The enclosed protocol was developed with materials from a book titled ‘Overcoming Depression’, by Gary Emery. The book was distributed in the United States by Publishers Group West in 2000. Additional sources include the seminal work of Martin E. P. Seligman, ‘Helplessness: On Depression, Development and Death’, published by W. H. Freeman and Company in 1975, and, references to the materials of McKay, Fanning, Davis & McKay, from Thoughts & Feelings, New Harbinger Publication, Inc., 1997.
In the first edition of the Cognitive Behavior Workbook, we outlined the following protocol for depression.
Characteristics: Helplessness is the major characteristic of depression. Other symptoms may include:
- lack of interest
- lack of energy, exertion
- appetite change: gain or loss of weight
- feelings of worthlessness
- suicidal ideation
- poor concentration
- sleep disturbance
Protocol: Mastery Time
- Technique #12 Getting Mobilized • 4/8 weeks
- Technique #01 Perceiving Reflex Thoughts • 1 week
- Technique #02 Altering Limited Thinking Patterns • 1/4 weeks
- Technique #03 Changing Distressing Thoughts • 1/12 weeks
- Technique #13 Problem Management • 3/7 weeks
- Technique #16 Stress Inoculation • 1 week
We then provided the individual Techniques listed above to carry out this protocol. The material included in this booklet expands some of the potential techniques [e.g., Motivation and Goal Development, The Calm Technique, etc.] that can be added to the protocol as it is used for children with depression. The material included in this booklet does not detail how to do the techniques per se. That information can be gained through the individual technique booklets. This material provides some ‘mortar’ for holding the techniques together and gives ‘grist for the mill’ in providing more detailed information about the nature of depression. This will give you information about what you may say to the child about depression and the skills they can learn. The selection of techniques and how full or sparse the protocol should be for the individual child are choices that the clinician will make based upon the severity of the problems the child is experiencing and the unique status of the individual child.
General Language and Concepts of Depression
The current system of defining depression is descriptive. Researchers define depression by the symptoms – how you think, feel and act. This descriptive method makes it easier for professionals to agree, and allows for an effective way to define the disorder. Depression is a group of enduring symptoms that last anywhere from a few weeks to years. Symptoms are broken down into four clusters:
- how the person thinks [a negative view of the self, the world and the other people in it, and the future],
- how the body reacts [trouble with sleep and/or appetite],
- how the person acts [slowed down, apathetic], and
- how the person feels [sad, anxious, guilty, hopeless].
A person can be considered depressed if s/he answers yes to two broad questions:
- Have you had a distinct period of feeling unhappy or a distinct period of loss of pleasure and interest?
- Have you suffered from five  or more of the following eight symptoms for at least two weeks?
- appetite or weight change
- sleep problems
- excessive tiredness
- physically slowed down or agitated
- a loss of interest or pleasure in usual activities
- feeling guilty
- slow thinking or indecisiveness
- thoughts of wishing yourself dead or killing yourself
It is important to note that the defining characteristic of clinical depression is not sadness. It is helplessness and the resulting hopelessness. When sadness becomes the result of helplessness and hopelessness, rather than the cause, a clinical condition is manifest.
Depression is a natural state in response to loss or defeat. From an evolutionary perspective, depression allows the person to shut down until the dire conditions improve. Everyone is prone to the characteristics of depression since the mind and body are operating exactly as they were designed to do in facing what appear to be insurmountable obstacles. Most people muddle through as best they can. Because depression is usually self-limiting, it will likely lift after a while. However, some people, perhaps because of thoughts, attitudes, and beliefs of pessimism, may extend normal depression by mental processes that maintain the state. Such people lack the resilience to ‘bounce’ back from defeat since they expected to be defeated in the first place. Depression then becomes a trait, from which some of the population garner certain secondary benefits of sympathy and caring from others, which helps to reinforce and maintain the status quo. For these people, giving up the symptoms is particularly difficult, since there is not only a diminished capacity for corrective action, there is a reward for not acting.
From this perspective then we have three types of depression:
- normal response to perceived circumstance, in which the symptoms will dissipate over time
- normal response to perceived circumstances extended by the personality type into a trait that will not dissipate unless addressed
- normal response to perceived circumstances extended by the personality type into a trait that has generated secondary reward. This is difficult to dissipate unless formally addressed.
A fourth type of depression can also be identified, and that is bipolar depression or manic-depression. This type comprises only a small portion of depressed people and it is believed by many, although not demonstrated, to be inherited . Drugs such as lithium can generally control this disorder. However, there is an anomaly here. The symptoms are often triggered by stress which indicates a psychological component to the problem. Three types of bipolar circumstance can be described:
- persons for whom drugs work wonders and they go on with their lives
- persons for whom the drugs work wonders, but they thrive on the ‘highs’ of their mania and choose not to use the drugs.
- persons for whom the drugs offer only minimal support and will benefit from cognitive behavior management as well.
Obviously, the first type is unlikely to need further support from professionals except to monitor the medication itself. The third type would benefit from the techniques outlined here. The second category is the most difficult, and creates an ethical dilemma for the clinician. Does the person have the right to refuse to take the drugs when not taking them causes such difficulty in their lives [they do come down from the highs] and often in the lives of others [the highs can be tedious, if not dangerous to others]? While the traditional system takes the position of coercive action and demands compliance, we would cite John Stuart Mill [On Liberty, 1859]:
“The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him, because in the opinions of others, to do so would be wise, or even right.”
The role of the clinician is not to control his/her clients, but to support them in making appropriate choices. There are consequences to the choices we make in life, but we have the right to make them. Offering this type of person the choice of using the cognitive behavior management depression protocol can help them make decisions more appropriately in whatever phase of the cycle they happen to be in at the moment.
It should be noted that different physical problems – among them infections, cancer, epilepsy, vitamin deficiencies, some forms of arthritis, and disorders of the endocrine symptoms mimic the symptoms of depression. In this case, the depression symptoms are secondary to the physical problems. For these reasons, a thorough physical examination that includes an inventory of current medications should check for depressive side effects.
The new anti-depressant drugs have become an increasingly popular form of treatment despite the fact that their degree of effectiveness is questionable. In the few controlled studies done to date, they have been found to be only slightly more effective than placebos [Schiffer, 1998]. Such drugs also have rather concerning side effects that at minimum include drowsiness, dizziness, dry mouth, and loss of sexual interest. Additionally, a second major problem is one of psychological and social dependency production. Not only does the child learn to depend on chemicals to control his/her behavior and thinking, but the child also receives a message that s/he does not and cannot have self-control. These messages are consistent with drug abuse and dependency. In short, we as a society, have subtly, and without consciousness, promoted the very drug abuse problem we now find rampant in our culture, and desperately seek to eliminate [Steven T. Padgitt, 1998] .
Clients generally are not prone to find the drugs helpful, except in the case of the one type of bipolar clients. These concerns should make drug use the last option selected by the clinical helper. Emphasis perhaps should be placed more on correcting the causes that maintain depression, rather than masking the symptoms.
Cognitive behavior management places emphasis on learning how to master your internal world of thoughts, feelings and motivation. The basic principle of the approach is: How you think about your experiences determines how you react emotionally and behaviorally.
Seligman reports  cognitive behavior intervention as providing marked improvement in 60% to 80% of those who use it with less than a 20% chance of relapse and no side effects. Compared to antidepressant drugs that may have highly toxic side effects and a higher relapse rate if the drugs are stopped, this is a highly effective approach.
Time for Mastery
This plan for overcoming depression will take place over ten  to sixteen  weekly sessions with the following steps:
- situational evaluation: review of the assessment report and evaluation of the situation as seen by the client. The creation of a Plan of Change agreement.
- understanding language and concepts of depression: teaching the child about the role that negative thinking plays in their situation and identifying the skills that must be learned to overcome depression and maintain resilience. Teaching how to monitor thoughts and revise them.
- mastering behavioral symptoms: focuses on how to counter cognitive distortions by taking proactive steps.
- activity monitoring involves the identification and awareness of the activities that are actually occurring and measuring the degree of pleasure and satisfaction that is occurring.
- activity scheduling involves identifying pleasure and mastery activities and adding them to the daily activities,
- taking action on procrastination: how to tackle difficult tasks that have been put off by breaking them down into manageable steps.
- strengthening interpersonal relationships: dealing with issues of grief, role transitions, interpersonal disputes and interpersonal deficits.
- mastering emotional symptoms: involves awareness, attendance, analysis, alternative creation and adaptation to new thoughts that mediate the way we feel,
- identifying automatic thoughts involves how to use thought records to detect errors in thinking; particularly focused on the cognitive errors contributing to depression
- attending to automatic thoughts: teaches how to use thought journals to track trends in thinking and improvements in thoughts
- analyzing automatic thoughts: teaches how to answer the thoughts that keep the child depressed and what actions can be taken
- creating alternative thoughts: teaches a child how to reframe the thoughts in a more realistic manner and to use creative thinking procedures to create new thought alternatives
- adapting to new thoughts: teaches how to catch and drop negative thoughts while adding new thoughts to the habitual nonconscious mental contexts
- challenging core beliefs: One of the chief features of humans is the tendency to create theories and then find evidence to support them. This tendency becomes a major problem as the depressed person convinces him/herself that they are helpless and hopeless. Focuses on the dysfunctional beliefs [silent assumptions] about self, others and future prospects that make the person vulnerable to depression and how absolute beliefs about important issues such as love, health, security, attractiveness, social status and career success can set them up for depression.
- problem management: teaches how to effectively reduce anxiety associated with procrastination and the inability to make decisions
- review, closure and planning follow-up: will sum up what has been learned and teach skills in anticipation of future actions to inoculate against relapse
The heart of the program is the real life practice of skills and new understanding. Through practice of the skills the client will be able to stop being depressed and learn how to prevent future depression. Since cognitive behavior management is an educational approach, you will be asking the client to practice skills between sessions and to complete homework assignments. Thus the ten  hours of direct intervention will be expanded by these assignments. The success of this approach depends on the commitment to do weekly assignments. Thus, the client will get from this approach what they are willing to put into it. In order to substantiate that commitment, the clinician may want to complete a Goal Development Technique #27, in order to have motivational components to draw on if and when the client resists doing the work required.
Forms & Charts
CBP#01-001 Action Schedule
CBT#01-001 Basic Thought Journal.
STEP 1. SITUATIONAL EVALUATION
We will presume that the child has been referred to you after a Functional Cognitive Behavior Assessment [FCBA] process that has identified not only the child’s maintenance thoughts but has indicated where in the child’s personal network there may be people who initiate and maintain such thoughts. We will further assume that if such is the case, someone is addressing these communication issues. If the first circumstance is not true, we would recommend that you have a FCBA completed ASAP. If the second circumstance is untrue, you will need to find some way to inoculate the child from maintenance communication. This can be done by making the child aware of these variables and discussing ways to handle the occurrence.
Use CBP#01-001 Depressed Mood Scale [CES-D] and CBP#01-002 Depression Questionnaire [self rating scales] to create a baseline for the child in terms of his/her own depression. These tools will then be used on a regular basis [daily, weekly] to track progress.
With this information in hand, your first responsibility is to determine whether the child is motivated to address the issues of depression. To do this, you will need to describe the process that will be undertaken. There are specific points that should be addressed:
- that you are teaching a skill, which if learned will not only reduce the present depression, but provide the child with skills for avoiding depression in the future.
- this is a learning process and requires homework and practice.
- this process will lead the child to address directly some issues that they have been avoiding.
The major feature of depression is that the person systematically distorts experiences in a negative direction and has an overall unrealistically negative picture of self, the world and the future. S/he makes three major thinking errors:
- Permanent – s/he thinks the implications of a negative event will go on forever,
- Pervasive – s/he thinks that it will spread to all areas of life, and
- Personal – s/he thinks that s/he is to blame because of some inherent fault. S/he sees him/herself as a loser in all areas of life, for all time.
Because the depressed person believes this and believes that s/he is helpless to change, s/he is depressed. Feelings of total defeat logically follow from these misperceptions. If you think you are doomed and will always be doomed, depression is logical. It is much more useful to look at these negative notions as possibilities that need to be checked out. Some negative thoughts may, in fact, be true. But most people are able to agree that if we discover that many are not true, they will seek to change those thoughts. Unlike feelings, thoughts are subject to direct influence and control. Since feelings follow from thoughts, this process affords the individual a sense of increased control and hope.
Every depressed person is to some degree, ambivalent about getting better: the positive side wants to get better, the negative side doesn’t think it is possible, so why waste energy trying?
- If not now, when? What are the criteria that will determine that they are ready to change?
Part of what may need to be explored is the secondary benefit that the child may be receiving by being depressed. Only as this becomes conscious can s/he actually make a decision about whether s/he is ready to give this up in order to change his/her quality of life.
If the child indicates a readiness to proceed, begin with the Action Schedule. Because depressed people generally believe that nothing is accomplished during the day you can use The Action Schedule to test the truth of this assumption.
The process is to ‘get moving’. This will seem at first, counterintuitive. The client’s complaint is that they ‘can’t do anything’ and you are suggesting that they ‘do something’. Doesn’t seem very logical. But remember the power of thought. The client believes that they can’t; you place an expectation that they can – what is the message? The message is ‘you are mistaken, you can do things’ and another message is: I BELIEVE IN YOU. And if you do believe this message, it becomes even more salient. However, we cannot simply create a difference of opinion and then try to persuade each other of our own positions. We must give new information about their inability to objectively judge. This is the purpose of activity monitoring.
While the child may believe that nothing is going on in his/her life, the Action Schedule collects information to see if these thoughts and beliefs reflect reality or whether they reflect the distorted thinking that keeps them depressed. By recording, on an hourly basis, what s/he is actually doing and what his/her sense of mastery and pleasure is from the activity, s/he can see what s/he is overlooking by thinking in all-or-nothing terms about the future, life and him/herself.
STEP 2: UNDERSTANDING LANGUAGE & CONCEPTS OF DEPRESSION.
Using the language and concepts of the introduction, help the child understand what depression is, what type of depression they are experiencing, and the nature of the skills that they will be learning. Spend as much time as necessary in helping the child absorb these concepts. Emphasize the “think – feel – behave” linkage so that they understand clearly the role their thinking has in how they feel.
STEP 3: MASTERING BEHAVIORAL SYMPTOMS
A. Activity Monitoring [CBT#12-001]
- Have the child write down what s/he does on an hour-by-hour basis .Remind the child that s/he is always doing something [watching television, laying in bed or staring out the window]. These may not be activities that give much satisfaction, but they are activities and should be recorded.
- Have the child rate how much pleasure and mastery s/he feels from each activity – 1 to 5.Studies find that depressed people discount or forget the pleasure and mastery experiences. By having the child immediately rate how much mastery and pleasure s/he experienced, you can counteract this tendency.
Mastery refers to your sense of achievement – how difficult was it for you to accomplish a given activity. You would rate 1 if the activity took little or no effort, 3 if it took moderate effort, and 5 if the activity was extremely hard to do. Remember, this rating is based on how the child is feeling and acting when depressed. When feeling normal, going to the store might be a 1 in mastery, but when you are depressed, this can be a 5.
For pleasure, have the child rate a 1 if there is no pleasure and a 5 for a great deal of pleasure.
By monitoring activities, the child will begin to gather hard data on what s/he is doing and achieving. S/he will be able to challenge the belief that s/he is doing nothing. S/he may find out that s/he is more active and competent than s/he thought. But it is important to keep good records. The child should carry the schedule with him/her. Remind the child that when you are depressed, you notice and remember more negative and unpleasant events more readily than you notice positive and pleasant ones. The good things that happen are blotted out by pessimism.
Remember, you, as helper, are dealing with thoughts of hopelessness and helplessness. You create some degree of hope by simply assuring the child that s/he can overcome depression. Your belief in this is critical. If you don’t believe it, you are likely to create for yourself a self-fulfilling prophecy and act in a manner that will sabotage the process and prove you own negative thoughts. You also create hope by challenging the child to monitor his/her activities on the belief that s/he is doing much more than s/he thinks. Obviously, if you are right, this is a good sign. Finally, you dispute helplessness, by asking the child to do something. This is a message that s/he can do something. S/he is capable.
- Maintain the Action Schedule every hour of every day. You can break it down to fifteen-minute segments, if you choose. If you are forgetting to do it, set an alarm or timer to ensure that this is done.
Discuss with the child the past week and their ratings. Discuss the Activity Schedule. What did s/he do? Did it seem to him/her more than s/he expected or less? What were the activities s/he most enjoyed? What did s/he like least? How did s/he feel about the mastery items. Did s/he help someone else? If so, compliment on this fact. Helping others is a non-trivial activity, particularly for a child who is depressed.
Once these issues have been discussed, you will need to help the child use these collected data toward a better understanding of some of the paradoxes of depression with a particular focus on the fact that a) it can be changed, and b) it is natural and not a sign that s/he is distorted or ‘crazy’.
Almost all people want to be happy, healthy and have good relationships, meaningful work and creative outlets. When you become depressed, you act contrary to what you normally want – effectively reversing from a positive to negative perspective. To understand this paradox, you need to understand that everyone has two separate ways of thinking – positive and negative. The situation is similar to a person who wants to quit smoking, while at the same time, doesn’t want to. The idea of dual ways of thinking explains why you may not want to take steps that you know will help you get undepressed.
A pessimistic explanatory style is at the core of most depressed thinking. You think this is personal [‘It’s my fault!’], permanent [‘It is going to last forever!’] and pervasive [‘It is going to ruin everything!].
Such an explanatory style is quite out of line with the most typical behavior as indicated by the following quotes from How We Know What Isn’t So: The fallibility of human reason in everyday life, by Thomas Gilovich, 1991.
Man prefers to believe what he prefers to be true.
“We are capable of believing the most flattering things about ourselves, and many scholars have argued that we do so for no other reason than that we want them to be true.”
“…we tend to make optimistic assessments of our own abilities, traits, and prospects for future success.”
“…the average person purports to believe extremely flattering things about him/herself – beliefs that do not stand up to objective analysis.”
People are also prone to self-serving assessment when it comes to apportioning responsibility for their successes and failures.
“…people have been found to attribute their successes to themselves, and their failures to external circumstances.”
Such statements seem to solidly establish that human beings are rather optimistic animals who rationalize away their deficits and see themselves in rather positive light. What has happened to make the depressed person make just the opposite assessment?
It is an evident consequence of being self-aware that if one has some conception of one’s own nature, then one must also have some conception of the nature of things other than oneself, i.e. of the world. Thus, the very existence of a moral order, self-awareness, and therefore human being, depends on the making of some distinction between ‘objective’ (things that are not an intrinsic part of the self) and ‘subjective’ (things that are an intrinsic part of the self) [Hallowell, ‘Orientations for the Self’, 1955]. However, as a consequence of this skill and the ability to ‘imagine’, human beings are able to view themselves as both subject and object. The consequences of this skill have a psychological downside. Often when we view ourselves as the object, we are subjectively viewing ourselves as the ‘victim’ of some act by others. This negative way of thinking about ourselves has a profound effect on the way we think about self and others. If our tendency is to think of ourselves as the subject [e.g., the actor in the scenario], we tend to think positively.
The object thinking of self as not intrinsically a part of the self is a paradox of immense proportion. As not intrinsically ‘there’ we are a ‘thing’ with no control over our circumstances. When we think of ourselves as the object or recipient in the scenario, we tend to think negatively, hopelessly and helplessly. This is based on the epigenetic rule that we have a bias toward our own actions and against the actions of others.
Thus, when we consistently see ourselves as the subject, we are optimistic about ourselves and generally think positive thoughts. But, when we consistently see ourselves as the object, it seems that we become the equivalent of the other and lose our positive self-bias. Now we can make the classic cognitive error of attribution that states that if I am explaining my own actions [I am the subject], the reasons for the actions are generally seen as external. However, if I am explaining the actions of another [myself as object], the reasons are generally seen as internal. By viewing myself as the object, I not only see things negatively, but I am biased to identify these negatives as being my own fault.
You can help to reorganize the child’s negative thinking by becoming aware of how these negative and positive thoughts are phrased. We generally use active language when thinking in a positive mode [I can do that!], while more passive phrasing characterizes a switch to negativity [Why does everything happen to me?]. Optimistic thinking takes a subject position and acts on the world. The less hopeful thinking takes the object position and feels acted upon.
A second group of issues is a negative change of mood. When you are depressed, you feel awful; sad, discouraged and helpless. Formerly enjoyable activities become flat. Anxiety and irritability are also often present. Getting mobilized is very difficult and yet as you are mobilized, your mood changes.
A third cluster concerns behavior: passive, indecisive and inert. Depressed people often cannot get started on anything but the most routine tasks, and they give up easily when frustrated. They find it hard to choose among alternatives. Such thoughts can lead to increasing immobility, which becomes a self-fulfilling habituation that can be hard to break. But movement breaks all immobility. Friends and family need to understand that they should not ‘give up’ in their efforts to get the child involved.
This cluster should also include the interactive activities of the individual. In 1976 Coyne suggested that depression is the result of this interactional process; the depression-prone [distorted ‘inner logic’] person inappropriately elicits support behaviors from persons in their general surroundings. Over time these support behaviors become intermixed with rejection attitudes that develop as the person subjected to the inappropriate solicitation becomes increasingly wary and weary of it all. The depression-prone person, sensitive to this underlying rejection attitude, increases their support seeking behavior in order to elicit more supportive behaviors from others until these others eventually withdraw from the interaction. It is these interactions of the depression-prone persons with others that are believed to initiate and maintain depression.
Excessive support seeking and lack of receiving social support have been associated with depression onset and an unfavorable course of depression. It is assumed that social support is implemented through observable behaviors that express involvement. Certain factors were supposed to express the presence or lack of involvement during an interaction. Low involvement was reflected by less speech, less eagerness (as demonstrated by yes-nodding and no-shaking), less speaking effort (as shown by head movements, looking and gesturing during speech) and more active listening (intense touching of one’s own body and head movements during listening) together with less encouragement (yes-nodding and ‘um- hum’-ing during listening). More involvement would, of course, be the reverse of these factors.
Several interpersonal assumptions seem to underlie the research:
- Persons with poor social skills and few friends would be more prone to depression
- Persons with significant others who provide less social support would be more prone to chronic depression
- Persons who are depressed and excessively seek support are more likely to get rejection
Such assumptions lead to the conclusion that interpersonal relationships as much as the distorted thoughts that lead to these excessive behaviors are a critical factor in depression. The skill of interpersonal relationships becomes a major factor, therefore, in recovery leading inevitably to interpersonal counseling as a means of enhancing the person’s ability to become socially competent.
A fourth cluster is somatic – meaning that the body feels it. The appetite diminishes – you can’t eat. Sleep is affected – you wake up too early and toss and turn. You may hurt in the pit of your stomach. These are, of course, secondary responses to the shutting down of activity.
Your state of mind determines your outlook on life. All of these symptoms are related to how you think. The negative side focuses exclusively on what you don’t want [what you think needs to change] and not on what you do want. The positive side is activated anytime you make a positive choice. The child can always choose to think about what you would like to see happen. When you focus on what you want, your negative focus on what you don’t want fades away. Thus, goal development becomes a major motivational consideration [See Motivation and Goal Development – Technique #27].
Reality is neutral and you can make the choice to think about any situation from a positive point of view. Depression is marked by passivity and self-absorption. You avoid doing what you perceive as too much work for too little reward. You can counter this by consciously taking action on present moment needs. You do what needs to be done, no matter how difficult or easy it may seem. Along with optimism, the child should learn and understand the concept of the Calm Principle [Technique #26], which essentially makes every act of the day an act of meditation. All it demands is that each thing you do, you do completely and to the best of your ability. While you are doing that one thing, you ignore distractions and concentrate all your attention on that one moment. You approach even the most unexciting or most trivial task as if it were the most important thing that had ever happened in your life. Again, it is important to get this thought into the hierarchy of thoughts. Because of the difficulty the child is having with disinterest, it is not likely to happen easily, but the belief that it can happen is significant.
Talk this out. Check to see if the child understands. Use the story of the blind men in India describing the elephant by its parts as a parable about how they are describing the world about them. The blind men had limited sight. Depression is a normal response to certain life experiences. But it has gone awry with them and needs to be corrected so they can get on with their life. Like the blind men, they are limited in what they perceive. Talk about thoughts, mood, behavior and somatic conditions. Find out what is and is not occurring with this child. Help the child understand that changing the way s/he thinks will address all of these issues.
B. Activity Scheduling
Point out to the child that it is not the experiences that s/he has that make him/her depressed, but rather it is the interpretation of those experiences. When you are depressed and happen to have a positive thought, feeling or occurrence the tendency is to dismiss it and look for something negative to focus on. You then project these negative thoughts into the future and feel hopeless. What keeps you dwelling on the negative is often ‘how’ questions. When you ask yourself, ‘How can I do it?’. You tend to over-focus on your negative, hopeless, feelings. Better questions are ‘what’ questions: ‘What do I want?’ and ‘What do I need to do next?’.
The negative side focuses exclusively on what you don’t want [what you think needs to change] and not on what you do want. Your positive side is activated anytime you make a positive choice. You can always choose to think about what you would like to see happen. When you focus on what you want, your negative focus on what you don’t want fades away.
It’s time to encourage the child to increase both pleasure and mastery activities during the week. Have him/her identify at least ten hours on the Activity Schedule when s/he is engaged in an optional activity that provides neither pleasure nor a sense of mastery. See if s/he can find one or two of these hours each day. Soon you will have him/her schedule new pleasure or mastery activities for these hours to replace the old, unprofitable activities.
Using the Pleasure Activities List [CBT#12-002] have the child begin to think about and develop a list of his/her own. The Pleasure Activities List is a short list and include both adult and child interests. There are many other possibilities for activities that would bring pleasure. Provide some of your own ideas about pleasurable activities. Have the child think back to the things s/he has enjoyed. Encourage the child to remember everything s/he ever tried that was fun. Review the list above and try to turn some of the generic categories into specific things that give the child pleasure. For instance, under games, s/he might have enjoyed playing Simon Says, monopoly or cards. Under crafts, s/he might have enjoyed needlepoint or building miniature models. Under artistic activities, s/he might enjoy finger painting or singing. Under calling or visiting friends, there may be certain people that the child would enjoy spending more time with. Have the child fill in all the specific pleasure activities that s/he has enjoyed or can imagine enjoying in the future.
Don’t be surprised if many of the things the child enjoyed in the past seem totally without interest now. Or if things s/he once looked forward to seem more of a hassle or a burden. This is the effect of depression. When s/he begins to schedule pleasurable activities into his/her week, s/he will feel better, even if the activities seem uninteresting at the moment since the very process of scheduling is promising of a potential change.
Have the child select five  to seven  pleasurable activities [one a day] to schedule on the next week’s activity chart.
At this time you should also try to have him/her add one  new mastery activity each day. Often these are self care efforts the child may be neglecting. S/he may need to shop, run errands, clean or straighten something, write letters, or make important calls. When you’re depressed and immobilized, even normal self-maintenance can seem impossibly hard. Thus, you may find that even personal hygiene such as brushing teeth or taking a shower, needs to be scheduled. The Mastery Activities List [CBT#12-003] is a prompt of some activities that the child might schedule into his/her week.
Make a list of mastery activities that might give the child a feeling of accomplishment. Have the child identify all possible mastery activities that might eventually be scheduled into the week. From the list s/he made of possible mastery activities, have him/her select from five  to seven  to sprinkle through the coming week, in the same fashion as with pleasure activities. Make sure that the child does not do more than one extra mastery activity a day.
Take notice of the hours in the Weekly Activity Schedule CBT#12-001 where the child has typically been unproductive and depressed. These can be identified by you and the child on the baseline schedule and are prime opportunities to substitute a mastery activity that can give a sense of achievement.
Note that some mastery activities may be too involved to accomplish in an hour, or simply too overwhelming when tackled all at once. It may help to break a mastery activity into smaller steps that can be accomplished in no more than five to fifteen minutes. For example, a plan to improve the appearance of the bedroom might involve many steps, starting with a decision to buy and hang a new poster. Some mastery activities may stretch over two or more weeks as the child works through each step in the process. Remind the child to use the Calm Principle as they carry out their schedule.
A very important part of planning activities is trying to anticipate how they will make you feel. Most depressed people make very conservative predictions about the amount of pleasure or achievement they will feel during a planned activity. It’s OK for the child not to feel hopeful. S/he may anticipate very little in the way of good feelings from planned activities. But s/he should do them anyway and evaluate what happens.
Have the child use a blank Weekly Activity Schedule [CBT#12-001] to plan the new mastery and pleasure activities for the coming week. S/he should use the 1-5 scale to predict how much pleasure or achievement s/he will feel, and circle that number on the schedule.
During the week the child should write the actual mastery or pleasure rating for each new activity. This can be placed right next to the circled prediction.
C. Addressing Procrastination
When you’re depressed, you feel guilt, apathy, fatigue, poor self-esteem, low mood, and have trouble with people. All of these symptoms can be countered by taking action on what you have been putting off. One of many paradoxes of depression is that you are extremely reluctant to put out any energy; however, when you take action, you feel better. You often fail to follow through on promises and obligations to others. This often makes you feel guilty, lowers your self-esteem, and causes others to reject you.
The child probably already knows that s/he needs to be more active in doing what has been put off. Friends and relatives may have urged and even harassed him/her about doing more. This, however, is seldom enough to motivate.
When you feel defeated, you see little reason to invest any energy in something that has little possibility of return. In economic terms, when you’re depressed, you don’t believe you can gain, you can only lose; so, you don’t want to invest. This can become a vicious cycle – the less you invest, the lower your return, which reinforces the notion that you can’t win.
You can, however, interrupt this cycle of hopelessness and futility. When you can see the value of taking constructive action you will feel more ready to help bring about a success cycle.
Just as negative symptoms feed back and perpetuate depression, you can get a positive feedback loop going the other way. Once you take action on what needs to be done, you generate positive feedback. This further motivates you to take more action and increases your sense of resourcefulness. You show yourself that you can start and complete projects, impressing yourself far more by action than you ever could by talk.
Because each mood has a corresponding state of mind, as your mood improves, so does your state of mind. Constructive action is the best way to raise your mood and overall outlook.
No matter how depressed you are, you will nearly always feel better after you become physically active. Researchers have found a simple, brisk ten-minute walk will raise your state of mind for several hours. Physical activity reduces body tension and shifts your focus off negative thoughts and feelings.
If the child is still not convinced, consider taking a look at the following advantages gained by thwarting procrastination.
- Taking action on avoidance moves you from where you are to where you want to be and raises your mood level.
- Through directed action with specific targets, you gain mastery over your thinking and feelings. You choose the actions you want to take and you reinforce thoughts and feelings you want to have. By taking action, you program yourself for the experiences you want.
- Action means you’re sincere. Your mind gets the message that it’s not just talk. Your action reinforces your commitment (“I am going to do what I have been avoiding”) and build evidence that proves to yourself that you can overcome avoidance.
- With each action against avoidance, you will find insights and new awareness that will help you continue moving forward.
- You can create motivation by acting in accordance with a desired feeling or belief. Avoidance decreases motivation, action strengthens it.
- Taking action on what you have been avoiding increases your focus, which in turn creates energy. Passivity drains energy. Taking action combats thoughts and feelings of helplessness. When you take action, you start to see you can get what you want.
- Avoidance of what needs to be done to reach your goals creates body tension that drains energy and leads to fatigue. Once you confront the avoidance, you relax the tension and begin to feel physically better.
- Taking action on what you have been avoiding is one of the best ways to get undepressed. By taking action, you stop negative thinking, focus outside of yourself, raise your mood, and expand your awareness.
When you’re depressed, motivation works backwards. Normally, you want/need something and this generates energy with which you then act. With depression, you have to act in order to generate the energy. It is like priming the pump. [For those of you who have never used a pump to get a drink, it works like this – sometimes you have to pump and pump for a while with nothing seemingly happening, then when the water starts coming, it will continue to gush without pumping for some time. This enables you to stop pumping and take a drink.] At first the person with depression wants a drink, but is unmotivated to take action to get a drink; but, if s/he takes action anyway, s/he will then begin to feel motivated [or energized might be a better term]. Paradoxically, the depressed person only feels like taking action after s/he has already taken some. S/he doesn’t even have to act toward a specific concern. Make the aim of the action simply to take action, not to do something, or have something. Then we will see what happens next.
Explain to the child that when you become depressed, your mental functioning drops: you have trouble concentrating, remembering, and learning because your brain does not believe it has any real, winnable challenges, it does not gear up. The best way to get your mental functioning back is to take action on what you have been avoiding. When you take on challenges, no matter how small, solutions to problems you once thought unsolvable start to appear.
By emphasizing how a child feels, at the expense of what the child does – mastery, persistence, overcoming frustration and boredom, and meeting challenges – parents and teachers are making this generation of children more vulnerable to depression.
People guided by the popular ‘feeling good’ viewpoint are ready to intervene to make the child feel better. People guided by the ‘doing well’ approach are ready to intervene to change the child’s thinking about failure, to encourage frustration-tolerance, and to reward persistence rather than mere success. Martin E.P. Seligman – 1995]
To get your own approval, what counts is what you do, not what you think or feel. If you do what needs to be done, you think well of yourself. The opposite often holds true when you avoid taking action. Your self-esteem takes a beating when you’re depressed, because you put off what needs to be done.
Fortunately, you can regain your own self-approval relatively quickly. Simply start doing what you have been avoiding and then pay attention to how you feel about yourself. You’ll discover that you start feeling better about yourself, and more able to take care of business.
After you have taken action, tune in to how you now think and feel about yourself [your self talk and emotional response]. Give yourself credit, even if your depressed thinking wants to discount it. One of the reasons that you stay depressed after you do something that is difficult – you minimize it. Make sure you reinforce your efforts at taking action [create a self talk mantra and self reinforce].
Remember, it’s all relative. When you feel good doing extremely difficult jobs may be easy and take little will or courage. However, when you are depressed, doing easy tasks can seem extremely difficult – so you should give yourself even more credit for doing them. To build momentum, notice how you really feel after you take action, giving credit where credit is due.
By becoming aware of the relationship between doing what needs to be done and how you feel about yourself, you will quickly realize that taking action is the means to self-esteem and meaning. When you do something that is difficult, you gain your own approval; when you fail to do this, you lose your own approval. If you like yourself, it doesn’t matter what other people think about you. And if you don’t like yourself, the approval of others won’t help.
When you’re depressed, you exaggerate how much other people don’t like you. However, there may be a kernel of truth in this because depressed folks can be bad company. When you’re depressed, you have little energy or will to be pleasant or generous with others, something friends may understand at first, but may grow tired of. After a while, people may begin to stay away from you if you remain depressed. Many people will be unhappy with your refusal to take action. Your lack of participation isolates you from others. You can only turn down so many invitations before people stop asking.
Your avoidance can cause real problems at school and with friends and relatives. When you are depressed, you tend not to keep promises and fail to follow through on agreements, which can upset and hurt other people. Generally, you can rectify the situation by acknowledging your failure to follow through and correct the situation by taking action on what needs to be done.
People close to you could be the most upset by your passivity. They may begin to nag and even harass you about your lack of motivation. Unfortunately, this has the opposite effect when you are depressed: the more demands on you, the more oppositional you become. Others’ displeasure with you causes you to feel worse about yourself and less motivated to take action. One of the advantages of taking action is that it stops others from nagging you.
Acceptance and Taking Action
Before you can take action in the present, you have to accept what you didn’t do in the past. You may not want to pay an overdue library fine because you cannot accept that you should have paid it earlier and would be embarrassed to now go in and pay it. Past avoidance leads to more avoidance. Acceptance is simply acknowledging what was, what is, and what might be.
Remember the three cognitive errors of depression:
- permanence – the depression will go on indefinitely,
- pervasiveness – it will spread to your whole life, and
- personalization – it’s all your fault.
The first step is to accept that because of negative thinking, you don’t want to take action. Realize that believing nothing will be of any use is a symptom of depression. Even if you don’t want to do what needs to be done, there is another part of you that does want to take action. Tension seeks resolution. Simply by accepting this paradox, you begin to allow it to resolve itself. Throughout your life you have done many things you have not wanted to do, but only because another part of you realized it was in your best interest to do so.
You want to avoid action because you feel locked into a bad situation or locked out of a good situation. Accept this as how you feel right now and take action anyway. If the accepted feelings are just feelings, they have no power over you. People who don’t feel well do most of the world’s work. By accepting whatever thoughts or feelings come to you, you become free to take action in the moment.
Choice and Taking Action
When you’re depressed, you rebel against being told what to do, even if you’re the one giving the orders. Everyone wants to be asked, not coerced. When you try to force yourself to take action, you will encounter strong internal resistance. Imperatives of what you must do take the fun out of any experience. You may enjoy reading, but if you think you need to read something, you don’t want to.
True Needs v. False Needs
False personal needs are what you personally think you need to be happy and secure. They can never be satisfied. You can never get enough of something you think you need, but don’t really need. False need comes from the assumption that something is missing or wrong with you. True needs are the impersonal requirements to bring about something. To earn a college degree means you need to take classes and exams. Whenever you choose to have something, real needs will appear in the equation. What you want comes first and what is needed follows.
This may be a time to interject goal development – what does the child want? Note, however, that you again have a ‘priming the pump’ paradox. Often children will indicate that they have no goals. You may need to help them understand that they are in fact expressing goals, but in the negative. They want to avoid something, rather than attain something. By helping them learn to reframe the avoidance goals, you may enable them to begin to think about achievement goals. [See Technique #27]
Notice the difference between telling yourself, “I need to take action,” versus telling yourself, “I want to take action”.
You don’t want to do what you think you need to do because of the absence of choice. You’re more likely to remember to get gas for the car if you tell yourself, “The car needs gas”, than if you tell yourself, “I need to get gas.” What makes the difference is that you take action because you choose to, rather than because you have coerced yourself. Notice also the subject/object change that occurs in the way the issue is framed.
Depression is full of paradoxes. One part of the person wants to get better, and at the same time, another side of the person doesn’t want to. S/he is overwhelmed, but under-acts. Reality is paradox-free; the paradoxes come only from the nature of the thinking. By taking action, s/he will be able to bypass the thinking that keeps him/her stuck in the paradox. After s/he has accepted what is and chosen what s/he would want to happen, s/he can take action quickly on what needs to be done in the moment to fulfill the want.
You use the activity schedule to add structure to the child’s life. Break down big projects into smaller ones, and then schedule these small steps. You can see each as an experiment – a way to test whether or not s/he can do it.
For example, if you’ve been avoiding writing letters, you can schedule a period of time just to get the addresses and other materials out. Then schedule another small step, such as writing the easiest letter, adding small step after small step, all the way up to the most difficult letters. Studies find that when people are depressed their success experiences lead to increased motivation. So what you want to do is build in small steps that will increase the child’s success rate, thereby increasing your motivation. Go from simple tasks to more complex ones.
You can use the activity schedule to take on a task or tasks the child has been avoiding, such as doing homework or starting to get in shape.
Give the Child Tips for Taking Action
- Make a stand. When you’re depressed, you often fail to keep your agreements and often have major projects or commitments that you avoid. The best way to gain your own approval and raise your self-esteem is to confront these avoided tasks and projects. Take a stand for what you care about by making an active decision in favor of something you really want.
- Surprise yourself. Do something that surprises you. Maybe it would surprise you to actually ask someone for a date, or to go into business for yourself, or to cut your hair off. Surprise yourself in big and small ways.
- Surprise someone else. If your mother always drives because you’re afraid of getting lost, tell your mother that you will drive. Take someone you don’t know well out to lunch. Do something that will catch someone else by surprise.
- Do the easiest step. Think of something that you have been avoiding and use it as a target for the next week. If you think that the task is too much for you, break the task down into small steps and do them one by one, easiest first. If going to the doctor is too much for you, then do the easiest step first. Look up the doctor’s phone number and then write it down. Do the easiest step and you will usually start to create some momentum that will help you move on to the next step.
- Do the hardest step first. Avoidance comes from your passive side. If you think you have to solve the ‘Big Problem’ perfectly, you may feel overwhelmed and stalled. Try taking the opposite tack. Drop the importance of the task and simply focus on the next step in front of you, letting results unfold on their own. Look around you and pick the hardest step. If your house seems to be closing in on you and you can’t seem to escape the clutter, decide to get up and clean out the biggest closet in the house. When you do the hardest step first, you create successes and build instant momentum.
- Do something you’ve never done before. Try a different hairstyle. Explore a part of town you’ve never traveled in. Novelty creates curiosity and keeps you from getting stagnant. The decision to do something new starts you moving.
- Vary your daily schedule. A low mood is your signal that you need to get movement into your life. Pick a project, big or small, and do it. You’ll find that just taking the first step of picking one will help you move. If you always get up at 8:15, get up at 7:30 instead. Watch a different TV show or decide to read instead. Do something different in your schedule and you will find you’re clearer and more free. Your thinking will take you outside of yourself and you will be moving.
- Do the opposite of what you feel like doing. If you feel like withdrawing from a confrontation, approach the person instead of hiding. Impulsively do the opposite of what your passive side is telling you to do and you will find that you have begun a movement away from passivity.
- Do a little before avoiding. Catch yourself avoiding and then avoid your avoidance, at least for a minute or two. For example, if you’ve been avoiding doing a report and decide to make yourself a cup of tea before you get started, do a little on the report before you make the tea. You’ll find that once you get started, you’ll want to continue to do it. If you are still forcing yourself after a couple of minutes, stop and do your avoidance strategy and then reapply the ‘do a little first’ strategy. Whenever you decide to put off working on a project (even for a moment), instead, do at least a small bit. After you take this small action, give your depressed side permission to leave the task to do the avoidance behavior. Then, repeat the action procedure after you’ve enjoyed the permitted avoidance.
- Choose actions that absorb your interest and concentration. Keep it simple. Taking action can be as simple as walking across the room or putting something away. Keep your interest outside of yourself. You are at your best when your thinking, feelings, and actions are in movement toward something you want – eating, cleaning closets, taking walks, making phone calls, writing letters, or shopping. Passive activities, such as watching television, often are too weak to hold your interest.
- Aim for balance in your life. Schedule action related to your normal activities-getting up in the morning, making breakfast, exercising, taking a walk, talking to someone, answering mail, checking the answering machine. The last activity you schedule for the day should be to sit down to schedule the next day’s activities.
- Choose ten action steps that you do each day. Look for what you would like to do every day, such as taking a walk or reading the paper. As you take action, focus your thinking as much as possible on what you are doing.
- Each night, write down ten success experiences. You might be bogged down in the middle of the journey. You may feel that you are farther from the end than when you started. If you list your success stories, you’ll find that you are closer to what you want and you’ll feel better. These successes are anything you wanted to do – and did do. They can be anything as simple as getting dressed or as difficult as confronting a major problem.
- Act ‘as if’. To feel better, act ‘as if’ you are already in this state of mind. For example, when you start to act friendly toward others, you start to feel friendly. Although this seems to be pretending, you are acting the way you most honestly would like to feel. Ask yourself, “What action can I take that is in my best interest?” Ignore the urge to “cut off your nose to spite your face.” Keep your thinking on your own best interest, and act as if you are in your active self.
- Plan your day. To move out of and stay out of the reactive, passive self, you may have to repeatedly shift your thinking away from yourself and on to the project. You can benefit from planning your actions in detail if you find yourself chronically in your reactive self. Your schedule gives you a sense of direction and mastery as you focus your thinking on planned activities. Schedule one part at a time. The idea is to engage in activities, not to perform them perfectly. The benefit comes from getting involved in the actual doing.
- Break down big tasks. Do one step at a time. You build self-confidence through small steps. By forcing yourself to take on too much, you sabotage your attempts to do it. Once you’ve taken small steps, you are ready for the next.
- Pick a task you have been avoiding that you want to work on.
- Break it down into steps, then do them.
- For each day you want to work on the task, fill out the tasks you want to accomplish on this week’s action schedule.
- Use the Activity Schedule as a planner and do the specific pleasure and mastery activities as scheduled.
- Continue to keep the Action Schedule as a monitoring activity.
- Do the pleasure and mastery ratings.
- Use the Calm Principle in everything you do.
STEP 5 Mastering Emotional Symptoms
Review and address the homework. Pay particular attention to rating the newly scheduled activities. One of the things you and the child are likely to notice is that actual pleasure or mastery experiences often feel better than expected. As noted earlier, depression tends to make you pessimistic. Comparing prediction to the actual pleasure or mastery levels experienced may help the child recognize how depression distorts his/her view of things. The fact that the new activities may feel better than anticipated could help the child resist the discouraging inner voice that says, “Don’t bother with anything new; it’s a lot of work and you’ll still feel lousy.”
A major benefit of scheduling activities is that you can find out what thoughts block the child from doing an activity. The thoughts that block often are the same ones that keep them depressed. S/he might think, ‘It’s too hard’; ‘It’s not worth the effort’; ‘I can’t do it, why bother?’; ‘It’s too painful to think about’.
Notice how these thoughts tie into expectation theory. People make decisions about their own behavior. People make decisions among alternative plans of behavior based on their perceptions [expectancies] of the degree to which a given behavior will lead to a desired outcome. If the task is considered to be too hard, or the effort required too much, or the value too little, they will choose not to do it. A pessimistic explanatory style indicts all of these elements.
A Identifying Automatic Thoughts
Identifying these thoughts also makes it possible to determine whether this thinking is, in fact, accurate. The first test is to just do what is on the schedule and then reevaluating your ideas to see if they were true or not. At the end of each day, review the schedule and the activities to see what was accomplished. The child should try to recall what negative thoughts cropped up before s/he did each activity and evaluate whether these turned out to be true. Sometimes the negative thoughts will turn out to be partially true, but most of the time you will find out that the activities were easier or more fun than originally thought.
You will need to help the child understand that all people are constantly describing the world to themselves, giving each event or experience some label. [See Perceiving Reflex Thoughts – Technique #01] In addition, all people automatically make interpretations of everything they see, hear, touch, and feel. They judge events as good or bad, pleasurable or painful, safe or dangerous. This process colors all of their experiences, labeling them with private meanings. The purpose of this understanding is to 1) help the child both see themselves as like all other people, 2) begin to think about what automatic thoughts other people may be having in relation to themselves, and 3) make private meanings public in order to open them to scrutiny both by the child him/herself and others.
These labels and judgments are fashioned from the unending dialogue that the person has with him/herself, a waterfall of thoughts cascading down the back of the mind. These thoughts are constant and rarely noticed, but they are powerful enough to create the most intense emotions. This internal dialogue is called self-talk or automatic or reflex thoughts. The person perceives these thoughts as though they are by reflex—without any prior reflection or reasoning; and they impress him as plausible and valid.” (Beck 1976)
Automatic thoughts usually have the following characteristics:
- They often appear in shorthand, composed of just a few essential words phrased in telegraphic style: “lonely . . . getting sick . . . can’t stand it . . . cancer . . . no good.” One word or a short phrase functions as a label for a group of painful memories, fears, or self-reproaches.
- Automatic thoughts are almost always believed, no matter how illogical they appear upon subsequent analysis.
- Automatic thoughts are experienced as spontaneous. You believe automatic thoughts because they are automatic. They seem to arise spontaneously out of ongoing events. They just pop into your mind and you hardly notice them, let alone subject them to logical analysis.
- Automatic thoughts are often couched in terms of rules: should, ought, or must. A woman whose husband had recently died thought, “You ought to go it alone. You shouldn’t burden your friends.” Each time the thought popped into her mind, she felt a wave of hopelessness. People torture themselves with ‘shoulds’ such as “I should be happy. I should be more energetic, creative, responsible, loving, generous….” Each ironclad ‘should’ precipitates a sense of guilt or a loss of self-esteem.
- Negative automatic thoughts tend to ‘awfulize’. These thoughts predict catastrophe, see danger in everything, and always expect the worst. A stomachache is a symptom of cancer, the look of distraction in a lover’s face is the first sign of withdrawal. ‘Awfulizers’ are the major source of anxiety.
- Automatic thoughts are relatively idiosyncratic. In a crowded theater a woman suddenly stood up, slapped the face of the man next to her, and hurried up the aisle and out the exit. The witnesses to this event reacted in different ways based on their own mental contexts.
- Automatic thoughts are persistent and self-perpetuating. They are hard to turn off or change because they are reflexive and plausible. They weave unnoticed through the fabric of your internal dialogue and seem to come and go with a will of their own. One automatic thought tends to act as a cue for another and another and another. The child may have experienced this chaining effect as one depressing thought triggers a long chain of associated depressing thoughts.
- Automatic thoughts often differ from public statements. Most people talk to others very differently from the way they talk to themselves. To others they usually describe events in their lives as logical sequences of cause and effect. But to themselves they may describe the same events with self-deprecating venom or dire predictions.
- Automatic thoughts repeat habitual themes. Chronic anger, anxiety, or depression results from a focus on one particular group of automatic thoughts to the exclusion of all contrary thoughts. The theme of anxious people is danger. They are preoccupied with the anticipation of dangerous situations, forever scanning the horizon for future pain. Depressed individuals often focus on the past and obsess about the theme of loss. They also focus on their own failings and flaws. Chronically angry people repeat automatic thoughts about the hurtful and deliberate behavior of others.Preoccupation with these habitual themes creates a kind of tunnel vision in which you think only one kind of thought and notice only one aspect of your environment. The result is one predominant and usually quite painful emotion. Beck has used the term selective abstraction to describe this tunnel vision.
- Reflex thoughts are learned. Since childhood people have been telling you what to think. You have been conditioned by family, friends, and the media to interpret events a certain way. Over the years you have learned and practiced habitual patterns of automatic thoughts that are difficult to detect, let alone change. That’s the bad news. The good news is that what has been learned can be unlearned and changed.
How are you going to teach these ten principles to your client? Methods will vary based upon the age and other characteristics of the child. But it is important that there be a repetitive dialogue about these factors. Do not expect to tell the child once, and have them absorb these concepts.
B. Attending to Automatic Thoughts
To appreciate the power of these reflex thoughts and the part they play in the emotional life, the child should be encouraged to keep a Basic Thought Journal CBT#01-001. The form is self-explanatory, except for how to rate feelings. The Thought Journal allows the child to assess the distress level with a scale running from 0 (the feeling causes no distress) to 100 (the most distressing emotion they have ever felt).
Make several copies of this journal for the child and have them carry it with them at all times
- Use the Activity Schedule as a planner and do the specific pleasure and mastery activities as scheduled.
- Continue to keep the Action Schedule as a monitoring activity.
- Do the pleasure and mastery ratings.
- Use the Calm Principle in everything you do.
- Use the Basic Thought Journal making an entry only when s/he feels a painful emotion.
C. Analyzing Automatic Thoughts
Along with behaviors, the second cluster of depression symptoms that must be addressed are the feelings. The negative feelings of depression come from your thoughts. How you think about yourself and your experiences is the single most important factor in how you feel. When the child thinks of him/herself as a loser and the world as a hostile and unfriendly place, s/he will naturally feel bad. The feelings are doing their job; the child just keeps skewing the data. Negative conclusions keep him/her from feeling good.
Depression distorts experiences to fit negative thinking. Positive experiences that normally would undercut the negative view are ignored or distorted. This is not something that you do by choice, but rather it is something that you do nonconsciously. Unfortunately, this nonconscious process leads to behavior that generally will generate self-fulfilling responses.
The second major tool of this protocol is the thought record. The purpose of the thought record is to make the private thoughts and meanings public, not only to others but to yourself. Since these automatic thoughts are generated by nonconscious mental processes and occur in a manner to make them very believable, it is important not just to attend to them, but to analyze them for truth and utility.
The process of analysis is first to bring them into consciousness so that they can be considered. The thought journal allows for the thoughts to be captured and written down so that an analysis can take place. Because thoughts, attitudes and beliefs lead to the symptoms of depression, the child will use the thought record as a systematic way to become aware of, analyze and alter his/her thoughts. The thought record is a tool to help the child consider situations that make them feel bad and then discover which thoughts prompted the negative feelings. Once s/he has identified these distorted thoughts s/he is then in a position to challenge their validity and to undermine their power.
Keep in mind that when you are depressed, you make three specific cognitive distortions:
- you jump to conclusions and believe a negative situation will go on forever
- you overgeneralize from the specific loss or disappointment to all areas of your life
- you see the loss as due to inherent fault and think in either/or terms.
These distortions limit the thought process. In Altering Limited Thinking Patterns Technique #02 there is a list of cognitive distortions and some study guides to ensure that the child is able to identify each type of distortion. Using this new information, the child is now ready to begin to examine these automatic thoughts to determine whether they are true and/or useful.
The first responsibility is to teach the language & concepts of the Patterns of Limited Thinking. Not all of these patterns need to be taught. If you have been able to identify the areas that the child uses, you can focus on them. The decision about what to teach ought to follow two principles: 1) the more information the child is able to acquire about how s/he thinks and the impact that it has upon his/her quality of life, the better, and 2) that the limits to optimal information sharing is a decision that should be made by the Clinical Supervisor and reviewed on a regular basis.
There are three exercises [CBT#02-001,CBT#02-002 & CBT#02-003], which are designed to help assure that a child understands the concepts and notices and identifies limited-thinking patterns. If the child is able to identify his/her own thinking patterns without additional help, you do not need to use these exercises. If they are necessary, the child should work through the exercises one after another. S/he can refer back to the above summary and carefully analyze how each statement or situation is based on one or more limited-thinking patterns. Once the exercise is completed, you and the child should analyze the material together and you can indicate where more work is needed.
- fill out the Basic Thought Journal daily
- identify the cognitive distortion that can be applied to the list of automatic thoughts
- use an instant replay procedure: if you have negative feelings and can’t quite catch the thoughts, replay the feelings over in your mind until the thoughts begin to emerge. Look for the meaning of the situation. Ask yourself, ‘what is the significance of the situation to me? What are the consequences?’.
D. Creating Alternative Thoughts
Upon review of the thought journal and the list of cognitive distortions, you will have a better idea if the child understands the concepts of cognitive distortions.
At this point you may want to help the child recognize the emotions that s/he has had in these situations, Many people are not used to labeling their emotions and the intensity of their feelings. In Changing Distressing Thoughts Technique #03 you will find an expanded Thought and Evidence Journal CBT#03-001 that now moves the child toward honing his/her thought skills. This journal includes a statement of feelings and a rating of the intensity of the feelings as well as providing space for developing evidence for and against the validity of the thought. The process includes seven steps:
Step 1: Select a Distressing Thought.
Select a ‘trigger’ thought from the record of reflex thoughts. Help the child choose a thought that impacted their mood either because of its power or frequency. Have the child rate each thought on a scale (0-100) that measures how strongly it contributed to their painful feelings. Have them circle the thought with the highest score – that’s the ‘trigger’ thought you’ll work on first.
Step 2: Identify Evidence that Supports Trigger Thought.
Now have the child write down the experiences and the facts that would appear to support their distressing thought. In the column marked ‘Evidence For’, insist that the child stay with the objective facts. Confine them to exactly what was said, what was done, how many times, and so on. While it’s important to stick with the facts, it’s also important to acknowledge all the past and present evidence that supports and verifies the trigger thought.
Step 3: Uncover Evidence against Trigger Thoughts.
The child will probably find this to be the hardest part of the technique. It’s easy to think of things that support your distressing thought, but s/he will often draw a blank when it’s time to explore evidence against it. They will most likely need some help.
To assist the child in the search for evidence against trigger thoughts, there are ten key questions you need to ask. Go through all ten questions for every trigger thought you are analyzing – each of them will help the child explore new ways of thinking.
- Is there an alternative interpretation of the situation, other than your trigger thought?
- Is the trigger thought really accurate, or is it an overgeneralization? Is it true that (the situation) means (the trigger thought)?
- Are there exceptions to the generalizations made by the trigger thought?
- Are there balancing realities that might soften negative aspects of the situation?
- What are the likely consequences and outcomes of the situation? This question helps the child differentiate what they fear might happen from what they can reasonably expect will happen.
- Are there experiences from the client’s past that would lead them to a conclusion other than the trigger thought? Identify positive experiences.
- Are there objective facts that would contradict items in the “Evidence For” column? Are there facts at odds with this interpretation?
- What are the real odds that what the client fears happening in the situation will actually occur? Help the child think like a bookmaker. Are the odds 1 in 2, 1 in 50, 1 in 1,000, 1 in 500,000? Think of all the people right now in this same situation; how many of them end up facing the catastrophic outcome that the clients fears?
- Does the child have the social or problem-solving skills to handle the situation differently? If not, can you teach them these skills or is there a place that they can learn the skills?
- Could the child, with your help, create a plan to change the situation? Is there someone that they know who they think might deal with this differently? What would that person do?
Have the child write on a separate piece of paper the answers to all of the questions relevant to their trigger thought. Or, write the responses down as you discuss with them these questions. The work the child puts into this step in the evidence-gathering process will directly impact their ability to challenge trigger thoughts.
The child may find it particularly useful to look for objective facts that either counterbalanced or contradicted each item in the ‘Evidence For’ column. S/he should keep asking him/herself, “What in my experience balances out this piece of evidence?” and “What objective facts contradict this piece of evidence?”
Step 4: Write the Alternative Thoughts.
Now have him/her write new, balanced thoughts that incorporate what has been learned from the gathered evidence. Synthesizing statements don’t have to be long. But they do need to summarize the main points on both sides of the question. Don’t be afraid to have the child restate the Balanced or Alternative Thoughts several times until the statement feels strong and convincing.
When you and they are satisfied with the accuracy of what has been written, have the child rate the belief in this new balanced thought as a percentage ranging from 0 to 100. If the child doesn’t believe the new thought more than 60 percent, s/he should revise it further.
Step 5: Re-rate Mood.
The client has identified a painful feeling and rated its intensity on a 0-to-100 scale. Now s/he should rate the intensity of that same feeling again to see if anything has changed now that s/he has gathered evidence and developed a new balanced thought.
Step 6: Record and Save Alternative Thoughts.
Encourage the child to record what s/he has learned each time s/he completes the process of examining evidence and developing balanced or alternative thoughts. Have them put this information on three-by-five file cards that they can keep with them and read whenever they wish.
Step 7: Practice Balanced Thoughts.
The child can use the completed file cards in a simple exercise that will give them practice with balanced thoughts. Have them start by reading the side of the card that describes the trigger situation and the trigger thought. Work at helping them form a clear visualization of the situation. Have them picture the scene; see the shapes and colors, be aware of who is there and what they look like. Hear the voices and other sounds that are part of the trigger scene. Notice the temperature. Notice if they are touching anything, and what it feels like.
When the image of the scene is very clear, have the child read their trigger thought. Try to get them to focus on it to the point of having an emotional reaction. When s/he can picture the scene clearly and feel some of the emotions that go with it, have him/her turn the card over and read the balanced thoughts. S/he should think of the balanced thoughts while continuing to visualize the scene, and continue to pair the balanced thoughts and the scene until the emotional reaction subsides.
This visualization/exposure technique may take some practice for the child in order to allow themselves to feel the emotions, particularly if the trigger thought is powerful.
- Keep the thought and evidence journal each day
E. Adapting and Habituating Alternative Choices
Using the thought records effectively is a skill that takes time to develop. The child will get better and better at it, finding it easier to do as s/he goes along. It is important that you help the child understand that writing out the material is crucial because this work is just too difficult to work out in your head. Writing it all down and reflecting on these thoughts is largely why this procedure works. It pushes the person to take the time, space and energy necessary to gain a real awareness of the thoughts and beliefs that have been controlling his/her feelings.
The third symptom cluster of depression involves how you think. While your thinking is behind the other symptoms, the symptoms in this cluster revolve around your core beliefs about yourself, other people and future prospects. Several interim symptoms may be present.
The child may have difficulty in concentrating. S/he may display memory problems. S/he probably will have difficulty making decisions, and s/he may have intrusive thoughts of wanting to harm him/herself. These difficulties exist because of the persistent, pervasive and personal thoughts that take up so much thought energy and you will need to deal with these directly. In the meantime, however, there are more simple distortions that pop up constantly throughout the day. The thought journals will probably not be able to catch all of these, but there is a procedure called Noting & Dropping that can be used.
Once the child realizes that many of these are simple distortions, s/he can note it [there’s a thought] and then drop it [stop thinking about it]. S/he may have to do this a number of times before the thought fades away, but eventually it will. The process is one of making sure that the thought is conscious [this is the noting] and the second is, once it is conscious, recognizing that it is nonsense and not worrying about it [dropping]. It is only in consciousness that you can ‘debug’ nonsense thoughts and this is a ’shorthand’ way to dealing with lesser thoughts. You know, once consciously examined, you can answer them and fundamentally alter them, so you just ignore them.
Noting thoughts will distance the child from them, which provides quick relief and actually can make your thoughts decrease in number. Although it may seem that they increase in the beginning, this is only because s/he is now becoming aware of them. Some people find just counting their negative thoughts helpful.
It is also important that you help the child benefit from critical incidents: those moments that create a fork in the road – a crisis equals opportunity event. A good strategy is to advise the child to take advantage of these opportunities by doing just the opposite of what his/her instincts urge.
- continue doing the extended thought journal
- practice Noting & Dropping
F. Changing Core Beliefs [See Technique #14]
To avoid depression in the future, the child will need to alter the underlying core beliefs that predispose him/her to the disorder. Core beliefs are your most basic assumptions about your identity in the world. The most important tend to be beliefs about self, others and future prospects. For instance, they depict you as beautiful or ugly, worthy or unworthy, lovable or unlovable and therefore able or unable to achieve.
From these beliefs or concepts the person creates rules to regulate his/her behavior. If the concepts are positive, the rules telling one how to live will be realistic and flexible. The reverse is also true: negative concepts yield negative rules that are restrictive and fear-driven.
Core beliefs and rules are so habitual that they have become nonconscious and go into action in nonconscious ways. They are so fundamental to a person’s personality that few people are aware of them. Yet every part of life is dictated by these beliefs and rules. They have enormous influence on automatic or reflex thoughts.
In summary, core beliefs are the foundation of the individual’s personality. They largely dictate what you can and cannot do (rules), and how you interpret events in your world (automatic thoughts).
The Thought Journal tracks negative core beliefs by recording the child’s automatic thoughts whenever s/he experiences negative feelings. These automatic thoughts are coherent with the child’s core beliefs. The laddering procedure uncovers core beliefs by working down, rung by rung, through the meanings of a statement in the Thought Journal until you reach the core belief underpinning the statement. To search for a core belief through laddering, select a statement from the Thought Journal. Now have the child write, “What if this automatic thought is true? What does it mean?”
The child should answer these questions with beliefs about him/herself, not her feelings. Feelings do not lead to core beliefs, but self-statements do. You need to continue to probe attitudes about these situations with the “What does it mean?” question until you have reached the basic core of the child’s belief about him/herself, others and future prospects.
Automatic thoughts can also be analyzed for themes. Several different automatic thoughts can suggest how the child believes s/he compares with other people or how s/he believes other people think about him/her.
Flowing from each core belief is a set of rules, a behavioral blueprint for how the child needs to act in the world to avoid pain and catastrophe. For example, if the child has a core belief that s/he is unworthy, typical rules might include “Never ask for anything; never say no; never get angry at anyone; always be supportive and giving; never make a mistake; never be an inconvenience”.
Consider with the child the consequences of breaking each rule. Behind each rule is a catastrophic assumption about how things will turn out if s/he ignores its mandate. Such core belief rules are usually based on assumed catastrophic consequences because the rules developed over time to cope with real emotional or physical danger. However, these rules may no longer be necessary and the consequences for disobeying them may no longer be catastrophic or even unpleasant.
Testing these rules will require the following steps:
- Identify one relatively low-risk situation in which to make your initial test.
- Begin a Predictions Log [CBT#14-002]. Have the child write a specific, behavioral prediction of what the catastrophic outcome to the situation will be, based on his/her core belief.
- Make a contract with yourself to break your rule. Have the child commit to a specific time, place, and situation. If you are not there for the test, s/he can report the test results.
- Script the new behavior. Have the child visualize what s/he will do. Have him/her practice an imaginary test with you and/or a friend, or tape-record a dry run of the test. To avoid incurring the very consequences the child wishes to avoid, check that the tone of voice and body language are not cold, frightened, or otherwise negative.
E. Test the new behavior and collect data. In the Predictions Log, have the child write the outcomes of the test. Write which specific parts of his/her predictions occurred and which did not occur.
F. Select more situations in which to test the rule, and repeat Steps B through E for each test. Choose situations that gradually heighten the risk. As the child obtains more and more positive outcomes to situations that break the rules, his/her core beliefs will be modified.
Develop New Rules. The child should then use these new, more positive core beliefs to write new rules. Write the beliefs on the left side of a page, the child’s new rules on the right. Have the child use “I” rather than “you”, and the present rather than the past tense to compose these rules. Write them as affirmations instead of commands or restrictions. If possible, include predictions with the rules. Here s/he may use the future tense.
Choice is a more useful concept than change. Rather than try to change the child’s beliefs, you will ask the child to choose a more moderate position. When you give yourself absolute imperatives, you become anxious, frustrated and discouraged. The new beliefs will also have rules, but they need to be rules that are more flexible and more open to positive considerations.
- continue the thought records with a particular focus on a core belief
- continue Noting & Dropping
STEP 5. Problem Management and Decision Analysis
One of the things that helps to overcome depression is the development of skills. Since the definitive characteristic of depression is helplessness, there is the embedded implication of being unable to function adequately. One area that this is often obvious is in the ability to solve problems. If you can’t solve problems, if follows that you are helpless. If you can solve problems that meaning must change.
You may decide, therefore, that teaching the client child how to solve problems is a worthwhile addition to the protocol. In order to do so you should use Technique #13 which provides a five  step procedure.
Step 1: State the Problem
The first step in problem management is to help the child to identify the problem situations in his/her life. People normally experience problems in areas such as finances, school/work, social relationships, and family life. The Problem Checklist Chart CBT#13-001] will help the child identify the area in which s/he operates least effectively and has the most problems. This is the area you and the child will concentrate on as you teach him/her to develop problem solving skills.
Using the Problem Checklist, help the child determine the general category that causes the most interference in his/her life. From that area, pick one of the situations that s/he has ranked as interfering moderately or a great deal.
Using the situation chosen, have the child fill out the Problem Analysis Form [CBT#13-002] . Have the child try to put at least one word in each blank. When a blank isn’t large enough, use a separate sheet of paper.
By describing the situation in terms of who, what, where, when, how, and why, the child will get the problem clearer in his/her mind. S/he will also uncover many more details than are usually available for consideration. Have the child take his/her time. The details of the behavior, feelings, and wants are also important because they will provide clues for generating solutions later.
Step 2: Outline Goals
Having completed the Problem Analysis Form, we may find that we have identified the goals that are being frustrated. You will need to have the child examine his/her response to the problem – what s/he does, how s/he feels, and what s/he wants. These statements are particularly helpful for developing specific goals. Clarify the fundamental purpose of the actions taken to achieve the goal. Generally, we will find that a goal statement will contain opportunities to develop objectives of smaller steps that one will take in pursuit of the goal.
Using the Defining Objectives Form CBT#13-003 the child can begin to list the goals and objectives. Once these are in place, the child can classify the objectives into MUSTS and WANTS. Help the child look for those objectives which are mandatory for a successful outcome.
It’s time to set one or more goals for change. Have the child examine his/her response to the problem – what s/he does, how s/he feels, and what s/he wants. These statements are particularly helpful for developing specific goals.
Step 3: List the Alternatives
In this phase of problem management, you will need to ‘brainstorm with the client to create strategies that will help to achieve the newly formulated goals.
Brainstorming during this phase should be limited to general strategies for achievement of goals. Leave the nuts and bolts of specific actions for later. The child will need a good overall strategy first. Particular behavioral steps come in the next phase.
Use the Alternative Strategies Form [CBT#13-004] to list at least ten alternative strategies for accomplishing each of your goals. It is important not to give up the search for alternative strategies too quickly. Your tenth idea may be the best one.
Step 4: View the Consequences
The next step is to select the most promising strategies and view the consequences of putting them into action. Pick the goal that is for the child, most attractive.
Have the child list these three strategies in the spaces provided on the following Evaluating Consequences Form [CBT#13-005]. Under each strategy, have the child list any negative and positive consequences s/he can think of.
When you have the major consequences listed, have the child go over each one and ask him/herself how likely it is to come about. If the consequence is very unlikely, have the child cross it out – s/he is simply telling him/herself horror stories or being falsely optimistic.
Note that consequences can be both personal and long range at the same time (total score of 4), affect others long range (total score of 3), and so on.
Add up the scores for each strategy to see whether the positive consequences outweigh the negative. Then select the strategy whose positive consequences most greatly outweigh the negative consequences.
Now you need to encourage the child to decide on the steps s/he will have to take to put the strategy into action.
Step 5: Implement & Evaluate the Results
The last step will be the hardest one for the child, since s/he will now have to act. You’ve helped him/her to select some new and different responses to an old situation. It is time to put those decisions into effect.
Once the child has tried the new response, s/he must observe the consequences. Are things happening as s/he predicted? Is s/he satisfied with the outcome? Being satisfied means that the new response is helping you reach your goals in a positive way that the old ‘solution’ was not.
- repeat the five step process with a different problem
STEP 6. Review, Closure and Planning Follow-up
After a review of the homework assignment, the first order of business is to take stock of what the child has learned. Step by step, go over each procedure and discuss the progress that has been made. Emphasize the positive developments. Emphasize the skills that have been learned and the tools that will be available to the child in the future. After evaluating the overall progress, a decision will be made about whether to continue the counseling, take a break or end it. If the decision is to end, two specific things should be addressed.
First, there should be a thorough discussion about how other people, particularly family members who have been very close during the most difficult periods, can inadvertently contribute negative thoughts. It is not unlikely that someone will ask if the child is sure s/he is doing better, and then remind him/her of failure in the past. Such events are not likely to be overwhelming unless they occur frequently and intensely. Nonetheless, it is important that anticipatory strategies be formed to deal with such issues. Two particular facets should be discussed. First, there should be a ‘script’ prepared, a planned response, in which the clinician plays the ‘devil’s advocate’ and ask the most irreverent questions in an attempt to shake the child’s faith, and the child has prepared responses to each attempt. You may choose to have the child visualize the worst-case scenario with someone s/he thinks may blunder into this path, and then help the child develop the script. Try to make the script as inclusive as possible.
Second, the child needs to review the negative automatic thoughts and with the clinician, make a decision as to what constitutes a potential relapse and plan how to self monitor and what response to make to such a situation. You will need to emphasize to the child that you do not expect such a relapse, but that you want to be sure that if s/he has fears that s/he can handle it. Part of this process is to know when and how to reach you for support.
Two beliefs should accompany the child as s/he leaves this process: 1) s/he is capable and competent and 2) s/he has learned the skills to stay that way.