Topic 5: Behavioral Activation & Automatic Thoughts {by 2/27}

[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 2/27.  Have your two replies posted no later than 2/29.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

34 Comments (+add yours?)

  1. Robert Salvucci
    Feb 24, 2020 @ 14:09:21

    Happy Monday fellow scholars!

    Behavioral Activation

    1. I’m curious as to some of the specifics regarding Mark’s schedule. He mentions feeling rushed in the morning and a sense of being overwhelmed at work, so ideally I’d want to gradually help Mark craft a schedule that minimizes behaviors that are irrelevant to his productivity, well-being, and sleep schedule. We don’t get a sense of the activities Mark is engaging in when he wakes up other than breakfast, his time at work, or his nighttime routine.

    Highlighting his morning routine may give hints into ways he can be more efficient and productive, he may or may not be procrastinating on getting ready and engaging in distracting behaviors like playing on his phone or watching TV, or other behaviors that cut into his time getting ready. Aside from opportunities to increase mastery and pleasure experiences, looking at his nighttime routine may offer opportunities to set an earlier bedtime, allowing him to slowly get into the habit of getting a better night’s sleep while waking up a bit earlier, which could mitigate his feeling of being rushed in the morning and contribute to increased focus, mood, and energy at work.

    Mark mentions his thoughts and feelings related to being not good enough and feeling overwhelmed at work. This is also an opportunity to use behavioral monitoring to investigate how he is actually spending his time at work. He may find that he is most productive at a certain time, or that certain behaviors like browsing facebook or eating a sugar snack etc.. decrease his motivation and lower his mood. Certain negatively reinforcing behaviors may also serve as a distraction, and if he were to minimize then and behave more systematically, he may find that he has more time at work then he initially realized, and implement graded task assignment techniques more effectively.

    2. I’m usually inclined to link automatic thoughts and core beliefs to overarching tendencies, and I notice that Mark mentions perfectionism and seems to have a pervasive sense of not feeling good enough. His response to his friend’s cancelling also seems to be indicative of a general tendency to personalize and catastrophize, however I’m curious if the fear of his friends not caring about their relationship is linked to some preoccupied anxious attachment tendencies that operate independently of his depressive episode.

    The perfectionism Mark mentions pops up all throughout the session. He mentions briefly feeling angry for not having his morning go as planned, he mentions that he seems to never be satisfied with his work since his depressive episode, and he mentions that his friends cancelling created distress partially because things didn’t go as planned. Dr. V also points out his tendency to be intolerant of ambiguity and fill in the blanks with worst case scenarios. This intolerance of ambiguity seems partially to be a result of a desire for things to always go as planned. This may be related to needing or having an unrealistic expectation to mitigate anxiety caused by low self-efficacy beliefs in regard to being flexible in new situations.

    Automatic Thoughts
    I believe one of the biggest challenges to modifying automatic thoughts and core beliefs lies in the reluctance to changing ways of thinking about oneself that are comfortable and familiar.

    Sometimes we self-handicap ourselves as a means to avoid responsibility. If we’re depressed or anxious and accept the fact that we are, in fact, intelligent, competent, and capable, then how many things will we need to change in order to reach our potential? Many negative emotions and thoughts worry in particular, function as protective mechanisms. They motivate us to avoid potentially threatening, scary, and difficult situations. Cognitive distortions around daily events make them seem much more threatening or difficult than they are, which makes us feel justified in our avoidance of doing things we otherwise know will make us happy, things like exercising, changing our diet, minimizing substance use, asking someone out, being vulnerable, asking for a promotion, etc.. Part of human nature seems to be taking the path of least resistance to achieve desired outcomes and repeating cognitive and behavioral patterns that have been engaged consistently, often times patterns that originated in childhood.

    The idea of adopting novel ways of thinking can sometimes feel like deep parts of us are changing. These thought patterns may have been habitual ways of thinking about the world for many years. Changing them isn’t always as simple as identifying them and then writing down and saying a more realistic thought, it takes a lot of practice, motivation, and consistency to slowly alter these patterns. Ironically, many clients will have negative automatic thoughts about changing negative automatic thoughts, which puts some responsibility on us to communicate how the process works and to instill a sense of hope, optimism, and the importance of a scientific attitude.

    An incredibly important component of successful therapy is having a client leave with the willingness to engage in meaningful but difficult tasks on a regular basis, despite the occurrence of negative automatic thoughts. As we help clients realize the illogical nature of their thoughts and beliefs, they become more able to appraise situations realistically and commit to action despite having a bad feeling or negative thoughts about a situation. It is important to offer psychoeducation about habits and that the initial resistance to change is very likely going to decrease over time, especially if committed to consistently. The idea of finding time to work in exercise or meditation or journaling or almost any taxing new behavior often seems undoable or overwhelming. However, when we’re doing these things with consistency and they become a habit, the resistance begins to fade and out brain accepts them as part of life, we even begin to expect these behaviors to occur. This is the case with automatic thoughts as well. One of the most motivating parts of CBT is the potential to slowly change one’s internal dialogue to be more realistic on autopilot. The more clients practice a way of thinking, the more natural it begins.

    Reply

    • Ashley Foster
      Feb 27, 2020 @ 19:49:47

      Hey Bobby!
      I like how you mention looking into Mark’s evening schedule. I think at first glance it is easy to jump to conclusion and just focus on Mark’s morning schedule, but we could learn a lot about Mark and the origins on why his mornings he seems to struggle so much based on his evenings. I also like your thoughts on his perfectionism. I think a lot of his maladaptive thought could be manifested by this core belief and should be further more examined.
      Great Job with the post!

      Reply

  2. Renee Gaumond
    Feb 24, 2020 @ 16:41:42

    (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?
    I’d like to know more about activities that were initiated and completed at work as well as activities that were initiated and not completed. It’s be good to know what exactly he is getting accomplished and what is not being completed at his work in order for him to feel like he’s not good enough and overwhelmed at work. It may benefit Mark to rate his accomplishment for each activity that he attempts at work in order to monitor possible times of the day that work best for him. If Mark is in fact, accomplishing a lot at work and just feels like he’s not, this may show up well on the weekly activity logs. If he’s not getting things done, this will show up too. So it’d be beneficial to know if what types of tasks he’s completed at work and which ones he’s not.

    (2) What automatic thoughts (or core beliefs) do you think warrant further attention moving forward with more cognitive techniques?
    I think Mark’s perfectionism is a thought process that should be given attention. His low sense of accomplishment at work may be due to the perfectionism telling him that whatever he is getting done isn’t good enough. The cognitive technique of disputation may benefit Mark with his perfectionism. If he ever notices he’s engaging in perfectionistic thoughts, he should take a step back and identify irrational beliefs that are causing the self-debilitating thoughts. By debating his thoughts, he can find the falsehoods in them, allowing him to change his perception of his accomplishments.

    (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)?
    A challenge I might find is what to do when a client doesn’t complete the weekly activity log. It’d be important to access why the activity log was difficult to complete. Asking the client about the homework would be beneficial. They possibly didn’t understand how to do the homework or they might have been overwhelmed or distressed by the task. Exploring thoughts and feelings around why the homework wasn’t completed could be good insight into some difficulty the client may be having completing other tasks such as work demands. It may take time for the client to learn how to be active in the therapy process. The reason could also just be because of the therapist’s lack of attention to the homework.

    Reply

    • Jessica Costello
      Feb 26, 2020 @ 14:14:01

      Hi Renee! I like how you suggested differentiating between what Mark has started working on and not finished versus what he’s actually accomplished. This would be a good way to establish the validity of his negative automatic thoughts surrounding his perfectionism. I also think that his perfectionism, which is rather obvious in his work activities, could also apply to his reaction to the friends’ cancellation as an example of personalization. He blames himself for them not coming to dinner, when the actual reason most likely has nothing to do with him. I think future interventions with Mark should focus on the perfectionism as well.

      You also made a good point about the client not being engaged in or interested in completing the therapy homework assignments. That only reinforces why therapists should monitor the homework. Good job!

      Reply

    • Melanie Sergel
      Feb 26, 2020 @ 15:43:28

      Hi Renee! I also think that Mark’s perfectionism should be looked into further. His perfectionism could be affecting how he views his accomplishment level. It also seems to impact how he puts himself down even if he accomplished a certain task. I like how you make the point that the cognitive technique of disputation could benefit Mark with his sense of perfectionism. I think that would be very helpful for him. I also think I may struggle if a client does not complete the weekly activity log. With any homework assignment a client does not complete, it can be challenging for therapists because they expect the client to put in work too. I agree that it would be very important to explore why the assignment was not completed, including the thoughts that occurred with why it was not done, and it could have also been the therapist not explaining the homework assignment well enough for the client to understand.

      Reply

    • Erin Wilbur
      Feb 27, 2020 @ 18:50:17

      Hi Renee,
      I really like how you suggested a specific technique that you thought would help Mark with his perfectionism. Disputation would definitely help him because he already has a good level of insight, so he should be able to debate these irrational automatic thoughts. This would improve his insight and hopefully help him cope in more healthy ways as opposed to isolating.

      Reply

  3. Shelby Piekarczyk
    Feb 24, 2020 @ 17:25:40

    1. When listening to Mark speak about his day and his thoughts about what has happened, I would want to further understand his morning routine, and his friends not making it to dinner. When listening to Mark talk about his morning I would ask him how waking up earlier and being able to cook breakfast made him feel in the moment and throughout his day to follow. If Mark felt good about his morning routine this could correlate with feeling better at work and being more productive. I would like to know if Mark felt this way and saw an increase in his work productivity after waking up earlier in the morning. Additionally, Mark stated by the end of the morning he began to feel rushed again. Moving forward if Mark made a plan to lay out his clothes and belongings for work the night before, which would lead to more time in the morning. I would also ask Mark if he engages in miscellaneous activities (e.g. watching tv) in the morning that could be minimized. Another question I would ask Mark is if he spoke with Melissa about how she felt regarding their friends not making it to dinner. Hearing her thoughts/emotions about the situation could possibly help Marks in the moment negative thoughts.

    2. I think the automatic thoughts/core beliefs that elicit further evaluation are Marks feelings of being unlikeable and his self-blame, feeling like he is not good enough. These specific automatic thoughts and core beliefs are negatively impacting Marks life and are irrational thoughts that have developed. For example, Mark believed that by his friends cancelling their dinner plans, this meant that his friends did not like him and no longer wanted to be his friend. However, this is an irrational thought because Marks friends informed Mark, they could not make it because of a family problem. Using cognitive techniques for these negative thoughts will help lead Mark to a more fulfilling social and professional life.

    3. I feel as though the hardest component to handle when encountering an automatic thought is the validity they hold for an individual. Automatic thoughts are seen to be true and concrete, where the individual may be unaware, they are experiencing one. Because automatic thoughts are so concrete, the challenge for the therapist will be revealing that automatic thought to their client and then changing it to a more adaptive thought. Additionally, automatic thoughts are shown as emotions, so helping the client to discover this emotion is an underlying thought will be a challenge for the therapist. Helping the client to understand this thought as negative and want to make the change will be a challenge for the therapist.

    Reply

    • Jessica Costello
      Feb 26, 2020 @ 14:29:32

      Hi Shelby! I agree with you on wanting to know more details about Mark’s morning routine. That would allow him and his therapist to work on making specific changes that he could track with future activity logs and then connect to how he felt after making those changes. You also made a good point about asking Melissa how she felt about the friends not making it to dinner. Seeing what another person thought about the situation would help us see whether Mark is reacting rationally.

      I also agree that challenging a client’s thoughts will be difficult because they manifest as emotions, which are so real and valid to the client, regardless of the actual thought’s validity. Though it will be challenging, I think therapists can begin to work at changing these difficult thoughts and emotions through psychoeducation and explaining the models we work with. Great job!

      Reply

    • Erin Wilbur
      Feb 27, 2020 @ 19:05:52

      Hi Shelby!!!!!!!!!!!!!!!!!!!
      *thumbs up emoji*
      I agree that I’d like to know what Melissa thought about their friends cancelling dinner. Mark mentioned that he withdrew briefly after getting the phone call but that Melissa asked for his help shortly after, and he obliged. I’d definitely like to know if he spoke to Melissa about it because it will help us to understand if Mark coped with these feelings himself or if talking with Melissa helped him to think about the situation in a more rational way.

      Reply

    • Renee Gaumond
      Mar 02, 2020 @ 12:16:25

      Hi, Shelby,
      I agree that his automatic thoughts and core beliefs of him being unlikable is something that should be evaluated more. These thoughts and core beliefs are feeding into each other and with his personalization of cancellations, the beliefs only get stronger when the thoughts aren’t being addressed. Mark was given the explanation of a family problem from his friend, though he still ruminated on how it was because of him and that the real reason was due to people not wanting to be around him. Focusing on the automatic thoughts and core beliefs would help him with his distorted thinking such as personalization and rumination.

      Reply

  4. Erin Wilbur
    Feb 24, 2020 @ 19:16:33

    1. While I was listening to Mark’s session, I was interested in hearing about a few things. First, I noticed that it was mentioned that his expected pleasure at work went up a little throughout the week, and I think that’s important to note. I would’ve liked to have heard a little more about how his actual pleasure at work influenced his level of expected pleasure when planning the following day, and if the expected pleasure increased because he noticed he was enjoying work more than he thought he was. I think pointing this out could have been helpful when he was discussing that he felt overwhelmed at work, to remind him that he isn’t always feeling that way and can enjoy working. I also would have liked to ask Mark if there was anything particularly difficult about using the Daily Activities Schedule. I think this could have been helpful for exploring possible automatic thoughts, like when he planned dinner with his friends, was he excited? Did he have those thoughts that maybe they didn’t want to spend time with him originally, or was that only because they cancelled suddenly? It could have also helped in planning for the next homework assignment, because strategies for making it easier or more manageable could have been discussed if necessary. I think getting more information about his daily routine could have been helpful too, because he mentioned that he feels rushed both during his morning routine and at work. Asking for more details about what exactly he does in the morning, and also what he focuses on while at work could help in planning more techniques to help him make more productive use of his time. He mentioned that he has trouble focusing at work, which may also be an issue in the morning, so I’m interested in hearing why this is and being able to plan some interventions that could improve his daily routine.
    2. There are two main automatic thoughts that I think are important to focus on moving forward with Mark. The first is the thought he had when his friends cancelled on dinner, whether they value him and want to spend time with him. The second is that he isn’t doing enough at his job to recruit potential employees and make people want to work at his company. It seems like these both stem from the core belief that he doesn’t think he is good enough. I think these things are important to pay further attention to in future sessions because they impact both his personal and work life and are detrimental to his self-esteem. His tendency to personalize every event makes it difficult for him to be rational and instead creates self-deprecating automatic thoughts that he is incapable or unworthy.
    3. I think the potential challenges I might face when attempting to modify a client’s negative automatic thought would be using role-play to elicit automatic thoughts and examining the evidence to determine the validity of an automatic thought. Using role-play to elicit automatic thoughts that arose from the situation can be difficult because clients may not remember the situation clearly, or may become distressed due to the negative thoughts that are elicited, and I don’t want to further the negative emotions. I also think it will be difficult with certain clients or automatic thoughts to examine the evidence of an automatic negative thought. The thought may be valid, in which case the client will not be interested in examining any contradicting evidence because they will be convinced of the thought’s truth, and may be struggling to accept this, therefore also refusing to use or learn any coping techniques. If the thought is particularly negative and elicits very strong emotions, the client may struggle to come up with evidence against it. The client may also simply refuse to think about it further, making it extremely hard to work on disproving the evidence supporting the thought. It may also be distorted, causing the client to identify supporting evidence that may not be accurate.

    Reply

    • Shelby Piekarczyk
      Feb 27, 2020 @ 18:46:29

      Hi Erin,

      I agree completely when considering Marks work situation. Since he has mentioned situations where he enjoyed work I think this would be a very important part of therapy moving forward. This can help him see the positive aspects and see that it is not all negative. I also agree with your statement about the dinner with friends and seeing maybe why he got so upset about it. Have his friends cancelled a lot in the past? Do they show excitement when talking about hanging out? This would make a difference when moving forward in therapy. Great job!

      Reply

    • Renee Gaumond
      Mar 02, 2020 @ 12:24:17

      Hi Erin,
      I agree that role play might be a challenge. I think my initial thought on role play being challenging is that clients might reject the idea of it because it could make them feel awkward. Anxious clients that are self-conscious may not want to do a role play because they might feel awkward taking on a role, especially if it involved acting out intense emotions or events that have or could cause shame. My thought in this situation is exploring thoughts about role play and reasons why role play would benefit the client.

      Reply

  5. Jessica Costello
    Feb 26, 2020 @ 13:57:28

    1. After hearing Mark’s description of his morning routine and how he feels overwhelmed at work, I would want to know more about both these facets of his life. In terms of his morning routine, he didn’t discuss much beyond his recent lack of a good breakfast. He said he felt better when he was able to cook breakfast, so I would want to get a sense of how much time he has in the morning, what time he has to be at work, etc., so that perhaps we could work together to craft a schedule that would facilitate having a healthy breakfast and other behaviors that he reported making him feel better. He mentioned the dog would wake him up sometimes, impacting his sleep schedule. I would want to know more about his environment in the morning, in particular if Melissa lives with him and if so, some potential ways she could help him better structure his morning routine.

    Another maladaptive behavior Mark mentioned that he engaged in when his friends canceled dinner was withdrawing from helping Melissa cook. I would want to know if the feelings he experienced while withdrawing into the other room persisted later into the evening or if he ever talked about them with Melissa or someone else, or how they related to what he feels about work. Counteracting this maladaptive behavior with a more positive outlet for his negative feelings is another potential goal of developing subsequent activity schedules.

    2. In regard to Mark’s activities at work, his sense of overwhelm seems to be coming from a sense of perfectionism and the belief that no matter how much he accomplishes, it’s not enough. He mentioned that part of the problem in his recruitment successes could be his company’s structure and how it doesn’t pay well. I would like to get a sense of how Mark’s coworkers feel about this issue, to be able to establish whether there really is something wrong at the company that affects everyone who works there and Mark is putting too much pressure on himself to perform at an unrealistic rate, or if Mark is highlighting a personal obstacle to getting work done.

    3. I think one challenge I foresee myself running into is eliciting negative automatic thoughts in a client by perhaps talking about different examples than situations they have already discussed in which they experienced a negative automatic thought. Participating in roleplays might also be difficult since I may not have the same understanding of the situation as the client does. Also, it may also be harder than usual to get clients to dispute negative automatic thoughts when these thoughts do have a certain degree of validity. If the thought seems to be accurate, the client may not see the value in changing it, even if they can recognize the thought’s negative influences on their emotions, behaviors, and general functioning.

    Reply

    • Melanie Sergel
      Feb 26, 2020 @ 15:35:14

      Hi Jess! I also think Mark’s feeling of being overwhelmed is coming from his sense of perfectionism. He has completed goals some of his goals but does not seem to give himself much credit for them because the sense of perfectionism is blocking that. I think you make a great point about getting a sense of how Mark’s coworkers feel about the company’s structure. It would be helpful to know with helping him with his negative thoughts. Although, it may be challenging for Mark to ask his coworkers this because he may not want to come off that he is putting the company down to his coworkers or he might not want to let his coworkers know that he is struggling with his work. I also agree with you that it may be difficult to participate in role-plays. We don’t have the same understanding of the situation that the client does and that is going to play a role in how effective it will be for the client.

      Reply

    • Monica K Teeven
      Feb 27, 2020 @ 11:44:14

      Hi Jess! Great blog post this week! For your answer to question 1, I did not even think about asking Mark if Melissa or if anybody else for that matter lived with him which could effect his morning routine. Great thinking! Your answer to question 2 was the same to my answer that Mark’s negative core belief is perfectionism. However, in my response to this answer I gave the example about he was initially angry at himself for not having enough time to eat the breakfast he made at the dinner table like it was planned out on his schedule. He wanted the planned activity to turn out perfectly. After the fact, he was overall proud of himself for waking up earlier before work and was successful in making himself a good breakfast. Whereas, you related his perfectionistic core belief to his current view of his work life. These two examples show us that his perfectionistic core belief negative is effecting him in multiple areas of his life.

      Reply

    • Shelby Piekarczyk
      Feb 27, 2020 @ 18:49:12

      Hi Jess,

      I agree where we would need to find out more information on Marks morning. I think he could possibly wake up earlier to help with his morning routine or maybe even pick out clothes/work belongings the night before to help him in the morning. When thinking about the dog I think this would be an important fact to consider because does he allow the dog to sleep with him? Does the dog sleep in a crate? This information could impact how Mark sleeps. Good job!

      Reply

  6. Melanie Sergel
    Feb 26, 2020 @ 15:24:05

    1) When watching the Mark go over his Daily Activity Schedule, there are several questions that I would ask him. After hearing him discuss how he feels overwhelmed at work, I would like to know more about how he rates his accomplishment and pleasure at work. He mentioned that his pleasure went up at work and I would want to do look more into to what had increased that. I would ask him what his thoughts at work were when this pleasure went up. By doing this it could show contradictions to some of the negative automatic thoughts that he is experiencing about work. I would also want to know if there was any activities that was initiated but were not completed. I think it is important to know why certain activities that he has initiated were not completed. I would also want to know more about how the rest of Mark’s day was affected by him waking up earlier. He only discussed how it helped him with not being hungry during the day because he was able to eat a good breakfast. I think it is important to see if his pleasure and accomplishment that specific day went up. He could have started the day feeling more accomplished with getting up

    2) There are a couple automatic thoughts that I think need further attention moving forward. The first automatic thought would be how he felt that his friends did not value him or how he thought his friends did not want to be friends with him anymore when they cancelled dinner. I think this is very important to look further into because it can be seen that it did significantly impacted the way he felt the rest of the night. I think it is important to note that he was able to acknowledge that Melissa did not look at it this way because this can be a step closer for him to be able to turn this negative automatic thought around. Other automatic thoughts that I think need to be looked into further is the thoughts that he experiences with work. He seems to self-blame himself for people not accepting job offers and he often asks himself if he is doing a good enough job. He also finds himself thinking “well is it me or the company”. This is clearly affecting the way he performs his job because he was explaining that he becomes overwhelmed and he cannot keep his thoughts straight. He reflects a lot of things at work onto himself and when he thinks about doing his job, he gets a sick feeling. The thoughts that came along with his friends cancelling dinner and his thoughts at work both show how he may believe he is not good enough. I also think it may important to explore into how he mentioned he experiences a sense of perfectionism. This perfectionism seems to play a role into how I mentioned he may believe his is not good enough. The perfectionism seems to stop Mark from acknowledging that he completed goals he has been working towards and he has difficulty feeling proud of himself for accomplishing what he wanted.

    3) There are some potential challenges I may encounter as a therapist when attempting to modify a client’s negative automatic thoughts. I think that the main challenge I would come across would be teaching the client to recognize their negative automatic thoughts. Clients can struggle with differentiating between negative thoughts and emotions. These thoughts also feel very real and accurate to the client that I may have trouble shifting a client from away from believing that it is true. Another challenge I may come across is using role-play. Since I was not there for the situation, I think it will be challenging to provoke those negative automatic thoughts. It also may be harder for the client to see those automatic thoughts again through role-play because it is not the same for them. Another challenge I could come across would be a client not completing their negative automatic thought tracker worksheet. If the client struggles with completing this then it will be harder to work towards modifying those thoughts.

    Reply

    • Ashley Foster
      Feb 27, 2020 @ 20:43:49

      Hey Melanie!
      I like how you talked about how one of the hardest tasks we have as clinicians is bringing to light these negative automatic thoughts and core beliefs and furthermore get the client to see them as so and change them. This task is challenging in the sense of if your client has accepted these thoughts of core beliefs, the work is just that much harder as they believe these thoughts to be true. I find with these clients as well, they cycle in being stuck in these negative thoughts.
      Great job with the post!

      Reply

  7. Jenna Nikolopoulos
    Feb 26, 2020 @ 16:45:20

    1. One thing I would want to know more about is Mark’s expected and actual pleasure at work. It was mentioned that his pleasure increased at work, even though he talks about how overwhelmed he is feeling regarding his work responsibilities, and I would want to know if there was anything in particular that caused him to enjoy work more. Additionally, I would want to know how his expected pleasure at work influences his actual pleasure at work and if his actual pleasure at work one day influences his expected pleasure at work the next day. Another thing Mark mentioned was feeling rushed in the morning. I would ask Mark about why he felt rushed in the morning and if there was something that inhibited him from having extra time to be able to sit down and eat the breakfast he had made. I would also ask about Mark’s daily morning routine to see if there is a way we can plan his morning so that he does have enough time to do everything while being able to enjoy his breakfast, without feeling rushed, before going to work. Lastly, Mark mentioned how once he heard that his friends had cancelled for dinner, he started to withdraw from Melissa. I would want to know if Mark had a conversation with Melissa about how he was feeling regarding the change in dinner plans. I would also want to know how the rest of the night played out and if how he was feeling after the phone call was still how he felt the rest of the evening, or if something had changed and that allowed him to enjoy the rest of his night with Melissa. If he did enjoy the rest of his night, I would want to know what happened that caused his mood to change and his thoughts and feelings surrounding that event.

    2. The first automatic thought that comes to mind is how he questions whether his friends want to actually be friends with him and feels that maybe they don’t value him as a friend once they cancelled their dinner plans. This kind of gave way into a potential core belief of Mark’s of feeling unlikeable. I think this is something that warrants further attention because those feelings around the cancelled dinner plans influenced Mark’s actions for the remainder of the night where he started to withdraw from Melissa and stopped helping as much to prepare dinner, which caused Melissa to question what had happened. I think Mark acknowledging how Melissa interpreted the event in a different way is important for him and when Dr. V brought up the question of “Do you think they would say yes to you to come over if they didn’t like you or want to be friends with you and Melissa?” I think this question allowed Mark to think for a second about the rationality and validity of his thought. Another automatic thought I think needs to be looked into further is this sense of perfectionism. He mentions how at work he is feeling overwhelmed about his job and how a big part of his responsibilities are to recruit new people. He is feeling this pressure to fill these jobs and he wonders whether people aren’t taking the jobs because of the company or if he is the reason why people aren’t taking the jobs. I think this is important to look into because he feels like he isn’t doing enough, no matter how much he actually is doing, which also plays into the cancelled dinner with his friends as it’s similar to him feeling that maybe he isn’t good enough. This thought pattern seems to be affecting his personal life and his work life, which makes it hard for him to be rational.

    3. One of challenges I may encounter is using role-play to elicit and modify a client’s negative automatic thoughts. Role-play can be difficult since only the client knows what happened in the situation and I’m trying to understand based off of the information they give me. It could be hard for clients to elicit negative automatic thoughts during role-play because of the emotions that are connected with the thoughts, which could cause the client to become distressed in the moment, and role-play can be kind of awkward for the client and they may not want to participate in it, which causes them to not really put much effort into the exercise. Another challenge I may encounter is in trying to get clients to recognize when their automatic thought is negative and irrational. Clients can have these negative thoughts that they feel so strongly about that to them it seems and feels valid when it’s actually not. Trying to get a client to recognize the invalidity of their negative thoughts I feel will be difficult, especially since people tend to reject evidence that disproves their negative automatic thoughts and only accept evidence that reinforces them.

    Reply

    • Monica K Teeven
      Feb 27, 2020 @ 11:56:50

      Hi Jenna! When I was answering question 1, I was focusing more on his morning routine, whereas it seemed from your blog post you were more focused on his work life. This area is really important to question because it can absolutely effect his morning routine such as having a hard time waking up early because he dreaded being at work in the morning or he had a hard time falling asleep the night before because he was stressed out about how the next day will be for him at work. For your answer to question 2, it was different from the negative core belief that I perceived Mark having. But, I do like the negative core belief that you saw Mark possibly having because it can be related to both his work life and his friendship life. For example, he said he thinks there’s a possibility that people are not accepting job offers at work because of people not liking him and when his friends canceled the dinner plans they made it lead him to believe they do not like him. Great job on your post this week Jenna!

      Reply

  8. Ashley Foster
    Feb 27, 2020 @ 10:38:09

    Behavioral Activation

    Question 1:

    After listening to Mark’s session, I would have some addition questions about how Mark feels he does in the adaption to change and being malleable in his world. Throughout the session, Mark talks on when there are changes to his schedule such as his friends canceling, or not waking up as early as he wanted to, and how much work he does. He tends to reflect on these events and puts blame on himself through internalizing and personalizing of automatic thoughts. I would also examine rational and irrational thinking for some of the thought patterns he was explaining. This leads to most of his distress throughout his week based on this session.

    Question 2:

    The automatic thought or core belief of personalization and internalizing should be more examined. Mark seemed highly distressed about his friend canceling. He went on to talk about how it affected him for most of the night. In the other event of his reflection of him waking up, he also internalized and spoke on how he felt like he could have woken up early, minimizing the success he had made. Finally, he personalized and internalized his job tasks. More precisely, he talked about how when he makes offers to these potential candidates for positions and the decline them, even though he knows that it is what the company’s offer, he took the blame on himself. This shows some irrational thinking as logically, it is the company to blame in this situation.

    Automatic Thoughts

    Question 1:

    There are some potential challenges as a therapist one would encounter when attempting to modify a client’s negative automatic thoughts. One challenge I have encountered with clients who are dealing with anxiety and or depression, clients tend to get stuck in their negative automatic thought, and a therapist, as we are challenging these thoughts, a client could cycle around your challenge and stay stuck or not believe your thinking to be true through catastrophizing. When a client is stuck in this cycle, it can be hard to break them out of their irrational thinking an put them on a more logic stance.

    Reply

    • Robert Salvucci
      Feb 28, 2020 @ 12:47:10

      Hey Ashley!

      Interesting to point out Mark’s relationship with change in his life. It does sound like Mark tends to get very distraught when things go exactly as planned, and ties into his tendency to fill in the blanks with negatives when something changes in his life.

      Mark definitely minimizes his successes, and even when he acknowledges that his company’s approach is partially responsible for job offer refusals, he weighs much more heavily on the role that he might play.

      You’re right to point out that many clients can feel stuck in their negative automatic thoughts. Unfortunately this is a very common characteristic of negative automatic thoughts, particularly with anxiety. Part of being an effective therapist is helping clients feel motivated to change their patterns

      Reply

    • Taylor O'Rourke
      Feb 29, 2020 @ 14:53:10

      Hey Ashley!

      I think it is really important how you mentioned that Mark internalizes and personalizes what happens in his life. The fact that Mark thinks he is unlikable or his friends never really wanted to have dinner with him is what them cancelling on him means shows that he still has a lot of negative automatic thoughts going on that should be worked through. I think rational and irrational is also another important concept to think into with Mark, as you mentioned, because it seems that many of his thoughts are not logical for the actual circumstance. Doing some processing on these thoughts in therapy may really help him change his thoughts and become more adaptively functioning.

      Reply

  9. Monica K Teeven
    Feb 27, 2020 @ 11:11:26

    Behavioral Activation
    1. I would have asked Mark if he thought waking up a little earlier would allow him to eat breakfast at the table rather than in his car while driving to work. I think this would have been a good question to ask as he enjoyed not getting hungry before lunchtime because he had eaten a good breakfast. Another question I would ask Mark is if he notices if he fills in unanswered information with negative automatic thoughts when things do not go as planned, like when his friends canceled their dinner plans. Asking Mark this question may open new opportunities for insight for Mark to realize what situations trigger him to have negative automatic thoughts.
    2. The core belief that that should be looked at is Mark’s belief of needing to be perfect. In this session, Mark mentions that when he was making breakfast, he was kind of angry at himself because he was not able to eat his breakfast at the dinner table as planned. After the fact, he is now more proud of himself for making the change of waking up 30 minutes earlier to make breakfast for himself. This core belief of having to do everything as planned creates some negative automatic thoughts when the event is occurring, but do not occur after the fact. Reviewing Mark’s activity schedule and seeing if his level of happiness shifts downward when an activity does not go as planned, should indicate to the counselor that this negative core belief is affecting Mark negatively in several different situations and should be addressed.

    Automatic Thoughts
    1. There are two common challenges when working with automatic thoughts: pinpointing an important negative automatic thought and selecting a suitable Socratic technique to alter the negative automatic thought. When a therapist assists a client in evaluating and modifying their negative automatic thoughts, there are six common Socratic techniques that can be used. These include: assessing the evidence, lowering the perceived negative aftermaths, studying other possible rationalizations, evaluating the level of influence of the negative automatic thoughts to be true, disconnecting the individual from the negative automatic thoughts, and moving attributional prejudices. However, it should be noted that not all of these techniques are suitable for certain thoughts. Figuring out which techniques may be more beneficial for a client for a particular negative automatic thought can be tricky. For example, some people may benefit from the Thought Record (TR) worksheet. However, if the client has a lower functional performance rate, does not like writing, or is unmotivated, this technique will not be helpful. An easier worksheet called “Testing Your Thoughts”, may be more appropriate for some clients. However, some people will not benefit from completing these worksheets nor from discussing the completed worksheet with the therapist. An alternative solution would be teaching them the AWARE technique. Where A says to acknowledge the anxiety, W says to observe the anxiety with no judgment, A says to act as though the anxiety is not there, R says to repeat the previous three steps, and E says to anticipate the best outcome.

    Reply

    • Taylor O'Rourke
      Feb 29, 2020 @ 14:49:23

      Hi Monica!

      I like how you mentioned that it might be beneficial for Mark to wake up earlier so that he can actually have time to enjoy his breakfast, I thought this was a good idea too! I think being able to have time to oneself before work is an important way to destress and prepare mentally and physically for the day, so I think that Mark would definitely benefit from this. I thought it was also interesting that you thought maybe Mark fills in the extra space in his schedule with negative automatic thoughts. This would make sense seeing as he seems to need to stay busy in order to stay in a more pleasant mood.

      Reply

    • Tim Keir
      Feb 29, 2020 @ 17:54:30

      Hey Monica!

      I agree, further exploration of Mark’s expression of automatic thoughts would have been fruitful. I definitely think it would have been interesting to see what he himself would have liked to see changed in his morning routine, getting up earlier included. Also, fantastic breakdown of different strategies in dealing with automatic thoughts! Your examples that illustrate how different methods will help different clients was well done.

      Reply

  10. Taylor O'Rourke
    Feb 27, 2020 @ 12:20:45

    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 of the additional information I would want to know based on what I
    gathered from Mark and his Daily Activity Schedule is some of the adaptive behaviors that should have been validated and reinforced, in regards to the dinner that he had planned with Melissa and his friends. Mark expressed that he was upset and felt unlikable after his friends cancelled on him last minute for dinner, however there was not a lot of information gathered about how (or if) he coped with these feelings. He mentioned that Melissa did not share the same feelings as him, but he did not talk about anything adaptive that came out of or could have come out of the situation. This was more apparent when Mark talked about his morning routine and how pleasant it was to get up a half hour early and have time to make a better breakfast, although he still was in a bit of a rush to work. I would also have liked to know what Mark’s general thoughts were in response to the overall schedule that he created and used. I think getting feedback on how he felt about it would provide insight into if this is an effective technique for him moving forward. I think that for Mark as a client that presents with MDD, it is extremely important to reinforce his adaptive behaviors so that it gives him that extra push to stay away from previous maladaptive behaviors. By using additional schedules moving forward, seeing how successful it was this time, that it will continue to improve Mark’s overall adaptive thinking and decrease his negative automatic thoughts since his actions have already made progress towards becoming more pleasurable.

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

    The main thing that stood out to me as I was watching the session with Mark is
    his negative automatic thoughts surrounding his friends cancelling on him. Although he was slightly understanding that his friends could not attend his dinner party due to family reasons, Mark was still very upset and reported this on his activity schedule to discuss in session. With further questioning, it was revealed that Mark was not as much upset as he was truly hurt by the fact that his friends must not like him enough to actually come over for dinner, hence why they cancelled on him. I think that the concept of being unlikable or unlovable is something beyond a simple negative automatic thought and is more of a cognitive distortion that is a core belief. Because of this, I think it definitely warrants further attention moving forward. Another automatic thought that I think should be further looked at with cognitive techniques in future sessions is the overall amount of pleasure that Mark feels in regards to the activities he is doing and how this could be increased. Mark reported going from an eight to a six of one of his activities and I think it is important to note that things still get in the way of being pleasurable for him. I think determining why his numbers can go down throughout the day is important to address, as well as figuring out what really triggers his levels of pleasure both in the negative and positive directions.

    3. 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)?

    One of the potential challenges I may encounter as a therapist when attempting to
    modify a client’s negative automatic thoughts having a difficult time identifying ones that are relevant. When attempting to discuss negative automatic thoughts with a client, it is important to elicit thoughts that have a high emotional intensity and believability. In addition, therapists should help clients focus on their intense physiological arousal surrounding these thoughts, and not just the thoughts and emotions themselves. Clients may have a difficult time talking about automatic thoughts that are recent and relevant to daily life and its distress. To try to combat this difficulty, therapists should try to work backwards by starting with behaviors that may stimulate intense emotions. Another potential challenge is when a client struggles to understand the difference between thoughts and emotions. At a quick glance, thoughts are a phrase or sentence whereas an emotion can be only one word, so this is the easiest way for clients to learn to differentiate. The therapist should also provide examples of the difference using the client’s own words to help teach them and get them to understand. Another challenge when trying to modify negative automatic thoughts is when the therapist has a hard time using appropriate Socratic techniques for modification. To combat this difficulty, the therapist should try to start off by gathering as much information as possible to help determine if the thought is invalid or not. A thought that is largely invalid is the only want that actually warrants changing. Running through this modification process in your mind first before actually applying it with the client is useful too because it allows for possible outcomes to be thought of. This challenge can also be avoided by trying multiple techniques until one actually works to change the automatic thought. It may be necessary sometimes to use more than one technique anyway. A final challenge when attempting to modify negative automatic thoughts is having a difficult time working with valid negative automatic thoughts. As mentioned previously, anything that is valid should not be modified. However, the focus should be on its utility. Also, there could still be a cognitive distortion in the conclusion of the valid negative automatic thought, so this is what can be worked on to develop an alternative conclusion with problem-focused coping skills.

    Reply

    • Jenna Nikolopoulos
      Feb 28, 2020 @ 13:59:11

      Hi Taylor! I totally agree with your thoughts about Mark’s potential core belief of being unlikable/unlovable. I believe his negative automatic thoughts surrounding the cancelled dinner plans aren’t just because he was upset about his friends cancelling, but stem from this core belief that made him feel more hurt than upset. I also like your second thought about Mark’s overall amount of pleasure and that is something that should be looked at further. If Mark can recognize the kinds of triggers that cause his pleasure to decrease throughout the day, he’ll be able to better manage his reactions to those in the future and can learn to engage in positive triggers that will help to keep his pleasure at a good level.

      Reply

  11. Mariah Fraser
    Feb 27, 2020 @ 12:38:59

    1. I would be interested in hearing more about Mark’s ratings in regards to accomplishment and pleasure. It may be beneficial for Mark to identify a pattern in his ratings of accomplishment and pleasure. Understanding what isn’t getting done on days of low ratings of accomplishment, the cause of the lack of accomplishment and the relationship between that and his pleasure rating may be important for Mark to think about. From there, determining why it is on certain days or at certain times he feels unproductive and how to work towards a goal of getting more done throughout the day may be a next step. I also would be curious about his feelings about his friends not making it to dinner. I would want to know if Mark had the opportunity to chat with Melissa about this, and to see if she had similar feelings or if she had a different response. Someone who is very close to him and spends a lot of time with him may be able to provide a different perspective that he can relate to and understand. Melissa may be able to provide some insight and provide guidance for Mark when he is feeling upset about plans falling through. Also, it seems that when Mark can distance himself from the situation and his feelings by giving advice to a friend who is in the same situation, he is able to have a different perspective, and the advice he would give a friend seems to resonate in his own situation.
    2. One particular negative automatic thought that should be addressed is with regards to Mark’s thoughts and emotions regarding plans with his friends falling through. He talked about thinking his friends didn’t value him or they didn’t want to be his friend anymore because they cancelled dinner. He seems to ruminate over these thoughts and feelings and it has a significant impact on the rest of his night. As mentioned above, talking with Melissa seems to be something to explore because she does not always share his same views, and this may prompt Mark to look at the situation through a different lens. Another thought that may need some attention would be about Mark’s tendency to seek perfection. His perfectionism seems to put him in distress because he thinks that no matter what he does at work, it’s not good enough — he wonders if he has trouble recruiting people because he’s not doing something right. He seems to internalize these thoughts and it generates feelings of self-blame.
    3. It may be hard as a therapist to get the clients unstuck, and to get them out of the cycling of negative automatic thoughts, behavior, and emotions. Even though they don’t typically have much validity, the power of the automatic acceptance of these thoughts makes people really believe that they are true. Even if the therapist can generate evidence contrary to the thought, it can be a challenge for the client to adopt that new way of thinking because it is so easy to fall into the same pattern when a similar situation happens in the future (friends bail on dinner; work through negative automatic thought; skills are still knew and fresh; then another friend bails on lunch; negative automatic thought surfaces again; further reinforcing the core belief associated with it).

    Reply

    • Jenna Nikolopoulos
      Feb 28, 2020 @ 14:12:02

      Hi Mariah! I definitely agree with your thoughts in regards to how hard it may be for a therapist to try to get clients to modify their negative automatic thoughts. Once we have a negative automatic thought that can relate to multiple situations, it’s really hard to try and get out of that mindset and not apply it to other parts of our life because of how real the thought can feel, even if it is invalid. I too believe it’ll be hard to try and get clients to adopt a more adaptive way of thinking about negatively perceived events because it is so much easier to just continue to think in the same way we always have. But as therapists, we have to try to get clients to step outside of their comfort zones and actively implement new skills that will modify their future negative automatic thoughts. Obviously, this isn’t something that will happen right away, but will take time and practice, but if we can get our clients to commit to practice using these skills on a daily basis, then hopefully they’ll begin to see the positive changes that come with this more adaptive way of thinking!

      Reply

    • Tim Keir
      Feb 29, 2020 @ 17:00:12

      Hey Mariah!

      I appreciate your focus on the positives in Mark’s life, and the things that are already naturally motivating him. Considering his negative thinking, a greater understanding of what works well for him could potentially be further generalized. Getting Melissa’s input, especially since Mark was so confident in her ability to handle the situation, could also be beneficial. You’re definitely on-point with Mark’s feelings of excessive perfectionism!

      I agree that it will be difficult for clients to get out of automatic thoughts, especially if the thoughts are actually accurate. It will be interesting to find a way to dismantle thoughts that turn out to actually be accurate but dysfunctional as well – how do you help the person whose fears are substantiated? Hopefully we will be able to give them the skills to turn their situations into far more positive ones.

      Reply

  12. Tim Keir
    Feb 27, 2020 @ 17:30:07

    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?

    I’d have liked to have heard more about Mark’s morning routine. A more structured task assessment of how Mark’s morning went and where his time went may be beneficial in him having the perfect morning he desires. His performance in getting up earlier already seems to have gone well for him, so encouraging some more minor changes like preparing his clothes the night before may help him have the calm breakfast that would set him on the right path for the day.
    It seems like it was not a large issue, but I was also curious as to why Mark wasn’t able to make it to the dog park specifically. His ability to find an alternative was appropriately encouraged though.

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

    Mark has a high negativity when referring to his own accomplishments; his mind-reading over his friends’ cancellation over dinner is readily apparent, but so is his minimization of his morning routine accomplishments as well as his magnification of the fact that his breakfast was still not ideal. His comparison with Melissa as well (that she is more understanding than he) represents his tendency to discount his own successes or positives. It is clearly recognized that Mark has a tendency to “fill in the holes” with negative interpretations, but his tendency to oversell the negative aspects and undersell the positive is also worth exploring.

    3. 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)?

    One large concern is having clients that are resistant to or slow to learn the concepts of automatic thoughts. I can imagine a client becoming easily stressed and irritated by the pursuit of automatic thoughts, especially when asking them to examine particularly unpleasant experiences or emotions. Similarly, I have experienced several people who have difficulty going through with self-exploration due to the intensity of self-loathing and shame they experience over their thoughts. Being tasked to decouple the knowledge of a person’s automatic thoughts with the stress that they are incorrect and bad for thinking that way is a very possible scenario. Having clients mistake thoughts for emotions and vice versa also seem to be a common issue, one which may take special focus to properly differentiate and teach to the client.

    Reply

  13. Robert Salvucci
    Feb 28, 2020 @ 12:37:21

    Hey Tim!

    Fine tuning Mark’s morning routine could definitely be beneficial for him, as well as doing things the night before which could make the morning go more smoothly. I’d also me interested to see what his bedtime routine is like to gauge how it affects his morning.

    Good observation in noting how Mark is discounting his accomplishments as well highlighting the negative. He has a tendency to fill in ambiguity with negative interpretations, as Dr. V mentions.

    It was insightful to point out that examining negative thoughts can be overwhelming for some clients. Doing this introspection can feel very vulnerable and overwhelming, especially if the thoughts are believed to be very true.

    Reply

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Adam M. Volungis, PhD, LMHC

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