Topic 5: Behavioral Activation & Automatic Thoughts {by 10/11}

[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 10/11.  Have your two replies posted no later than 10/13.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

29 Comments (+add yours?)

  1. Alyce Almeida
    Oct 07, 2018 @ 18:42:41

    1) The additional information i’d like to know would be when he was talking about the dinner date that didn’t go as planned. He was able to identify that the night wasn’t completely ruined. I would of asked as he was wrapping up that feeling of the situation how this reaction relates to a past reaction: “Mark you did a good job at realizing that though it didn’t go as planned, it wasn’t as horrible as it could have been. How do you think your reaction now is different than a reaction you would of had lets say a few weeks back before using this activity schedule?” I feel that asking this question could help Mark see another strength and perspective of his growth throughout therapy, praising him for his achievement and new skills. Also asking this question could help asses whether Mark deems this strategy useful for him in identifying his own negative thoughts. This helps see if we could use this strategy again in future sessions, or maybe introduce a new strategy that could help promote identifying and modifying negative automatic thoughts. I think the automatic thoughts that could be focused on in future sessions would be Mark’s focus to blame himself immediately if recruitment doesn’t go well at work. I know the GTA helped break down tasks for him, to make it seem more achievable, but I noticed in both discussions of the dinner and work Mark always self-blames for something out of his control. This could be a could focus to reflect on once Mark starts shifting his core beliefs into a more realistic view that those situations are completely out of his control, and not just reliant on him as a person with specifics to his companies recruitment process.
    2) I think that the whole process of modifying automatic thoughts is a challenging process itself. First, you have to guide your client into identifying the negative thought in the first place. secondly, you now have to develop a new thought that your client can apply to their daily life. The whole process itself is already difficult, but I think implementing the client practicing identifying negative thoughts independently with homework and also having conversation around these thoughts within session will be the most difficult. I find the homework assignments beneficial, but I do fear that after educating clients and guiding clients through the homework assignment in session, that this information won’t convey for clients outside of session having to complete such assignment. The challenge would be to have clients commit to such tasks. What if that doesn’t happen, how exactly do I alter or create another option for the client to get them to want to give it a try? Another aspect is my own frustration tolerance when my client isn’t following through. I’ll most likely feel like i’m doing something wrong for my clients not wanting to cooperate with me and question the therapeutic rapport as a whole. The other challenge I think is difficult, is identifying the individuals negative automatic thoughts, and having them discover it themselves. I’ll have to do my part of identifying such thoughts content to myself (no pressure or anything), but my fear is the strategy I use like the Negative Automatic Thoughts Records for example, wont be enough for my clients to therefore identify such thoughts collaboratively. I fear that i’ll be doing too much of the initiation and identification of such thoughts, and that my client won’t necessarily be demonstrating the skills to discover their negative thoughts on their own. It’d make me think that I messed up along the way of therapeutic sessions, with the psychoeducation portion specifically. I guess my challenges go back to whether or not i’m providing enough information and guidance for my client and if my explanations around automatic thoughts suffice for them to actively identify and modify such thoughts collaboratively during sessions. I guess the challenges relate back to my competence as a professional, and whether or not i’m implementing such interventions appropriately to ensure great client response from them.

    Reply

    • Deanna
      Oct 08, 2018 @ 15:36:02

      “I find the homework assignments beneficial, but I do fear that after educating clients and guiding clients through the homework assignment in session, that this information won’t convey for clients outside of session having to complete such assignment. The challenge would be to have clients commit to such tasks. What if that doesn’t happen, how exactly do I alter or create another option for the client to get them to want to give it a try? Another aspect is my own frustration tolerance when my client isn’t following through”

      Alyce,
      You bring up a really valid concern! It will be super frustrating when clients don’t do their homework! Especially after we have explained the value of doing the homework! This scenario that you brought up made me think of a few things. It is important to: explain thoroughly to a client why doing the homework is important, model how to do the homework, explain how the homework can benefit them, explain the fact that the homework will be used in session, as well as explaining that the homework can help them practice things done in session or bring up problems not thought of/identified during session. You made me think of how even challenges like this we can gain some kind of benefit. Whether by building up therapeutic rapport by investigating why the client didn’t do the homework and then collaborating with them on how they can do it in the future. But it can also help us to understand our clients further. Is the client avoiding activities entirely? Are they struggling to complete the assignment or understand its utility? Or is there something more concerning involved, such as the client is in greater distress. Even when things don’t go as planned, just like our clients, we can learn something from the change!

      Reply

    • Amanda Russo-Folco
      Oct 08, 2018 @ 19:31:46

      Alyce, reading your response to the challenge of modifying negative automatic thoughts was very real and true. I have had those same thoughts myself. It can be frustrating and difficult to modify or challenge someones negative automatic thoughts. Giving homework assignments is very beneficial, but I also feel that it depends on the client and when a good time would be to give the client homework. Some clients may get intimidated by the term homework so I would try and find other ways that would work for clients so I know they would follow through with their homework assignment. As you said, this could be the tricky part. But, I also agree with your response and I feel that all beginner counselors would have all those same thoughts as you have. Discussing and learning about this information is one thing, but to actually do it with actual clients is another thing. Thank you for sharing your honesty! You are not alone in this, I feel the same way with this too.

      Reply

    • Jayson Hidalgo
      Oct 08, 2018 @ 21:44:34

      You make a lot of good points. One of those points I would like to address on is when you mentioned about not being able to convince a client to follow through something. It probably will be very frustrating to know that you are trying to do everything you can to help this individual, but the individual seems like they do not want to contribute to get better. It will probably be annoying for all of us that you want what is best for the client, but it is hard to convince the client to see our perspectives. If we cannot make the client follow through with things, then this will hinder the relationship and recovery process.

      Reply

    • Nicole Plona
      Oct 13, 2018 @ 10:14:09

      I thought your response was really well thought out and you acknowledge a really important factor when it comes to modifying automatic thoughts and core beliefs. The main part of it being that the process of modifying these thoughts to begin with is hard without all the added factors. Making soneone realize that their thoughts are both negative and for the most part unture can be an extremely daunting task for a therapist.

      Reply

  2. Amanda Russo-Folco
    Oct 08, 2018 @ 15:25:14

    Some additional questions that I would ask Mark about his daily activity schedule to assist in moving forward with additional daily activity schedules and future techniques with his negative automatic thoughts and maladaptive behaviors are what other things could he have done to make time for his breakfast? Could he have tried to do things to help him become more tired the night before, like reading a book? Could he maybe have picked out his clothes the night before, so he doesn’t have to worry what to wear the next day to make more time for breakfast? Also, when his friends canceled on him, what coping skills did he use to get through his emotions of being upset? Or were his coping skills just to withdraw from the situation and be alone? I feel that finding out this information would be helpful for future scenarios. Also, was he going to call his friends again and reschedule their dinner night or just give up on the situation? It is important to find out why he is always so hard on himself when the situation about his friends was out of his control. But, he does have control of how his morning goes and he has noticed that which is a good thing. He is taking little steps to accomplish his morning goals. The automatic thoughts or core beliefs that I think warrant further attention moving forward with more cognitive techniques is his emotion of upset. When the therapist dug deeper with the emotion, he found core beliefs of that his friends do not value him or like him, which led him to feel unlikeable. It is important to further these thoughts and emotions and core beliefs because it could lead to something more serious in the future with his friends. If his friends keep canceling and making him feel this way, he could just withdraw himself and not be motivated and always want to be alone. This could harm his relationship with Melissa and others. Also, I feel that is it important to discuss how Mark is always hard on himself when something does not go as planned. But, I did like how Mark noticed he set a goal and accomplished some part of the goal and he realized what he actually got accomplished. Even though he was not able to sit down and eat his breakfast, he did make a breakfast sandwich and was able to eat it in the car. It is very important to praise and acknowledge Mark’s accomplishments, so he can see how far he has come and can keep moving forward.

    Some potential challenges I may encounter as a therapist when attempting to modify a client’s negative automatic thought is that the client might lack awareness of their thought, so it might be challenging because they need to be aware of the negative thoughts that they are having. If they are not aware of these thoughts, then these thoughts cannot be changed. Also, the client might not believe they are having these negative thoughts and they do not notice their thoughts, so it is up to the therapist to elicit these negative thoughts. It is usually difficult for clients to attach the emotional aspect to their thoughts, so this could also be a challenge. Although thoughts are always coming and going, it is the emotional part of the thought that is difficult to change for the client. It is also challenging to figure out which category the negative automatic thought would be categorized based on their validity and utility. A few strategies that are used to elicit and modify these negative automatic thoughts are guided discovery, guided imagery, role play, differentiating thoughts from emotions, and tracking negative automatic thoughts. Guided discovery is using emotions to elicit automatic thoughts. For example, what was going through your mind? This gives a chance for the client to think about what was going on in their mind at that exact moment of the thought. It is important to validate the emotions, and this could be challenging for some clients. It is also important to observe for verbal and nonverbal cues from the client. Guided imagery is using images to elicit automatic thoughts. This is used when the client can imagine an event in their head, and they think about the thoughts that they are thinking about while this event is being played out in their mind. Role play is used to recreate the interactions to elicit their automatic thoughts, so they can see for themselves what thoughts they had so they can be more aware of what they were thinking. It helps the client relive this event, so they can remember how they felt and what thoughts they were experiencing. It is also important to be able to differentiate the thoughts from emotions and this could be a challenge for clients as well. A thought is a sentence or a phrase, but the emotion is a single word. Also, it is important for the therapist to track negative automatic thoughts that are occurring which includes the thoughts with the emotions and events. As a therapist overall, it will be challenging to modify and change the client’s negative automatic thought, but using these strategies could help with this process. Although, figuring out which strategy to use and actually using these strategies as a professional could be a challenge as well.

    Reply

    • Becca Green
      Oct 12, 2018 @ 20:58:28

      Hi Amanda! I thought a lot about those little steps that Mark took as well. Praise is important with depressed clients and having him recognize those little victories can be a huge step. I didn’t quite piece that connection between this and the different levels of control that he has over the situations. The problem with this is that seems as though he struggles with blaming himself regardless of the level of control he has. Good point that I didn’t connect before!

      Reply

  3. Deanna
    Oct 08, 2018 @ 15:27:32

    [Behavioral Activation] (1) The additional questions I would ask Mark about his daily schedule to assist in moving forward with additional Daily Activity Schedules and future techniques with his negative automatic thoughts and maladaptive behaviors are:
    -How did he feel about putting down actual schedules and activities in terms of his worries about ambiguity? Did having a plan help with his ambiguity? (general thoughts in response to the overall schedule and its impact on his thoughts). Basically, I want to know if planning out certain activities helps Mark with his worries about ambiguity. Does planning help fill in the gaps?

    -How did he feel once he completed activities that had some ambiguity around them? (Expected pleasure versus experienced.) Did completing the activities that he had some worries/negative thoughts about give him more pleasure than he initially thought he would experience?

    -When something doesn’t go as expected, is the day lost? In this session, dinner with friends was cancelled. Mark withdrew from cooking with Melissa, but he still had dinner with Melissa and carried on with his night. Mark kept up with his schedule. I want to ask Mark more about this and his thoughts on carrying his overinternalized thoughts over into other activities. Mark had previously noted that issues with previous activities tend to be carried over sometimes. I want to ask if he has been able to identify some automatic thoughts/overinternalizing thoughts more so than before and what changed this time so that he didn’t completely withdraw from his schedule. He struggled a bit when seeing the table still set for 4, and with feeling his friends don’t like him, but I want to know if his overinternalizing has changed.

    I would also like to know more about Mark’s thoughts on the daily activity schedule and if it helps him engage and complete activities, and even identify and evaluate his negative automatic thoughts. I want his input on if he thinks this cognitive technique works for him, and what we can do going forward if he does or does not like the cognitive technique. I want to collaborate with him on things he likes and dislikes about this task.

    Overall, I want to commend Mark for completing his homework and putting great effort into it, as well as completing the tasks that he listed despite some changes. I want to work on helping Mark identify, evaluate, and modify his automatic thoughts. As well as, I want to collaborate with Mark on what cognitive techniques are or are not working for him and what we/he can do going forward.

    (2) The automatic thoughts that I think warrant further attention moving forward with more cognitive techniques are self-blame and overinternalizing thoughts; “not doing a good enough job”, “feeling unlikable”. These thoughts came up when Mark’s friends cancelled dinner, and when Mark talked about applicants at work that would decline positions. I would like to help Mark work on balancing his internalizing and externalizing thoughts to be more realistic views. In the scenario where possible applicants turn down a job, I want to help Mark see that they turn down the company/job, not him, due to work related facts and not his own qualities. Same as with his friends cancelling dinner, Mark was not successfully able to balance the internalizing and externalizing features. He overinternalized the situation as his friends not liking him, rather than considering that their reason for cancelling was a family matter. I want help Mark identify his self-blame and overinternalizing thoughts, evaluate them in the given situation, and reframe them to be more balanced/realistic.

    [Automatic Thoughts] (1) Some of the potential challenges you may encounter as a therapist when attempting to modify a client’s negative automatic thought are: identifying the negative automatic thought, helping the client to identify the negative automatic thought (and its difference from thoughts and emotions), modifying valid negative automatic thoughts, choosing the appropriate techniques for modifying automatic thoughts.

    -Identifying the negative automatic thought/helping the client identify the negative automatic thought
    It can be challenging to identify the negative automatic thought, as you can only identify it based on what a client tells you. It can be difficult to illicit the negative automatic thoughts depending on: client cooperation and insight, emotional intensity and believability, client distress sharing, client difficulty in guided discovery and/or imagery, role play, separating negative automatic thoughts and emotions, and tracking negative automatic thoughts. Clients can struggle to be forthcoming about their distress as well as determining the difference between negative automatic thoughts and emotions. They can get stuck on how emotions are typically one word or a feeling rather than a thought or a short phrase about oneself. They can even get stuck in the client therapist interactions/role plays used to recreate the automatic thoughts that clients experience.

    -Choosing the appropriate techniques for modifying automatic thoughts
    It can be challenging to identify which techniques would be appropriate for modifying automatic thoughts as some techniques don’t work for some clients, the negative automatic thought may be valid for the client’s situation/distress, the client may have difficulty role playing out their negative automatic thoughts, the outcomes from one technique may not be the outcome you or the client was expecting, you may need to try and/or implement multiple techniques, the client may not respond to Socratic thinking either by resisting the differing thinking, not understanding it, or their negative automatic thoughts are resistant and need multiple techniques and multiple exposures. They may even struggle with decatastrophizing negative outcomes, exploring possible explanations and internalizing versus externalizing, assessing the impact of their negative automatic thought, and even separating their thoughts from themselves exclusively. If the client has difficulty rethinking their negative automatic thought, coming up with alternative information to their thought, as well as devaluing the negative outcomes, it can be difficult for them to respond to many techniques to modify negative automatic thoughts.

    -Modifying valid automatic negative thoughts
    Some automatic thoughts can be valid for some clients and situations. Depending on the distortion and distress, these valid or not valid negative automatic thoughts need to be addressed differently. The challenge in this can be identifying the validity of the thought and the distortion of the thought. The client can experience distress regardless and the distress and/or distortion can be difficult to evaluate for validity and distortion, due to the client specific situation. Client’s can resist the techniques and strategies you use to help them, thinking: “Why do I need to change these thoughts if they are valid?” Even if the client is not actively resisting modification, the negative automatic thoughts and distortions can act as defense mechanisms that the clients use to “protect them”, and still have difficulty modifying them.

    These are only a few examples of some challenges one might experience when attempting to modify a client’s negative automatic thought. But there are plenty more. If there is difficulty in any of the steps/techniques for eliciting and identifying negative automatic thoughts, then there will be trouble modifying them as the negative automatic thoughts have not been identified or concretely determined.

    Reply

    • Jayson Hidalgo
      Oct 08, 2018 @ 22:02:25

      You bring up some good points. I point that I want to focus on is when you mentioned about the challenge of modifying valid automatic negative thoughts. You make a good point that the client may resist on the treatment of modifying their valid negative thoughts when they are valid. However, from my understanding from the reading, the main focus is to not modify their valid negative automatic thoughts, but help them learn to accept the situation and focus on changing the conclusions developed by the valid negative automatic thoughts. So its not really changing their valid negative automatic thoughts because they are valid, it is more focused on allowing the client to develop a realistic view with their negative valid automatic thoughts.

      Reply

  4. Sam
    Oct 08, 2018 @ 15:30:31

    1. After watching this module with client Mark, there are a few questions I would ask to help move forward with the behavioral activation. However, I would first begin with acknowledging, praising, and emphasizing Marks efforts, as well as the value he gives to himself for completing a task. For example, Mark was very proud of himself for getting out of bed a half hour early and being able to make breakfast. Here, it wouldn’t be important to praise mark and validate his feelings of accomplishment. A question I would ask to help move forward with behavioral activation would be “what were your general thoughts and responses to this schedule?” This question allows Mark the opportunity to express what worked for him and what didn’t, which can provide information on what activities should be scheduled and worked on in the future. Additionally, it could benefit Mark to ask him his levels of pleasure and accomplishment for each activity. This question can help to move forward because in recognizing completed tasks, even with a low pleasure rating, it can show Mark that he is making progress in completing tasks that he previously would have not attempted. This can boost his motivation to plan and complete more activities.

    Mark seems to engage in automatic thoughts that are often routed in feelings of being unlikeable or rejected by others. In this case, Mark questioned the value of the relationship with his friends, and jumped to conclusions after they canceled dinner plans. Mark expressed “Do they value me? Do they value this relationship”? In order to move on with behavioral activation and schedule more social activities with him and his friends, this negative automatic belief should be addressed and modified. If not, Mark will continue to feel that he is not valued, which may result in issues with planning social activities. Additionally, in the video, Mark engaged in some negative automatic thoughts in regards to his job with recruitment. He expressed negative thoughts of self-blame and personalization when asked about recruitment— “Am I doing a good enough job”. This negative thought is important to pay attention to and challenge with Mark, in order to return to that state of “I used to not have a problem with completing a recruitment job”. Challenging and Modifying his negative automatic thoughts of self-blame will allow mark to complete his work activities without anxiety.

    2. In modifying negative automatic thoughts, it is important for the therapist to begin with eliciting them, or teaching their clients how to identify these thoughts in and outside of therapy. During session, a therapist should listen to a client’s verbal and non-verbal cues such as their language, fidgeting and changes in facial expressions. Noticing these actions may allow the perfect opportunity to bring a client’s thoughts to their attention and help them to identify the thoughts that lead to different or negative expressions. However, once these thoughts have been identified, it can be difficult to modify them. In this case, a therapist may have a difficult time identifying which thought focus should be placed on. Once a negative thought is identified, I feel that this could uncover more and more negative thoughts, making it difficult to be able to determine which thought is most important. Ultimately, a therapist should focus on thoughts that are likely to bring about the greatest change and that adhere to the client’s goals. Additionally, difficulties may arise when a client has a difficult time in understanding the difference between emotions and thoughts. In this case, it would be important for the therapist to remind the client that thoughts are what elicit their emotions. Finally, in modifying automatic negative thoughts, Socratic techniques can be utilized. However, you may encounter challenges when you are unsure of which method to use. Here, it wouldn’t be important to remember that finding evidence that supports the negative thought should be the first step in modifying it. This is because not all negative automatic thoughts need modifying, only those that are invalid.

    Reply

    • Deanna
      Oct 08, 2018 @ 15:42:58

      “This question allows Mark the opportunity to express what worked for him and what didn’t, which can provide information on what activities should be scheduled and worked on in the future. Additionally, it could benefit Mark to ask him his levels of pleasure and accomplishment for each activity. This question can help to move forward because in recognizing completed tasks, even with a low pleasure rating, it can show Mark that he is making progress in completing tasks that he previously would have not attempted. This can boost his motivation to plan and complete more activities.”

      Sam,
      I want to jump on your train of thought. I was thinking the same thing here. I like how you added that asking Mark this question can help him gain more insight into his schedule and activities, in terms of which he struggles with, which he gains more or less pleasure from, as well as what he can do for the future. I especially like how you remarked on how Mark can see his own therapeutic progress through completing tasks on his schedule that he had avoided or had not been doing before due to his distress. I agree that this task is great for Mark because he can see his own progress and gain a better sense of self-efficacy and motivation to continue to work hard on his therapy and its related techniques. Nice post!

      Reply

    • Amanda Russo-Folco
      Oct 08, 2018 @ 19:21:09

      Sam, I absolutely agree with your statement about modifying Marks negative automatic thoughts. In order for him to continue to schedule his social activities, his negative automatic thought of being undervalued and rejected is very important and needs to be changed. If not, then he will be stuck in his old ways and will go backward instead of forward. I also liked how you talked about Mark and his job recruitment. In order for Mark to be able to move on, he needs to feel that he is good enough at his job again and that he can get through it. Having Mark do these tasks is a good homework assignment that is going to be very effective for him in the long run. I’m happy to see that we had similar thoughts!

      Reply

    • Alyce Almeida
      Oct 11, 2018 @ 22:27:31

      “Ultimately, a therapist should focus on thoughts that are likely to bring about the greatest change and that adhere to the client’s goals”

      I really like the focus on the thoughts that bring the greatest change. Dr. V mentioned in class about what if we ask therapists just questioned every thought- it’d be useless and a waste of time! Finding the thoughts that has the higher potential of change or may have a a higher quality in client response are the thoughts to best focus on. This will most likely promote more collaboration and success in the modification process, as the client would see the achievement of thus goals as attainable. Great job!

      Reply

  5. Shannon O'Brien
    Oct 08, 2018 @ 20:16:01

    I would like to question Mark a little further on the amount of control he has over his friends canceling dinner. As pointed out in the video, his automatic thoughts consisted of feeling unlikable and feeling unvalued in their friendship because they canceled. Those thoughts were addressed in the video, but the fact that he then withdrew from making dinner with Melissa is what I would want to explore further. Despite not being able to control his friends canceling, there were other aspects of that night that were within his control, such as continuing to help Melissa. I think the situation with his job also falls into my curiosity of his sense of what he can and cannot control. He seems unsure as to whether or not the recruitment is not going well because of something he is personally doing or whether it is the company or people just not applying for the jobs. He clearly personalizes the situation and states he feels dread and guilt when thinking about recruitment. This may cloud his perspective on how much of this really is under his control, which in turn causes him to feel overwhelmed. I’m also curious about how his morning routine is going to continue to progress. I think I would have asked if he could see himself continuing to get up early long-term. I think the automatic thoughts/core beliefs that warrant further attention are the ones of being disliked and undervalued. Mark perpetuates this through personalization, jumping to conclusions, and assuming. I thought that challenging the thought/belief of feeling unvalued by asking how Melissa felt about their friends canceling as well as asking “would friends say they want to come to dinner if they didn’t actually like you?” was important. Mark was able to ponder this new explanation and then further challenge this thought/belief.

    There are several challenges therapists may encounter when attempting to modify a client’s negative automatic thoughts. First, therapists must use psychoeducation in order to explain the fundamental components of automatic thoughts. Here, therapists must explain that automatic thoughts are experienced by everyone, in addition to some people experiencing distress when they are not aware or unable to change these thoughts. Therapists then must help clients elicit and identify their maladaptive thoughts. Therapists need to be able to actually elicit a negative automatic thought as well as identify one when clients state one without being prompted. This can be accomplished through guided discovery, guided imagery, roleplay, differentiating thoughts from emotions, and tracking automatic thoughts. Once they are able to recognize that these thoughts are even occurring, then therapists and clients can move on to the evaluation of those thoughts. Evaluation and modification of thoughts is the next step or challenge for therapists and clients. Determining if these thoughts have therapeutic relevance is essential before diving into modification. Therapists can accomplish this by focusing on emotion intensity, believability, or an event/person the thought may be attached to. Finally, the modification of these thoughts can be accomplished through examining the evidence in order to determine if the thought is invalid, decatastrophizing perceived negative outcomes, exploring possible alternative explanations, accessing the impact of believing the thought, separating self from the thought, and shifting attributional biases. Some of these techniques may not be suitable for one type of negative automatic thought, so it is up to the therapist to decide which technique will be most beneficial to the modification. So many of these steps pose challenges to therapists as there is room for variability. Therapists must be able to overcome the general challenge of clients (such as not participating in homework assignments, or being reluctant to share information) in addition to using their best judgement throughout all of these steps.

    Reply

    • Becca Green
      Oct 12, 2018 @ 21:17:43

      Hi Shannon! I also had some thoughts on the amount of steps you have to take with eliciting automatic thoughts and how quickly the whole process happens. I think that determining whether the automatic thought is harmful enough to need to go forward with it or if it isn’t, for lack of a better term, worth moving forward with. Definitely a lot to think about, but I think it will feel less scary when we’re in the middle of it. And if not, we can always move back and talk about previous thoughts.

      Reply

    • Mikala Korbey
      Oct 13, 2018 @ 12:03:57

      Shannon, I really like that you mentioned focusing on the things that are and aren’t within his control, I did not think of focus on that. That is an issue that clearly Mark struggles with and is worth exploring. Maybe the whole idea of identifying what is and is not within his control is something he could work on doing. I also would want to get at, what about his job does he find so difficult, like what part of recruiting. Also, maybe it would be important to know why he thinks he is not good at it. But overall, I really enjoyed reading the questions you had, and they definitely got my mind rolling.

      Reply

  6. Jayson Hidalgo
    Oct 08, 2018 @ 21:37:57

    Other information I want to know about Mark is if there was ever a time Mark had this feeling of “unlikeable” with his friends. The daily activity scheduled included that his friends were supposed to come over, but actually never came over. I want to know if Mark’s friends have ever made Mark feel this way before. I want Mark to think back to another time when he had this feeling of unlikeable. Another thing I would want to know about Mark is more on what he felt about not being able to go through something or have things go as planned. He mentioned he was upset that his friends did not come over, but he never really went into detail about his feelings and thoughts about not being able to accomplish something. The automatic thoughts and core beliefs I believe deserves attention is his belief of believing he is essentially “unlikeable”. He mentioned that he was upset that his friends did not come over and then brought that to a whole other level when he said he thinks his friends to not like him. It was a dramatic leap of thinking and Dr. V helps Mark realize that by saying he brought it to a whole other level. As I said before, I want Mark to bring up any other examples of when he felt “unlikeable” involving his friends. This could help him realize and realistically see that his friends do actually like him and are continuing to talk to him and schedule plans to meet up with him. This can help Mark understand more about his negative core beliefs with negative automatic thoughts.

    One of the potential challenges I know I will encounter as a therapist when attempting to modify a client’s negative automatic thought is being able to determine which automatic thoughts I should focus on. I know the therapist is supposed to evaluate the most distressing and most believable negative automatic thought to focus on, but I am afraid I will want to focus on more than just a few negative automatic thoughts. Sure, the therapist will deal with the most distressing thought, but that does not mean that once the therapist is done with that thought, the client will be completely relieved from distress. There are still other negative thoughts along with other negative emotions that can still cause distress to the client. I want to focus on all of them, but since time is limited, the client and I will have to choose a negative thought to focus on even though there may be a slight possibility I would like to focus on another negative automatic thought. If it is possible, I would like to eliminate a client’s full distress rather than just eliminate a chuck of it. I am aware that people will always have stress, but I just want to get rid of much distress as possible.

    Reply

    • Mikala Korbey
      Oct 13, 2018 @ 12:11:02

      Jayson, to quote you “He mentioned he was upset that his friends did not come over, but he never really went into detail about his feelings and thoughts about not being able to accomplish something.”

      I wonder if its not so much that he couldn’t accomplish something, and more if his feelings came about because his friends cancelled on him. But him not being able to complete the task could definitely be at play here. Having him walk through the situation and dispelling exactly what he felt, as you mentioned, could help him be able to mention more emotions and thoughts that were going on. Especially what we saw last class, when his co-worker did not want to go to lunch with him. It seems like his feelings of being unlikeable are a common theme for him and really worth exploring.

      Reply

  7. Mikala Korbey
    Oct 09, 2018 @ 19:30:55

    Behavioral Activation:
    Some of the questions I might want to ask Mark are:
    -What were the activities that gave him good pleasure? Also maybe focus on what made him feel good? Use it as an opportunity to briefly highlight that and remind him to continue doing what makes him happy
    -Maybe ask what activities felt okay but gave him higher levels of accomplishments?
    -He mentioned an activity that made him feel proud of himself, what else makes him feel proud?
    -When his friends cancelled last minute, what did he do to help himself feel better in that moment?
    -What might help you to better cope next time when friends cancel? How are you able to notice negative feelings coming on? When you do notice them, do you try to combat them? Or do you let them in?
    -He had mentioned something that sounded like he withdrew for a little while shortly after his friends cancelled so I would want to ask how can we make it so he does not feel like he needs to totally shut down?
    -Would he want to try and get up 45 minutes earlier to try to sit and eat? Or is it not important enough for him or is he happy how with the 30 minutes went? I am only thinking 45 minutes so that maybe he can sit down to actually eat your breakfast if that is important to him.
    Mark’s automatic thoughts that stuck out most to me are- “Do they even want to be friends with me? Do they value me? Do they value this relationship?” Mainly surrounding his friends canceling on him and his girlfriend Melissa, and seem to fit the category of core beliefs surrounding unlovability. These thoughts seem to be the most important and could affect other areas of his life, if he does indeed feel unlovable.

    Automatic Thoughts:
    Automatic Thoughts can be very difficult to detect and modify, especially when the client is unaware of them. There is the possibility for many issues or challenges to arise when working to modify client’s negative automatic thoughts. It is possible that the client struggles to see their thoughts as negative, and may have trouble deciding which ones are most relevant to their distress. They may even have difficulty stating what is going on in their mind at any given moment. Also, sometimes it can be hard to know how distorted the client’s thoughts really are compared to the objective facts of the situation. The therapist does not want to approach modifying their thoughts as “challenging” their thoughts because you do not want the client to feel invalidated. Additionally, the client also may struggle to see any evidence opposing their thoughts because they are so deeply engrained. It is possible that the client does not truly understand the difference between thoughts and emotions. They may say that they understand, but struggle to prove that they do. It is possible that the therapist is experiencing difficulties when trying to choose the correct Socratic question to ask their client. The therapist may also experience difficulties when trying to decide which automatic thoughts are the most important to focus on.

    Reply

    • Melissa Pope
      Oct 11, 2018 @ 11:16:07

      Mikala,

      First off I must say, how impressed I am with the organization of thought in your response. I agree with everything you said. I too also think it may be helpful to find out if Mark is satisified with waking up at the time he did or if an extra 10-15 min may help him to feel less rushed and ready for the day. I did not think of, but completely agree with knowing what else makes him feel proud. I feel like so much of therapy has this shadow that is casted on focusing on fixing the negative when we should equal our time and energy, even briefly on the positve and adaptive parts in a pesons life to reinforce behavioral outcomes we want to increase. I also did not think of how Mark is noticing his negative feelings and how he is coping with them when he notices. Very good insight.

      Reply

    • Nicole Plona
      Oct 13, 2018 @ 10:26:47

      I really like and appreciate how you set up this post because it makes the questions you wanted to ask Mark clear and easy to follow. I definitely feel as though I’m going to use the more bulleting type of structure next time we have this type of discussion. Aside from that I also agree with the types of automatic thoughts you pointed out. Alot of his anxiety and depressed mood was surrounded by the ideas of if people actually liked him or wanted to be around him. These are the types of automatic thoughts that I would want to first focus on when moving forward in the sessions.

      Reply

  8. Becca Green
    Oct 10, 2018 @ 22:50:35

    Now that Mark has gotten the chance to try out the Daily Activity Schedule and has a better idea of his own schedule, I would want to further ask what he felt was missing from it. By this I mean that the focus on his schedule was obviously to plan something specific and then look at other parts of his day and how he was feeling about these activities compared to how he felt about them after. I would want to ask to see if he could notice any gaps in things he thinks he should be doing or wants to do that aren’t on the schedule. For example, if he wasn’t thinking about little personal care routine items or things that he used to do everyday that he doesn’t do anymore that he might have forgotten about. Even if these things aren’t the main goals to work on in therapy they can still be addressed in a more passive way to help bring more positive outcomes along with the main goals being addressed. It is possible that Mark may have replaced some positive aspects of his life with these maladaptive behaviors due to his negative automatic thoughts, and bringing these out may help him change his maladaptive behaviors. Moving forward the negative automatic thoughts that I think need to be addressed surround his feeling of not being liked. This was something noted as Mark he spoke about his friends canceling plans at the last minute and how he began to think that maybe his friends don’t like him or don’t want to spend time with him. This led to him feeling overall that he is unlikable. Although this has already been somewhat addressed it does need to continue to be looked at a evaluated in order to help change this automatic thought into a more realistic and positive one. Another automatic thought I noticed from Mark was the general idea that he is not good enough. I noticed this with both of his comments on being mad at himself for not making bigger improvements in his morning routine and for internalizing the lack of people taking jobs with his company.

    One of the main challenges I can see encountering as a therapist is not recognizing the stage of change accurately or pushing change before the client is really ready for it. I can also see a challenge in being able to elicit the emotions or negative thoughts in a way that isn’t more harmful to the client. It could also be a challenge to have the client recognize the automatic thought on their own and then be able to use the techniques learned in therapy to modify the thoughts in the moment. It may also be a challenge to understand which negative automatic thoughts are connected to certain core beliefs, and to then be able to see which are most critical to modify. The limit on the number of sessions allowed can impact the ability to address all negative automatic thoughts or core beliefs, so the goal is to be able to teach the client how to use the skills learned in therapy to apply it outside of therapy and in the future. It can also be challenging if the negative automatic thought or core belief if accurate to the client. In this case it would be more of accepting and adapting which can be challenging to move forward in.

    Reply

    • Melissa Pope
      Oct 11, 2018 @ 10:20:29

      Becca,

      I too agree with it being a challenge to elicit an appropriate response to the techniques being used. I am very afraid of challenging a negative automatic thought or core belief in the wrong way and it backfiring for the client. I think that the tools that are provided to help the client (thought records, graded task assignments) do make it easier but i also would not want to jump to these tools too fast without the client being ready to use them. Also what happens if they use them and there not helpful or they make the client feel worse about themselves.

      Reply

  9. Melissa Pope
    Oct 11, 2018 @ 10:12:39

    Behavioral Activation:

    I would like to know if Mark thinks that with the extra time he had in the morning, if he for now is satisfied with just at least getting up early and making a better breakfast or if he would like to have a few minutes more to be able to eat his breakfast at home.

    Would going to bed early, if he can attempt it again with different strategies help, or does he enjoy being up at night.

    In regards to work, the pressure seems to be a big part of his struggle and its exacerbated by his internal pressure and lack of concentration. Does he feel like more time at work to organize may help. The graded task assignment, which was assigned is a good way to break down the bigger picture to organize but I feel that once that is completed the next step would be to break each of those components down even further to a more easy to handle time line. Also in the past he said that he felt he could handle the job much better, without the negative automatic thoughts. What about the past has changed for him personally, despite the depression. And has anything internally at work (ie structure, role management) changed to maybe add to his job description or make the task harder.

    I think the overall automatic thought that seems to flow from home life to work life of, “am I good enough” needs a lot more attention. He seems to continue to have this automatic thought consistently in all facets of his life. When at home with friends who cancelled and then at work with not getting the recruitment results he is looking for. Exploring the actually validity of this thought needs to continue so he can put the events into a more realistic perspective. I also think this automatic thought ties into some core beliefs that he doesn’t feel good enough, and being a perfectionist as he mentioned cyclically put more pressure on himself to be unrealistically better.

    Automatic Thoughts

    After the readings outside of class and in class lectures, thus far, there are a few challenges I believe will be hard to overcome as a therapist, in attempting to modify a client’s automatic thoughts. The first of these is having the ability to narrow down the many negative thoughts in session to the ones that may need modification. Also, being able to decipher common themes amongst different negative thoughts to have insight to main issue (core belief). After evaluation, I also think it will be a hard transition to segue from one step in the modification process to another and still keep a smooth flow in session and high rapport. Once, pinpointing the negative automatic thought, I feel as if the literature is very concise and straightforward in what to do, especially with the tools accessible. I believe that the implementation and use of the specific tactics or strategies (thought records, thought trackers, ect.) is well broken down to use, but actually figuring out which one to use will be difficult. Lastly, most of the socratic techniques I feel are very helpful to challenge a clients negative automatic thoughts and for them to gain a realistic perspective of there cognitive process, but I feel that I will be hard to use a lot of these techniques in a way that “shows” them that there thinking is not realistic without coming off as bold or un-collaborative.

    Reply

    • Shannon O'Brien
      Oct 13, 2018 @ 16:42:44

      Melisa, I really enjoyed your comments on negative automatic thoughts. Especially the one about deciphering common themes among those thoughts in order to get to the underlying core belief! As we have read throughout some chapters, it seems that generalizing a negative thought from one bad experience to the next, or even to a slightly similar experience frequently occurs. Eventually, the feeling of inadequacy in math, generalizes to feeling inadequate about several subjects, and then to activities outside of the classroom because the negative automatic thoughts happen so frequently. This also help us to determine if there are any negative automatic thoughts that are not generalized and seem to only pertain to a specific experience or interaction. Thanks for this important reminder!

      Reply

  10. Marissa Martufi
    Oct 11, 2018 @ 14:46:03

    After watching the behavioral activation video, which included reviewing the completed daily activity schedule and graded task assignment, some additional questions that I might have asked Mark in session, came to mind. First, I think it may be helpful to also ask how the use of the activity schedule has changed his responses or reactions, prior to therapy and implementing the activity schedule. This may be beneficial to seeing how this is successful or beneficial to the client and gain some feedback. It is great that Mark has completed the homework, and it also seems he is comfortable reflecting on what he filled out in the activity schedule. Going forward, I might have then asked which activities he felt gave him the highest or greatest sense of accomplishment, while reflecting on the week. Talking about activities can serve as reminders for what brings him pleasure, and also produces more positive thoughts and feelings. It appeared that he was very excited and prepared for the dinner plans with friends, however this quickly changed when his friends cancelled at the last minute. Therefore, focusing on the the activities that brought him pleasure or accomplishment, might be helpful to remind him of what brought him positive feelings as opposed to negative; something he can also use as a way to cope. In relation to this, I may have also asked how he can cope, or how he might cope in the moment when things do not go as planned, similar to how his friends had to cancel at the last minute when they had originally planned for dinner. I might have also asked what coping skills he used when his friends cancelled. This can be helpful in leading the conversation about coping and managing thoughts and emotions in the presence of a negative or disappointing experience. The automatic thoughts that could warrant further attention moving forward would be his thoughts or beliefs regarding his job and its requirements, as well as his thoughts surrounding his friendships. It appears that when things do not go the way he planned, or as intended, Mark feels distress or negative thoughts. As mentioned in the video of the therapy session, Mark referred to beliefs that he was un-liked. As the therapist (Dr. Volungis) mentioned in response to this, if his friends did not like him, they most likely wouldn’t have made the original plans with him to begin with. I think that going forward, it would be helpful to address the thoughts and beliefs of feeling as though he is not liked, in order to help change these thoughts to more positive ones. In addition, coping strategies with these thoughts will also be important to how Mark manages similar feelings in the future.

    As a therapist, there are several challenges. However, there are several potential challenges when attempting to modify a client’s negative automatic thoughts. I think the first challenge is helping the client to identify these automatic thoughts and how they are impacting their lives, negatively. I think this is something that is challenging because as Dr. V mentioned in chapter 7, many individuals are unaware of their automatic thoughts. Although negative automatic thoughts are firmly believed or valid to the individual, they may not necessarily be aware of these thoughts because they are experienced spontaneously and are not always constant within the individual (Volungis, 2018). As a therapist, it is your goal to help transform client’s automatic thoughts to more positive ones, but this cannot be done without collaboratively identifying these thoughts in sessions. Because these automatic thoughts are almost always believed to be valid, it can be difficult to specifically target the thought(s) and acknowledge them without disproving or disregarding the beliefs held by the client. However, it is important to understand that some automatic thoughts may also be valid. I think this is another challenge as a therapist, because it may result in a client being resistant to change their thoughts. The challenge with regard to this may also be appropriately helping the client to manage their distress although their thoughts are valid. It is easy to assume that all automatic thoughts are negative or invalid and must therefore be transformed. However, in some cases, it is important to target the distressing component although the thoughts may be valid.

    Reply

    • Alyce Almeida
      Oct 11, 2018 @ 22:41:57

      Marissa, I liked your focus on the pleasurable activities and accomplished goals for Mark. You incorporated reminders to repeatedly promote positivity and I think realization in what Mark struggles with heavily which is his feelings of unlikable or unlovable. Strength based is always the way to go as we’re taught repeatedly. Using the worksheets to help guide this is a good process that we should get comfortable with as professionals. I agree with your ideas greatly!

      Reply

  11. Nicole Plona
    Oct 11, 2018 @ 16:03:30

    (1) When it comes do additional information that I would want to hear from Mark about his daily activity logs would be if there were any attempts to make the problems he seemed to be having, change. For example, when he is tired and up late at night, was there any attempt to try an activity that normally makes him more tired? I would also want to know if trying different routines and adding other activities like that are challenges that don’t cause too much extra discomfort and stress in his day. When Mark discussed his plans falling through I would want to know not only what he was feeling at the time but if he did anything to rationalize his feelings or thought. In those situations it would be common for Mark to have negative automatic thoughts are his friends cancelling plans but I would want to see if he I working to fix those types of responses.
    (2) When it comes to Marks automatic thoughts/ core beliefs, I feel as though his serious and self-defeating negative thoughts would be what needs the most focus. If Mark is in a state that makes him feel as though his friends are canceling on him because he is worthless or not good enough for people to want to hang out with, it can them lead to further depressed behaviors and issues later on. By working on these self-defeating or extreme negative thoughts it would eventually benefit the structure of the therapy sessions progress.
    (1)A potential challenges a therapist may encounter when trying to modify a client’s negative automatic thoughts could be ignoring or invalidating what a client is feeling. If a client feels as though they are worthless and nobody likes them then it would be the therapist’s job to make them understand that that is irrational. However, this can cause the person believe that the therapist is not validating their feelings. If someone is feeling sad or mad it is the job of the therapist to let them know that what they are feeling is normal but then learn how to progress past that. The same thing goes for these automatic thoughts. They might feel worthless and other people sometimes may feel that as well, but it is important to work with them to move past and rationalize these thoughts.

    Reply

    • Shannon O'Brien
      Oct 13, 2018 @ 16:49:39

      Nicole, your comments on Mark’s self defeating thoughts were spot on and I wish I had seen his experience from this perspective. I think a further depressed behavior he will exhibit is self-isolation. If he starts to feel that everyone will just cancel on him, then he may just stop inviting people over to begin with. He will most likely start to think, “What’s the point of even putting in the effort to call and invite them? They’re just going to cancel anyway since they don’t like me.” That is definitely something to attempt to avoid and work on proactively!

      Reply

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Adam M. Volungis, PhD, LMHC

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