions are often one word (e.g. sad).
    Therapists can struggle to identify which negative automatic thoughts are important to focus on and modify, and which are irrelevant. Clients will typically experience many negative automatic thoughts, so the task of identifying which automatic thoughts are most concerning can be daunting. Volungis (2019) suggests having the client rate their emotional intensity related to each automatic thought. In doing so, the therapist can figure out which automatic thoughts cause the most distress.
    Beck (2011) and Volungis (2019) both identify various classifications of automatic thoughts, which are based on validity and utility. According to these models, some automatic thoughts are valid (the client’s interpretation is accurate) and the conclusions drawn are also accurate. Therefore, these negative automatic thoughts cannot (and likely should not) be modified, as they are rational thoughts. Obviously, this is challenging, as rather than focusing on modification, the therapist must now help the client with emotion-focused coping and acceptance.

    Reply

    • Olivia Corfey
      Oct 08, 2019 @ 11:49:54

      Behavioral Activation

      1. Mark tends to internalize failures and externalize or minimize successes. Due to Mark’s belief that most failures are within his internal locus of control, it may be insightful to gain information or identify potential external factors that are influencing mark’s daily life (e.g. work related stressors and friend’s canceling). This may shed light into Mark’s personalization of external stressors leading to negative automatic thoughts and maladaptive behaviors. I would also want to know more about Mark’s intensity of his emotions and the believability of his thoughts. For example, Mark wrote that he was angry with himself that he was still a little rushed in the morning. Although, later he realizes that this was more of a reaction in the moment. Additionally, Mark still experienced pleasure in the activity. Understanding more about the consistency of intense emotion based on Mark’s desire for perfection may give insight into the pattern of thoughts that spark these intense emotions. In addition, I would also want to know about any patterns of days/times when accomplishment is particularly high or low. For example, Mark previously mentioned that Tuesdays were especially difficult due to specific work related stressors. Knowing more about whether days in which daunting planned activities influence Mark’s overall mood, accomplishments and feelings of accomplishment will help to focus on the challenges with these specific days.

      2. A common theme Mark has mentioned is the thought of not being good enough. This thought of not being good enough stems into Mark’s work such as self-blame and comparing to what Mark used to do although the situations are not synonymous. The thought of not being good enough also comes into play in Mark’s social life involving plans with his friends. Marks thoughts of not being good enough may stem from a core belief of unworthiness. Calling more attention to this repetitive thought may help to uncover and modify the belief. Involving Mark’s social life, he tends to jump to conclusions in order to fill areas of ambiguity. However, these conclusions tend to be negative in nature seeming from a negative automatic thought of “Do they value me?”. This may represent Mark’s belief of being unlikable. Exploring these thoughts may give insight into how to go about identifying and modifying the negative cycle of thoughts, emotions, and maladaptive behaviors moving forward with more cognitive techniques.

      Automatic Thoughts

      1. There are many challenges counselors may encounter when attempting to identify and modify a client’s negative automatic thoughts. A possible challenge is working with valid negative automatic thoughts. This challenge may seem daunting, especially with beginning counselors. Due to the importance of identifying and modifying automatic thoughts within CBT, if thoughts are largely valid, the counselor must remember to not modify these thoughts. Rather, focus on the consequences of the thought and in turn, make sure the client is not distorting the meaning or conclusions as well as focus on acceptance rather than modification. These thoughts may be troublesome if the client is ruminating on these thoughts. Although, valid negative automatic thoughts may pose as a challenge, the counselor must shift from modification to acceptance and realistic meanings. Another challenge counselors might face is the ability to identify which negative automatic thought is the most damaging and relevant to the client. If a client has a multitude of different negative automatic thoughts, it is important explore which is causing the most distressing and intense experience. A large shift in mood and a focus on present events effecting the client will help to identify which negative automatic thoughts to tackle first in order to reduce the client’s distress. Psychoeducation is extremely helpful with educating the client about negative automatic thoughts, core beliefs, and the reciprocal notion of emotions reacting to these negative automatic thoughts. However, it is a different experience for the client to be knowledgeable about thoughts and emotions and their ability to identify and separate these thoughts and emotions in their every day lives. Especially when one is typically used to reacting to an emotion and not thinking about the thought behind the emotion. Finding a new pattern of exploring one’s emotions and thoughts may be difficult for clients as well as for counselors. A way for a counselor to face the challenge is to provide comparisons between thoughts and emotions while using the client’s own experiences. Another helpful tip is to provide clients with easy tricks to differentiate emotions and thoughts, such as emotions are usually a single word while a thought is typically a sentence or phrase. As there are many challenges a counselor will face while attempting to modify a client’s negative automatic thoughts, there are many CBT techniques and strategies that may be implemented to best attend to the client’s needs as well as help the counselor in the process.

      Reply

      • Zacharie Duvarney
        Oct 08, 2019 @ 12:16:59

        Olivia,

        I see that you and I both emphasized how mark internalized failure and may need help realizing what is within his locus of control. You stated that it may be useful to focus on external stressors that are contributing to Mark’s internalizing, something I hadn’t considered. I am glad you expanded on this idea and compensated for a shortcoming in my thinking.

        Nice work.

        Reply

      • Adam Rene
        Oct 08, 2019 @ 16:25:21

        Olivia,

        Thank you for your post. I see that we both came to similar conclusions regarding Mark’s core belief of personalization. I especially liked your inquiry about times of day he feels most productive. I feel that this would lead to an interesting answer and potential homework assignment for Mark to complete during the week to become more aware of the trends in his productivity. I appreciated your discussion of Mark’s automatic thoughts, as I mostly focused on core beliefs in my own response.

        Your comment on working with valid negative thoughts almost made me want to redo my post. That is something I certainly agree with being a challenge and I wish i had included it in my response. I can foresee this being difficult for the therapist to manage and especially so for the client.

        Reply

      • Katrina Piangerelli
        Oct 09, 2019 @ 07:45:22

        Olivia, I think that you raise some great points about Mark and the reaction that he has towards himself. Initially Mark was angry with himself for feeling rushed in the morning and later admits that he did enjoy having the extra time he did allow for himself. I think looking deeper at the times that Mark feels accomplishment at markedly low or high rates would be beneficial in seeing if there is an established pattern. I agree with the core beliefs you chose to write about. It seems as though Mark does struggle with feeling as though he is not good enough and this plays a major role in the way that he perceives things. I also agree with your ideas about what may be challenging when addressing negative automatic thoughts. I thought that one of the more difficult challenges would working with valid negative automatic thoughts. I think that you shared some good insight on how to deal with this situation and make sure that the client is not distorting the meaning or conclusions of the event and to have the client focus on acceptance as well.

        Reply

  2. Paola Gutierrez
    Oct 07, 2019 @ 16:11:23

    Behavioral Activation
    1. I would have wanted to know more about Mark’s believability of thoughts and the intensity of emotions related to his different activities. Certain thoughts and/or emotions that are anticipated and/or experience at a particularly high believability and/or emotion level likely influence the likelihood of Mark incorporating particular activities into his schedule. For example, the intensity of the emotion(s) he felt in response to the cancellation of dinner plans may negatively affect his decision to reach out to his friends in the future. I also would have appreciated a greater depth of reflection/processing of Mark’s increased pleasure/accomplishment on certain tasks, and how these changes in activity schedule influenced his overall mood. He expressed pleasure in doing certain activities, such as walking his dog and making breakfast. I wondered if his mood had changed in response to the integration of more pleasurable activities. If Mark comes to the conclusion that scheduling and executing more pleasurable activities are beneficial for him both emotionally and behaviorally, Mark may maintain these positive changes to a greater extent, as opposed to simply focusing on the activities themselves. In other words, examining the bigger picture rather than the details and connecting this bigger picture to Mark’s treatment plan/goals.

    2. Mark tends to blame himself for events that are outside his control, so it’s important that he begins to recognize these events and monitor his thoughts/emotions when they occur so that they interfere less with his self-efficacy (i.e., complications with recruitment at work). I would also focus more on the negative automatic thoughts and core beliefs associated with likeability. Although the automatic thought of “My friends don’t value me” was evaluated in session, Mark did not appear too confident with the evaluation of this automatic thought. This particular outcome may be linked with his core belief of unlikeability. Moving forward, working on challenging such automatic thoughts and doing more behavioral experiments to further challenge these automatic thoughts is likely to influence his possible core belief of unlikeability. I would also examine potential core beliefs of helplessness, such as “I am incompetent” and “I’m not good enough.” Mark hinted at these core beliefs in his description of the situation at work, questioning whether the difficulty in recruiting people was because he was not doing a good enough job in this area. These particular automatic thoughts and core beliefs warrant further work with cognitive techniques.

    Automatic Thoughts

    There are several challenges that a therapist might face in modifying clients’ automatic thoughts. Therapists may struggle in eliciting automatic thoughts. Usually, a therapist asks the client directly what their exact thoughts were during a specific situation or event. If clients struggle to answer the question, the therapist can use visualization or role-play techniques and ask the client to imagine/recall the emotional and/or physiological sensations related to the event. Shifting the focus to physiological arousal is one strategy that a therapist can use to “bring back” the event and elicit similar automatic thoughts. Therapists can also phrase questions differently or pose a different hypothesis and work with the client’s response. Changing questions/doubts into statements also helps to identify automatic thoughts.

    Another challenge is that many clients struggle to differentiate between thoughts and emotions. Because automatic thoughts are seemingly spontaneous and fleeting, the automatic thought leaves behind emotional weight. Clients tend to confuse the associated emotion for the thought itself. One way to help clients distinguish between thoughts and emotions is by educating the client on the difference between thoughts and emotions. Therapists can also help clients bridge discrepancies between thoughts and feelings, correct the emotions associated with particular events, and rate emotional intensity to guide treatment.

    Because clients often have many automatic thoughts in a single day, some therapists struggle to identify which automatic thoughts are the most relevant and important to work on. Therapists can evaluate whether an automatic thought warrants significant attention by deciding whether the automatic thought is (a) a recurring one and/or (b) elicits a high degree of emotional distress for the client. Therapists are encouraged to use particular questioning techniques to evaluate an automatic thought as opposed to challenging the thought directly. “Evidence for/against” is a commonly used questioning technique to evaluate automatic thoughts. Automatic thoughts are evaluated based on their utility and validity; some automatic thoughts might be useful or valid, and therapists may have difficulty with not trying to change the valid ones. Therapists may also find that their evaluation of automatic thoughts was ineffective. This result happens for a number of reasons; for example, an automatic thought may also be a core belief.

    Although therapists may run into some difficulties in working with clients’ automatic thoughts, there are a number of questions a therapist can ask him/ or herself and many strategies available to overcome these challenges in working with this cognitive technique in CBT.

    Reply

  3. Zacharie Duvarney
    Oct 08, 2019 @ 10:48:55

    Paola,

    Regarding the first question, you and I have drawn similar conclusions. While you focus more on intensity of emotions and thoughts (whereas I focus more on Mark’s perceived locus on control), we both are concerned with how internal factors will affect Mark’s chances of success.

    Both of us analyzed how Mark seems to internalize failures that are attributable to external variables. I feel this is extremely important to focus on, and I am glad you thought the same. Externalizing is a key factor in the maintenance of depression.

    Good work.

    Reply

  4. Adam Rene
    Oct 08, 2019 @ 16:20:23

    [Behavioral Activation]

    1. For Mark, I felt pleased that he completed the daily activity schedule to the degree at which he did. I felt that his responses and the subsequent processing was beneficial for him to bring his own ‘data’ and process it with Dr. Volungis to identify how he handled certain activities and interpreted them. In particular, I felt that the dinner date activity had a lot of good quality CBT practice. For myself, I’d want to learn more about what Mark was thinking and feeling as he started to withdraw from Melissa after receiving the phone call as Mark has a history of withdrawing when he’s feeling upset or overwhelmed. In the future as Mark becomes more aware of his automatic thoughts and core beliefs I’d want to pursue some kind of strategy or plan when he feels the desire to withdraw to more adaptively cope with those thoughts he experiences.

    2. For automatic thoughts and core beliefs, Dr. V identified two key core beliefs that came up throughout this session: unlikeable and personalization. In particular, I feel that personalization should be pursued moving forward. Dr. V made a fantastic connection between the dinner with friends and Mark’s anxiety around his role as a recruiter. We’ve seen in past sessions as well how Mark personalizes and “fills in the holes” of what he doesn’t know or is unsure of with negative, self-deprecating thoughts – such as when Mark’s friend did not return his phone call and Mark began to question why.

    [Automatic Thoughts]

    1. With regard to negative automatic thoughts, there are several strategies to elicit these thoughts and provide opportunities for the client to modify them. Those strategies range from role-playing interactions to using emotions or images in guided imagery or discovery. For me, I would say that the most challenging strategy to elicit negative automatic thoughts would be in differentiating thoughts from emotions. In a previous course, Counseling Principles & Practices, I often struggled with probing for thoughts versus probing for emotions. I encountered some difficulties in differentiating thoughts and emotions, often relying on asking about or identifying emotions better than thoughts. However, I do have a lot of experience in my work as TM/TT&S helping my clients expand their emotional vocabulary which is an aspect of this strategy for differentiating thoughts and emotions. I feel that through continued practice, supervision, and education on these concepts I will grow and improve in this area.

    Reply

    • Katrina Piangerelli
      Oct 09, 2019 @ 07:45:48

      Adam, I agree about wanting to know more about Mark’s thoughts and feelings following the phone call that he received. I also would like to know more about how Melissa handles the event of Mark withdrawing. I also agree that there was a great connection made between the stress surrounding the dinner date and Mark’s anxiety at work. Mark does tend to “fill in the holes” when left with little to no information about what is truly going on.
      I think that you offer some great insight on how to elicit thoughts and how to provide opportunities to help the client modify them. I think that role-playing can be very beneficial and offer clients a great way to work through negative automatic thoughts as they are happening in the situation that is being played out. It sounds like you have also been working a lot in the area of probing for thoughts and I am sure that this is something you will improve in throughout work and school.

      Reply

    • Olivia Corfey
      Oct 11, 2019 @ 12:42:30

      Adam,
      Thank you for your post. I believe we have similar ideas about the prevalence of personalization within Mark’s life. You made several good points. I especially appreciated your desire for more information about Mark’s withdrawal from Melissa after receiving the phone call. As this is a common reaction for Mark, understanding more about this situation could be a key in getting to the root of his core beliefs and automatic thoughts. As for the challenges for automatic thoughts, I agree that differentiation thoughts from emotions is quite difficult, especially for someone suffering from Depression.

      Reply

  5. Katrina Piangerelli
    Oct 09, 2019 @ 07:44:44

    Watch MDD-8: Behavioral Activation – Reviewing Completed Daily Activity Schedule (also includes Graded Task Assignment). Answer the following:
    (1) What additional questions would you ask Mark about his Daily Activity Schedule to assist you in moving forward with additional Daily Activity Schedules and future techniques with his negative automatic thoughts and maladaptive behaviors (see Table 6.5). In other words, what additional information do you want to know?

    Some questions that I have moving forward are: Is Melissa aware of Mark’s automatic thoughts? Has he ever expressed these to her? Does Mark feel like he can share these thoughts with Melissa? Does Mark tend to have trouble falling asleep? Does he experience “racing thoughts”? I think that these questions would give me a better understanding of the relationship that Mark has with Melissa and how supportive she is throughout this process. Is she someone that Mark can turn to and is able to help him through these tough times?

    (2) What automatic thoughts (or core beliefs) do you think warrant further attention moving forward with more cognitive techniques?

    Some of the automatic thoughts that I think warrant further attention are: Do they want to be friends with me? Do they value me? Is it something I’m not doing right? Am I doing a good enough job? Is this because of me? Is this a reflection of myself? I think that these thoughts seem to come up for Mark frequently when things do not go as planned or change unexpectedly. He then internalizes whatever has happened as being a reflection of himself and fills in the missing information of why something happened rather than finding out what actually happened. This is shown in the video when Mark describes his friends cancel their dinner plans because something was going on with their family. This was vague and caused Mark to fill in the missing information with negative automatic thoughts.

    Some core beliefs that seem to be relevant to Mark are: being unlikable, blaming self or internalizing issues that occur, and not doing good enough. These core beliefs seem to be something that comes up frequently for Mark and that was incorporated into this video as well as previous videos. Mark tends to think of himself as being unlikable when someone cancels on him as shown through his friends not coming for dinner or when his friend had to get off of the phone in a previous video. Another one that kind of goes along with this is Mark constantly blaming himself or internalizing issues that occur. This is seen when these issues with Mark’s friends arise, but also when Mark talks about the hiring process at his work and when the CPR trainer does not come to his work. Mark believes these things are a reflection of himself.

    There are multiple readings due over the past two weeks (J. Beck – 4 Chapters; Volungis – 1 Chapter). For this discussion, share at least one main thought:
    (1) What are some potential challenges you may encounter as a therapist when attempting to modify a client’s negative automatic thought (consider the key components/strategies used to elicit and modify negative automatic thoughts)?

    There are several challenges that a therapist might encounter when attempting to modify a client’s negative automatic thoughts. The therapist might have difficulty in identifying negative automatic thoughts that are relevant, selecting appropriate Socratic techniques to modify negative automatic thoughts, and working with valid negative automatic thoughts. Clients may also struggle to differentiate emotions and thoughts. When clients struggle to identify their automatic thoughts, it may help for the therapist to rephrase questions or ask different questions. It may also be helpful to shift your focus to a different aspect related to the event. Some strategies could include asking the client where they felt their emotions or asking the clients to “guess” what they were thinking. Hypothesizing a possible thought with the client that is the opposite of what they were probably thinking may stimulate the client’s emotions and bring up memories.

    A client may also struggle to differentiate thoughts from emotions. Redirection or prompting can help the client stay on track, but some clients may need to provide some examples that will help the client process this difference. Thoughts are typically longer and full of sentences or phrases, while emotions are typically a single word. This can help a client differentiate between the two in a quick and easy way.

    The next challenge is in selecting an appropriate Socratic technique to modify negative automatic thoughts. Socratic questioning is used in CBT, and refers to asking clients direct questions about the negative automatic thoughts they are experiencing. The main focus is to help clients to identify they are thinking for themselves, rather than the therapist showing them. Some of the Socratic techniques are to examine the evidence, decatastrophize perceived negative outcomes, explore possible alternative explanations, assess the impact of believing the negative automatic thought, separate self from negative automatic thought, and shift attributional biases. Sometimes, however, it may be challenging to decide which of these techniques would be most beneficial for the client.

    The last challenge is working with valid negative automatic thoughts. The therapists concern should be on the consequence/utility of these valid negative automatic thoughts. Problem-focused styles of coping may be useful when the client is in distress due to a valid negative automatic thought, but in other cases the focus may be on accepting the situation by using more emotion-focused coping. There are some strategies that may help with dealing with valid negative automatic thoughts, such as assessing the validity of the conclusion, considering alternative conclusions, problem-focused coping, and acceptance and emotion-focused coping.

    Reply

    • Kelsey Finnegan
      Oct 11, 2019 @ 23:32:12

      Katrina,
      You bring up a good point about gathering more information about Mark and Melissa’s relationship. I did not consider this, but I think it could provide a lot of insight into Mark’s thought and behavioral patterns. I agree that it would be beneficial to further explore Mark’s internalizing issues and his core belief that he is unlikable.
      You mention helpful strategies for dealing with the challenges that can arise when helping client’s modify negative automatic thoughts. I like that you brought up emotion focused vs. problem-focused coping strategies.

      Reply

  6. Bianca Thomas
    Oct 10, 2019 @ 06:53:09

    Behavioral Activation
    1. Mark did a great job completing the Daily Activity schedule and seemed insightful about what activities made him feel good and accomplished and other events that made him feel “bad”. Mark seems to have an external locus of control and tends to find most of his challenges due to interactions, or missed opportunities with other people, such as his friend needing to cancel dinner with him. Something I would want to know would be what other coping mechanisms he has in order to deal with tough situations, aside from withdrawing, and if there are any beneficial coping mechanisms he has used in the past or currently uses. I would also want to know if he feels comfortable being a little more assertive with his thoughts and feelings, in a way of asking more questions in order to invalidate his negative automatic thoughts. I also would want to know why mark is having such trouble sleeping and if this has been an ongoing problem for a while.

    2. Automatic thoughts and core beliefs that I think warrant further attention moving forward include his core beliefs of being unlikeable or unlovable, that people don’t want to be around him or that he is not valuable, as well as his automatic thoughts of others not valuing their friendship with him if something comes up that requires them to cancel plans on him. Other core beliefs I believe warrant attention are his beliefs of not being sufficient enough or good enough, as well as his core beliefs including self-doubt in his capabilities to execute behaviors, such as waking up. I would also want to focus on his automatic thoughts of minimizing situations that seem to have created success, such as making a good breakfast and waking up early, which could stem from his external locus of control. A last automatic thought I would want to focus on stems from Mark’s personalization such as that he should have gotten dressed quicker and if he did he could have actually enjoyed the breakfast he made.

    Automatic Thoughts
    1. Some potential challenges I may encounter when attempting to modify a client’s negative automatic thought would be initially eliciting and identifying what the automatic thought is, whether it be because the client is unable to express the thought, or the emotion associated to it. Another challenge I may encounter will be assisting the client in differentiating their thoughts from their emotions, and thoroughly explaining how the two are different, yet play a role with each other. Another challenge I may encounter when attempting to modify a client’s negative automatic thoughts may be in the process of modifying the thought itself, and deciding which technique is the best option for which client. A final challenge I may encounter includes using the Socratic Technique and being able to accurately facilitate these questions with my client and get the answers needed.

    Reply

    • Olivia Corfey
      Oct 11, 2019 @ 12:52:22

      Bianca,
      I would agree that I would also want to know more about Mark’s alternative coping strategies in in times of stressful situations. As stressful activities may come in a time where Mark is not able to withdraw such as with work situations such as recruiting. As for the challenges with automatic thoughts, I agree that identifying and choosing the appropriate strategy to modify the thought is daunting. Your overall post was helpful and insightful.

      Reply

    • Anthony Mastrocola
      Oct 13, 2019 @ 05:07:41

      Hi Bianca,

      I also agree that Mark has trouble dealing with situations out of his control. It appears that when he has his mind set on something he is especially let down when it doesn’t go as planned. It seems that his feelings of disappointment validate some of his core beliefs and causes him distress.

      Reply

  7. Anthony Mastrocola
    Oct 10, 2019 @ 10:19:52

    (1) What additional questions would you ask Mark about his Daily Activity Schedule to assist you in moving forward with additional Daily Activity Schedules and future techniques with his negative automatic thoughts and maladaptive behaviors (see Table 6.5).  In other words, what additional information do you want to know?

    Mark appears to have been making progress accepting events that do not go as he expected. Therefore, Mark has been able to experience increased pleasure due to accomplished goals that he never expected possible (e.g. waking up earlier and having a good breakfast). I would like to learn about Mark’s emotions in the moment, and immediately after he accomplishes a positive morning experience. I’d imagine that he would feel exponentially better heading into work if he took a couple moments to reflect on his morning successes. Mark’s self-efficacy in work may improve as a result of immediate success in the morning. I believe this momentum may carry into work. In reference to the failed dinner plans, I would like to learn more about Mark’s interactions with his girlfriend during dinner. He noted withdrawal during preparation, which lead to decreased interaction with his girlfriend, but he also noted that she is more understanding than he is. He noted some automatic thoughts that resulted from failed plans, such as “do they even want to be friends with me?” and “am I even valued?”. His girlfriend likely externalized the cancelled plans. It could prove beneficial to discuss the failed plans with his girlfriend, because she may help confront the automatic thoughts before they lead to emotional distress and withdrawal. Mark also shared some distressing feelings regarding internalized failures at work. Mark describes pressures that he feels from himself, as well as management regarding an inability to recruit workers. There is some externalization, where Mark admits that the pay is not the best, which could be a reason for low recruitment. However, Mark attributes the failures to his poor concentration and feelings of overwhelming anxiety. Self-blame has reinforced his negative thoughts and maladaptive behaviors. It was noted that Mark was able to better function at his job before his depressive episode. I would like to know how successful he was at recruitment pre-depressive episode. Past successes may promote hope that future success is attainable. Overall, Mark appears to experience the most pleasure when he is able to surprise himself. I would like to know how the effect that immediate reflection of activity completion would have on his negative automatic thoughts. I would also like to further monitor his feelings of self-blame at work. He began to externalize some of the failures by attributing some blame to management, but ultimately internalized the failures. He seems to become increasingly hindered by feelings of self-blame.

    (2) What automatic thoughts (or core beliefs) do you think warrant further attention moving forward with more cognitive techniques?

    I believe that the most important automatic thoughts that Mark experiences are tied to events that do not meet his expectations. The planned dinner with friends is the most noteworthy experiences relevant to this claim. Mark noted that immediately after the phone call from his friend cancelling dinner plans, he started experiencing negative automatic thoughts. His reactions exceed surface level disappointment, but rather feelings internalized based on perception of self-value. Mark began to question whether his friends actually wanted to be friends with him. Then, Mark began to question if he is valued by his friends. Mark began to engage in cognitive distortions, such as jumping to conclusions and personalization that likely tie to Mark’s core belief that he is unlovable or unlikeable. Instead of externalizing the failed plans by thinking something must have come up, Mark thought he was the reason why they cancelled. He believed that they must not want to be his friend. These negative automatic thoughts are distressing for Mark, as they enhance depressed emotions and create withdrawal. The trend continues as withdrawal creates complications with Mark and his girlfriend, which then affects his thoughts, emotions, and behaviors. These automatic thoughts require the most attention, especially because they are tied to troubling core beliefs. Further cognitive techniques should be based on confronting the invalid automatic thoughts. Mark appeared to respond well when confronted about his feelings about the cancelled dinner. Possibly if Mark is able to identify patterns of invalid automatic thoughts, he will begin to think more accurately.

    (3) What are some potential challenges you may encounter as a therapist when attempting to modify a client’s negative automatic thought

    Negative automatic thoughts can cause emotional distress and influence maladaptive behaviors. Tied to core beliefs, automatic thoughts are persistent and difficult to modify. Before a counselor is able to modify automatic thoughts, the counselor and client should collaboratively engage in guided discovery to identify the most intense and distressing automatic thoughts. It can be difficult for clients to remember automatic thoughts in their past experiences. Guided discovery analyzes emotions that resulted from events perceived as troubling. Initial perceptions act as automatic thoughts that are involuntary and difficult to identify, yet entirely influence emotions. By working backwards, clients and counselors are able to start by discussing negative emotions, and see what thoughts were accompanied. Once automatic thoughts are identified, the counselor and client are able to work to modify them by rating validity, intensity, and frequency. Modifying automatic thoughts can be challenging. Automatic thoughts are commonly experienced, and it can be difficult to decide which automatic thoughts to address, and which automatic thoughts to not address. The most emotionally distressing automatic thoughts typically receive the most attention. Clients may experience intense emotional reactions to multiple automatic thoughts. It may be challenging to decide which emotional reactions are most intense. For example, if a client rates the intensity of the emotional experiences between 1-10, they may rate multiple emotions with the same level of intensity. I’m sure rapport would help distinguish, as well as asking the client which thoughts and emotions are most distressing will help deciding which thoughts to address.

    Reply

  8. Kara Rene
    Oct 10, 2019 @ 14:28:28

    Behavioral Activation
    1. It was clear from watching the discussion about the Daily Activity Schedule that Mark is continuing to struggle with negative automatic thoughts and appraisals about activities that do not go exactly to plan, but also that he is starting to be able to temper those negative thoughts by acknowledging that in reality the circumstances may not have actually been so bad, and may in fact have been pretty good. I would want to know how Mark feels when he focuses on a negative appraisal or automatic thought versus how he feels when he tempers those negative thoughts with more positive ones. I think this would be helpful to discuss as it is clear that the Daily Activity Schedule is helping Mark and Dr. Volungis uncover and discuss some of his common troubling automatic thoughts and because Mark is already starting to work to reshape those negative thoughts on his own (when he tempers the thought with a more realistic one).
    2. It seems that Mark struggles with personalizing and dramatizing negative circumstances. Throughout the videos thus far I have noticed that he is beginning to temper overdramatization- saying things like “It didn’t feel great, but it wasn’t as bad as I had thought it could be,” etc. However, he is clearly still struggling with not personalizing events that are out of his control not going to plan- for example, when his friends had to cancel dinner last minute, Mark struggled with thinking that maybe they were canceling because they didn’t actually want to spend time with him. In response to these thoughts, Mark isolated himself a little bit, although not as much as he has described in previous videos. I think that paying attention to these thoughts and applying cognitive techniques would help Mark to experience less doubt about his own worth, which I think would be valuable in raising his self-esteem and lessening his depression and tendency to isolate himself.

    Automatic Thoughts
    1. I think the main challenge I would be worried about as a therapist would be client’s holding onto their negative automatic thoughts. I think I worry about these types of clients first because I know that I sometimes do the same thing, myself! I think that in these cases, it would be necessary to focus on the negative impact of the automatic thoughts the clients are holding so firmly to, and to repeatedly draw the client’s attention to evidence that suggests that the thought is untrue.

    Reply

    • Kelsey Finnegan
      Oct 11, 2019 @ 23:53:09

      Kara,
      I would also like to know more about the difference between Mark’s feelings when he focuses on the negative automatic thought versus how he feels when he tempers with these types of thoughts. This could be a very productive conversation to have with Mark.
      I too would be worried about client’s being unable to let go of their negative automatic thoughts. Despite an awareness of the abundance of evidence that disproves a thought, it can still be very difficult to let go of that thought especially if it is one that has been recurring for many years.

      Reply

    • Tricia Flores
      Oct 12, 2019 @ 16:21:14

      Kara-
      I agree that Mark is making progress in not personalizing situations and being able to have more insight later. It was a good point that he continues to personalize situations that he doesn’t have control over such as friends cancelling at last minute. This seems like it is less likely due to Mark and more due to his friends. Having Melissa’s input would be helpful.
      I agree that client’s holding onto negative automatic thoughts is a barrier and I appreciate your personal insight into holding onto negative automatic thoughts yourself. I know I do too sometimes. I agree that pointing out the negative impact that holding on to these thoughts could help the client buy into change. If the client is able to see the benefit of change outweighs the current state he may be more willing to change. I see how psychoeducation could be beneficial in this because they might not be able to see the negative impact that their negative automatic thoughts are having.

      Reply

    • Anthony Mastrocola
      Oct 13, 2019 @ 05:03:09

      Hi Kara,

      You made an interesting point about Mark acknowledging his automatic thoughts rather than covering them up with surface level positive appraisals. I think that this is an interesting point, because through identification, Mark will ultimately be able to modify these distressing thoughts.

      Reply

  9. Kelsey Finnegan
    Oct 10, 2019 @ 15:03:54

    Behavioral Activation Video
    1.) After watching the video, it appears that Mark has a tendency to internalize his failures and externalize his accomplishments, which is a common cognitive distortion of depressed clients. I would like to gather more information about the believability of Mark’s thoughts and the intensity of his emotions. For example, to what extent does he believe his friends don’t value him and were just blowing him off? How angry did he feel in the moment when his friends cancelled on him, or when he didn’t get his morning routine “just right.” I’d be curious to see if this sort of perfectionism with the morning routine transfers to his work because he hinted that it might. I’d also be curious to know more specifics about Mark’s behavior the rest of the night after his friends cancelled on him. For example, what was he doing instead of cooking dinner with Melissa, and what did he do after they finished dinner?
    2.) An automatic thought of Mark’s that warrants more attention moving forward is “my friends don’t value me.” Also, his core belief that he is unlikeable should be further examined. I would be curious what evidence he has to support this belief, and it would be helpful to work with him to find evidence that refutes this belief.

    Automatic Thoughts
    1.) Therapists face many potential challenges when attempting to modify clients’ automatic thoughts. For example, many clients have difficulty distinguishing between their thoughts and emotions. Psychoeducation can be instrumental in overcoming this challenge. Also, it can be difficult to modify automatic thoughts that have a good amount of truth to them. With thoughts like these, it might be more helpful to examine the utility of the thought and develop alternative thoughts, rather than deconstructing and refuting it.

    Reply

    • Tricia Flores
      Oct 12, 2019 @ 16:12:37

      Kelsey-
      I agree that going into the believability of thoughts and intensity of emotions is appropriate. Looking at that in terms of friendships is valuable. I could see the usefulness in Dr. V asking how his girlfriend reacted to the situation. This was a good counterpoint to Mark’s reaction and gave Mark a measuring stick to how he reacted to it. It seems as if the intensity of emotions in the situation possibly changed from before and rating the intensity of this could bring that hunch into an empirical value. This could show Mark progress. Because while he might not be able to change the behavior of others he could change his reaction, which goes back to the idea of changing reaction vs changing the situation. Helping Mark understand this could assist in his development psychoeducationally.
      I agree that the core beliefs of unlikeability and the automatic thought of my friends don’t like me should both be further examined. Looking back at prior instances of spending time with friends could possibly explain the current situation or help develop a plan for Mark to have friends agree to spend time with him.

      Reply

  10. Tricia Flores
    Oct 10, 2019 @ 15:04:28

    Behavior Activation:
    1. Overall, Mark did well at completing the Daily Activity Schedule and discussing it in session. He continues to internalize negatives such as friends cancelling last minute and recruitment not going well at work. What adaptive behaviors should be validated and reinforced can be addressed further. Adaptive behaviors that Mark took included trying to go to sleep earlier, setting his alarm clock to a ring that he would pay attention to, making breakfast, taking the dog out, and calling friends ahead of time to make plans, and reengaging with his girlfriend after a shorter period of time of disengaging after disappointment. Some of these were validated during the session such as taking the dog out, making breakfast, and getting up earlier. Others to point out especially include calling friends ahead of time, which is something that had been discussed previously and Mark followed through on. It worked out better for the review that the friends cancelled because the negative thought of his friends trying to avoid him could be addressed. The validity of this was addressed by asking how the friends sounded when plans were made initially, which was excited. This helps to show evidence of the negative automatic thought being false and can hopefully work to eventually address the core belief of being unworthy.
    I would go further into the reported levels of pleasure and accomplishment for each activity. This was addressed in terms of ratings associated with the dinner that did not go as planned, but was not a failure. Going further into the topic related to morning activities and walking the dog could further encourage repetition of these activities.
    2. Mark has automatic thoughts of incompetence at work such as “I’m incompetent at my job” and a core belief of helplessness. This should be examined further to determine the validity. How much of it is external factors and how much is internal? Looking at how other people in his same field and position are doing and employee evaluations could be beneficial. Specifically in recruitment it is like sales and believing in the product, the company one is recruiting for. Changing Mark’s automatic thoughts regarding his abilities could result in behaviors that improve his ability to sell the company. Regarding his friendships, I would question the automatic thought of validity of “my friends don’t value me.” While it sounds like his friends do want to spend time with him, it doesn’t seem as if they are putting a high value on his friendship. This questions the automatic thought of “I am not likeable” but last minute cancellations, if they repeat over time may lead to validate “my friends don’t value me.” I would want to know further about what friends of his have more availability. Perhaps focusing on friends who have more availability might bring a more positive response to a behavior experiment. What friends consistently show up when plans are made?

    Automatic Thoughts:
    1. There are several potential challenges one may encounter as a therapist when attempting to modify a client’s negative automatic thoughts. Difficulties include difficulty eliciting automatic thoughts, difficulty remembering triggering events, difficulty distinguishing between emotions and thoughts, difficulty identifying which are the most important automatic thoughts to address, and difficulty determining the utility and validity of the thoughts.
    A client may have difficulty eliciting automatic thoughts, one technique is to focus on the response to the thought and work backwards. When the response is difficult to determine a therapist can utilize visualization and roll playing to identify the response. Through visualization a client can replay the experience. The client can identify his emotion and psychoeducation can be utilized to explain how that is a response to the automatic thought. Working backwards and with therapist assistance if needed the client can identify the thought. The validity of the thought can be discussed such as it was with Mark in terms of his friends coming over. It was discussed if plans had been made ahead, which they had, (step one), and how the friends seemed to response to the request, positively (step two), and lastly how his girlfriend responded to the cancelation, neutrally (step three). In this way the question of whether they wanted to spend time with him was addressed and evidence was provided to dispute the thought. A thought can be differentiated from an emotion in how it can be described. A thought is a sentence and an emotion is a word.
    The difficulty of determining which are the most important automatic thoughts to address can be addressed through rating scales. The use of a scale can get client buy in to what is the most important topic of them. Pointing out the frequency of discussion could also benefit the buy in for the client to change because he may not perceive it to be something that is a problem or he may perceive it is non-changeable when it is, which is another place that psychoeducation can be beneficial. I think back to teens I used to do case management with who did not think they could change the trajectory of a bad day. Being able to identify the automatic thoughts, responses, and resulting behaviors that supported this could be of great benefit for this group.

    Reply

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Adam M. Volungis, PhD, LMHC

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