{"model":"nomic-embed-text","dims":256,"chunks":[{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.2","t":"Published by the Department of Veterans Affairs, South Central Mental Illness Research, Education, and Clinical Center (MIRECC), 2021. Suggested citation: Cully, J.A., Dawson, D.B., Hamer, J., & Tharp, A.L. 2020. A Provider’s Guide to Brief Cognitive Behavioral Therapy. Department of Veterans Affairs South Central MIRECC, Houston, TX. To download a copy of this manual use this link: https://www.mirecc.va.gov/visn16/docs/ therapists_guide_to_brief_cbtmanual.pdf To request a copy of this manual, please contact VISN16SCMIRECCEducation@va.gov or complete an online order request at the South Central MIRECC website: https://www. mirecc.va.gov/VISN16/order/order-education-products.asp","e":[25,-17,-168,-56,36,-24,39,-19,9,-21,-7,-21,48,-8,20,-28,-10,-37,-27,-10,-73,-37,-32,-22,78,61,23,27,-25,1,84,5,-4,-44,-28,-47,27,-9,-38,45,46,20,-3,-101,19,28,79,18,14,-38,18,-38,65,-7,56,-9,-5,25,-1,-40,111,75,-40,20,27,-5,-45,48,-36,-1,47,-34,78,21,-67,-10,-41,-71,-20,1,48,-14,55,-41,63,4,12,27,11,56,36,85,-33,68,-55,-3,-36,-9,-40,-39,-69,-37,-1,8,27,50,-2,-12,-1,-10,-63,49,-25,1,12,-16,56,-16,42,42,-37,-39,33,33,15,26,-65,7,10,-21,10,0,-17,-11,2,40,-17,16,13,57,12,33,-6,10,-3,-31,11,-20,-40,-33,40,40,26,25,51,-60,-4,13,28,36,41,21,-20,63,-3,-52,18,45,14,-10,-67,-21,24,8,51,8,3,-8,48,-10,29,-25,48,28,16,-21,-5,12,-21,-33,-37,6,-70,-24,-82,-71,32,-67,40,-28,9,44,-4,34,-54,77,-54,-8,-26,-19,58,-28,-1,3,1,-19,6,-21,-24,18,18,-12,34,-36,29,-4,-42,-4,31,18,-14,-85,45,10,43,17,-20,59,18,41,21,34,52,7,-82,6,14,-45,29,30,29,-12,3,28,27,-2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.2","t":"We would like to thank the individuals and organizations that supported this work. The second edition of this provider manual was created through a generous grant from the South Central MIRECC as well as support from the Veterans Health Administration’s Office of Research and Development and Office of Academic Affiliations. We would also like to thank Ms. Raquel Gonzalez and Ms. Sonora Hudson, who made invaluable conceptual and editorial contributions. We would also like to give special thanks to the following content experts and reviewers: Terri Fletcher, PhD; Jessica Breland, PhD; Julianna Hogan, PhD; Stephanie Day, PhD; and Jan Lindsay, PhD. 2","e":[13,-33,-189,-28,51,14,-9,-2,30,6,-4,-37,82,16,40,-10,23,-23,-22,5,-64,-100,-47,-38,91,64,7,48,-36,-5,48,-40,10,-49,27,-38,-10,17,-50,62,41,7,-7,-85,-16,-4,48,28,4,-42,26,-28,24,72,41,-21,-6,8,38,-65,91,54,-59,38,30,-38,-32,27,-32,9,13,19,36,42,-28,10,-66,-26,-32,25,74,-4,51,-33,38,7,38,27,-18,57,37,53,10,63,-69,-3,-5,7,-69,-24,-38,-29,40,11,46,40,21,12,10,-22,-64,26,-33,4,8,-41,63,-41,29,66,-32,-34,15,33,10,14,-71,-19,24,2,-17,-14,17,-10,-1,16,-21,-21,31,24,22,42,-7,-37,17,-32,-3,-22,-27,-2,28,28,-11,40,37,-37,-15,0,1,33,65,20,-36,39,45,-31,17,-5,10,15,-3,-61,31,10,85,-30,6,-21,22,6,36,-40,33,27,13,-53,19,-15,-77,-54,-22,54,-25,-51,-76,-17,62,-48,28,-29,-24,31,-18,14,-27,96,-29,6,-54,-27,50,-15,8,14,13,-34,-30,-14,-17,11,18,-17,26,-41,-17,-40,-41,1,-16,-60,12,-107,46,-5,23,-19,-5,68,9,5,10,8,72,-11,-72,20,14,-36,29,75,63,-21,9,14,11,-43]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.3","t":"THE BRIEF CBT MANUAL This manual is designed for mental health practitioners who want to establish a solid foundation of cognitive behavioral therapy (CBT) skills. Concepts contained in the manual detail the basic steps needed to provide CBT (“Practicing CBT 101”) with the intent that users will feel increasingly comfortable administering CBT. The manual is not designed for advanced CBT practitioners. Instructional material in this program is designed to be used within the context of a psychotherapy supervisory relationship to ensure appropriate application of the training materials and timely feedback, which are viewed as critical to the development of CBT skills.","e":[22,25,-147,-41,60,-8,60,5,22,-35,-22,-12,38,12,6,-42,-11,-55,5,-1,-40,0,-42,-39,10,28,-28,20,-32,-40,36,-29,4,-37,-36,-49,77,34,-40,-3,51,-11,5,-79,4,11,85,3,-5,-5,20,-60,59,-47,121,2,2,21,-35,-82,104,76,-67,69,11,-28,-49,51,-27,-1,54,-14,45,56,-44,-34,-35,-36,12,43,35,-29,43,-31,66,9,-34,8,16,59,20,24,11,46,-84,7,-41,-15,-15,-17,-41,-20,25,10,7,49,-3,-19,-12,-14,-55,38,-35,8,-19,13,75,6,25,54,-24,-27,24,29,11,55,-72,-14,35,-37,-10,0,-24,-30,21,73,-1,27,14,43,20,2,-11,17,27,2,13,-5,-11,10,12,26,13,-6,59,-46,15,-13,29,17,45,17,-70,24,-12,-41,5,8,51,27,-48,-27,9,10,60,37,70,-3,-2,-75,23,-35,27,46,-2,-3,-4,-70,-40,-19,18,12,-47,-32,-100,-57,36,-20,41,-8,9,46,-23,40,-46,64,-27,-3,1,-38,48,-18,5,-21,-33,-13,-26,-10,-73,13,20,20,-6,-8,-7,19,-43,-17,2,24,-14,-71,13,13,25,11,2,30,-22,69,12,32,57,13,-86,-12,-5,-39,17,35,8,-1,41,-8,32,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.3","t":"The content of this manual is a compilation of foundational works on CBT, such as Judith Beck’s (2011) Cognitive Therapy: Basics and Beyond, with the addition of key skills needed for developing CBT providers. The information is condensed and packaged to be highly applicable for use in a brief therapy model and to aid in rapid training. 3","e":[38,33,-143,-25,43,-7,25,-7,23,-19,-33,-20,75,3,5,-41,-25,-24,26,40,-32,-14,-30,-18,37,23,-26,38,-41,-50,47,-39,5,-50,-43,-49,72,14,-58,20,18,-19,-7,-97,0,-22,96,-2,4,4,27,-58,49,-24,127,16,10,8,12,-59,86,72,-74,66,29,-40,-39,75,-51,8,51,-41,46,57,-47,-41,-64,-30,-1,51,49,-31,54,-18,45,28,-25,20,36,43,41,11,2,30,-59,15,-30,-21,-30,-25,-67,-13,47,-2,32,44,14,-47,-33,9,-58,47,-33,19,-38,3,67,-2,15,32,-12,-26,38,34,19,55,-83,4,24,-42,-15,-19,-19,-23,25,57,-5,-3,-1,41,36,19,-25,13,3,-22,2,-16,-15,23,4,36,-13,31,66,-46,5,-19,-5,21,56,13,-30,38,0,-21,4,26,42,47,-9,-52,-7,16,66,36,60,-6,9,-59,4,-5,23,23,8,-15,-4,-25,-37,-22,-14,20,-12,-22,-80,-76,36,-9,70,-26,9,46,-65,47,-61,98,-25,23,-25,-38,59,-28,3,6,-37,-36,-22,-23,-32,26,18,14,-8,-34,-12,3,-14,21,21,38,-24,-84,-1,27,27,42,-1,47,21,57,10,36,25,-8,-70,10,7,-33,7,42,-15,-12,27,18,18,12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.6","t":"CBT combines cognitive and behavioral therapies and has strong empirical support for treating mood, sleep, chronic pain, and anxiety disorders (Hoffman & Otto, 2017; Lepping et al., 2017; Shatkin, 2018). The basic premise of CBT is that emotions are difficult to change directly, so CBT targets emotions by changing thoughts and behaviors that are contributing to the distressing emotions. Figure 1.1. Cognitive SITUATION Behavioral Model THOUGHTS FEELINGS BEHAVIORS","e":[28,21,-172,-51,66,-10,29,-14,54,-26,20,13,76,-1,-11,-36,-34,6,-14,25,-58,-31,-3,-37,-27,77,-20,53,-11,26,69,-13,26,-43,-54,-31,69,40,-16,7,41,-7,43,-83,3,-38,89,11,24,-4,29,-70,20,-66,134,7,5,49,-7,-68,81,53,-62,71,56,-34,-43,55,-27,4,56,-20,28,60,-53,-33,-23,-23,-20,26,69,-46,49,-36,58,2,-18,5,-14,79,5,-5,7,31,-79,10,-1,-44,-15,-31,-69,-13,9,-13,8,12,-14,4,-16,25,-67,42,0,-15,-12,19,61,-16,8,56,29,4,14,47,5,55,-66,-14,15,-34,-11,-17,-7,-12,0,37,-16,3,-12,61,40,5,-1,19,-12,-12,7,-23,-44,-10,-11,16,12,13,48,-27,-18,28,57,26,32,10,-48,27,-17,-47,0,26,27,46,-74,-43,-23,28,91,45,46,14,13,-60,22,-8,33,40,10,3,2,-51,-60,-59,25,32,-44,10,-92,-30,25,-6,33,-48,0,20,-3,11,-42,78,-23,-5,-26,-51,66,-22,-7,37,-52,-10,-12,-46,-45,12,14,18,-13,-11,2,0,-10,2,8,30,-7,-75,48,22,33,64,2,22,16,67,34,48,36,23,-71,13,-6,-39,2,35,-17,6,-5,-6,62,-22]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.6","t":"This training manual is focused on second-generation CBT (Beckian Cognitive Therapy), which focuses on using cognitive restructuring and relaxation techniques to influence behavior change. From this perspective, we may understand situational feelings as influencing thought patterns, behavioral responses, and long-lasting emotional states. CBT builds a set of skills that enables individuals to 1. Identify how situations influence thoughts and behaviors 2. Become aware of the connection between thoughts, behaviors, and emotions 3. Improve emotional states by changing unhelpful thinking styles and behaviors linked to negative emotional sates.","e":[28,2,-167,-53,57,4,76,-3,40,-25,-16,19,64,22,23,-25,-7,-23,-29,38,-37,-14,-2,-7,9,56,-31,51,-28,-29,38,-15,-12,-39,-82,-37,68,-3,-17,24,28,-21,29,-107,13,-27,98,-15,43,-5,17,-64,30,-62,121,23,16,28,-18,-67,89,45,-48,83,3,-29,-55,54,-60,-3,54,-35,0,67,-36,-17,-52,-21,-1,36,51,-34,41,-58,70,18,-11,26,-25,74,15,-11,19,17,-79,34,2,-15,0,-20,-66,-29,6,-22,3,45,-5,-18,4,26,-72,44,-13,20,-20,-1,34,-4,5,34,33,-6,3,36,13,66,-103,-4,19,-31,-10,-23,-16,-9,9,49,-11,-2,-4,41,53,0,5,31,-7,-21,-6,-20,-40,-18,-31,2,23,-1,40,-26,-30,17,63,22,41,6,-24,24,-3,-23,29,27,47,37,-86,-54,-7,0,58,29,53,-45,28,-53,-7,-13,29,27,15,15,-8,-25,-50,-56,24,16,-61,-16,-86,-62,20,-25,29,-38,-3,16,-49,20,-36,35,12,-9,-25,-33,73,-31,-14,10,-36,4,-8,-18,-31,17,16,23,-16,-5,-15,-2,-37,-7,13,38,-23,-62,31,28,33,44,4,19,16,51,33,59,16,9,-60,23,20,-24,2,31,2,-1,6,-34,46,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.6","t":"The process of CBT skill acquisition is collaborative. Skill acquisition and homework assignments are what set CBT apart from “talk therapies” and nondirective therapies. Time in session should be used to help the patient obtain skills to address the presenting problem and not simply to discuss the issue with the patient or offer advice. Identifying and changing unhelpful thoughts and behaviors sets CBT apart from third-wave therapies such as acceptance and commitment therapy, mindfulness-based therapies, and dialectical behavior therapy. 6","e":[39,0,-161,-24,77,2,56,-14,34,-5,-25,-7,52,13,0,-50,-25,-52,-34,30,-46,0,-2,-23,-11,21,-39,12,-6,-19,44,-21,29,1,-30,-46,84,-18,-58,6,25,-7,15,-91,42,-6,86,27,21,21,59,-79,-12,-28,122,29,2,13,-9,-64,84,59,-48,84,41,-33,-20,74,-32,16,32,4,83,45,-56,-35,-41,-22,-6,35,28,-26,49,-25,57,2,-19,-2,-25,99,6,-6,-2,16,-83,41,-20,-5,-42,-43,-64,-16,25,-27,41,51,-1,-35,-14,20,-75,35,-32,-18,-1,3,32,-18,17,9,22,-24,-28,34,5,106,-68,-15,20,-18,-40,-3,0,13,-30,56,-30,-11,-12,31,53,21,-4,23,9,-11,5,-35,-54,2,12,23,22,7,44,-19,-13,-13,72,29,40,-22,-52,30,-35,-41,18,42,53,10,-44,-59,-12,8,51,54,36,-32,-13,-25,24,-28,0,40,23,-7,24,-45,-44,-47,25,15,-19,-12,-81,-53,30,-10,23,-34,-18,15,-54,38,-30,72,-26,-9,-17,-43,42,-12,-26,-15,-34,1,6,-13,-47,17,27,-10,-35,-20,9,1,-38,-1,-7,51,-32,-88,6,0,25,36,16,11,1,66,13,47,38,-9,-91,23,34,-44,-16,39,-3,37,4,-16,7,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.7","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 1 Brief CBT is the compression of CBT material and reduction of the average 12-20 sessions into four to eight sessions. In brief CBT the concentration is on specific treatments for a limited number of the patient’s problems. Specificity of the treatment is required because of the limited number of sessions. Additionally, the patient is asked to be diligent in using extra reading materials and homework to assist in his or her therapeutic growth.","e":[10,30,-167,-68,40,-26,46,-10,1,-12,-25,-10,25,-7,-8,-34,-22,-58,-21,3,-55,-13,13,-26,5,51,13,29,-38,-20,46,-44,-2,-34,-66,-54,68,27,-56,-12,33,-33,32,-72,8,5,82,29,-27,-2,11,-37,15,-39,145,24,-29,-7,0,-9,87,34,-88,83,11,-36,-43,45,-5,-17,47,-30,39,36,-29,-32,-54,-26,1,43,24,-27,66,-16,40,-20,-34,-1,-5,46,13,11,24,46,-70,35,-1,-23,-5,-21,-45,-18,12,-39,2,26,-14,-4,1,-17,-58,26,-30,-17,-20,-27,29,-20,30,16,-15,-35,21,46,42,46,-39,4,3,-31,-1,-14,-29,-7,13,29,18,4,-1,54,-2,5,-29,21,-22,-14,23,-29,-20,-9,5,-1,22,22,41,-27,9,-20,62,25,14,4,-49,29,-48,-26,8,29,30,19,-43,-43,-21,-12,29,55,82,-25,23,-56,1,5,26,59,3,-3,15,-61,-22,-20,10,21,-28,-19,-76,-66,34,-3,5,-53,-9,28,9,34,-24,76,-39,29,-18,-37,83,-17,-11,19,-33,-19,-18,-17,-49,27,46,28,8,-20,-1,18,-7,-19,-9,42,-25,-68,0,13,-10,38,-6,33,-14,54,34,32,57,10,-97,11,-6,-28,2,29,-26,-20,21,1,44,17]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.7","t":"Brief CBT can range in duration from patient to patient and provider to provider. The exact length of treatment will be determined by a host of factors involving the provider, patient, and treatment setting. Although variability exists, the table below shows an example session-by-session outline. You are encouraged to think flexibly in determining length of treatment. As indicated in the table, you are not expected to rigidly adhere to a \"set schedule\" of progress or topics but rather should be flexible and adaptive in approaching brief CBT applications. Time-limited therapy may offer additional incentives for patients and providers to work efficiently and effectively. For example, it is often helpful to work within a \"session-limited framework\" in which the patient receives four-to-six sessions of \"active\" treatment, followed by one or more follow-up sessions that occur at increasing intervals after the active-treatment phase (e.g., two weeks posttreatment with an additional booster four weeks after that).","e":[55,55,-157,-54,15,-35,45,-24,43,-34,-27,-3,60,-12,7,-73,7,-68,-26,23,-33,-6,-31,-33,-34,37,10,46,-20,2,60,15,31,-20,-37,-65,79,4,-7,-20,58,-17,33,-61,42,-44,94,76,-24,-48,-3,-19,-33,-20,117,18,-41,34,5,-27,121,26,-69,70,58,-14,-20,44,-37,-20,24,-8,43,49,-7,-2,-52,5,-11,41,38,-2,41,-52,46,19,-11,3,-14,92,-6,9,33,45,-92,8,-3,-27,-27,-5,-62,6,29,-8,12,53,12,-13,6,-30,-72,0,-49,15,-32,8,64,-23,17,26,-12,-25,16,29,6,45,-69,11,31,-21,-16,-5,-31,23,13,50,41,-12,-22,35,9,-24,2,14,2,3,-4,-26,-24,26,15,19,6,44,48,-35,-13,-16,20,14,31,6,-54,28,-43,-7,-7,22,4,-13,-40,-66,-8,-7,84,50,89,-13,-12,-46,18,-35,0,50,3,3,26,-50,-49,-53,34,-1,-44,-4,-87,-50,52,-22,13,-40,-6,31,-41,43,-7,69,-35,11,-31,-59,84,11,-43,30,-45,-23,-17,3,-40,36,61,-1,14,-67,24,-5,-41,6,-29,39,-7,-56,0,8,-2,5,24,-8,-3,56,-6,26,42,36,-84,-15,10,-38,-4,43,-14,12,35,5,19,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.8","t":"Certain problems are more appropriate for brief CBT than others. The following table summarizes problems that may and may not be conducive to brief CBT. Problems amenable to brief CBT include, but are not limited to, adjustment, anxiety, and depressive disorders. Therapy also may be useful for problems that target specific symptoms (e.g., depressive thinking) or lifestyle changes (e.g., problem solving, relaxation), whether or not these issues are part of a formal psychiatric diagnosis.","e":[42,57,-125,-47,23,-17,32,-26,48,-36,7,3,53,9,-29,-22,-2,-40,-25,26,-47,8,-23,-43,-31,82,6,28,-31,9,34,-18,29,-50,-38,-43,97,51,24,-2,80,-26,15,-91,22,-17,103,61,17,-39,48,-85,20,-54,87,36,-12,23,12,-52,63,32,-45,59,47,-25,-20,43,-16,9,65,9,43,74,-49,-32,-4,-4,-3,20,12,-6,37,-52,82,17,-33,17,23,62,2,25,22,43,-54,52,-10,-27,-24,-29,-41,1,-7,24,11,16,-7,-13,-31,-13,-90,63,-22,-30,-1,4,41,-42,22,81,-17,-8,18,24,10,39,-53,-4,72,-36,-41,-25,-20,2,23,54,0,20,-19,14,55,-2,-3,28,-9,7,-9,-6,-40,3,-13,-1,13,15,50,-9,-3,21,68,-12,9,10,-67,44,-9,-21,-8,54,25,52,-64,-57,13,16,83,43,90,-24,23,-55,25,-36,15,19,7,5,24,-42,-47,-46,23,19,-45,4,-99,-58,32,-6,7,-38,-7,49,-26,36,-9,74,-31,-28,-4,-79,82,-32,-10,13,-55,-2,-17,-10,-37,31,21,-18,-10,-38,25,26,-39,-12,-20,20,-19,-95,67,20,34,28,0,-4,-11,70,-2,14,50,29,-66,-3,-20,-42,5,29,-27,14,17,8,33,-9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.8","t":"Brief CBT is particularly useful in a primary care setting for patients with anxiety and depression associated with a medical condition. Because these individuals often face acute rather than chronic mental health issues and have many coping strategies already 8","e":[15,37,-165,-77,28,-10,2,-5,30,-37,12,32,54,-19,-6,-14,-31,-27,-14,2,-54,-6,-20,-11,-17,73,31,49,-19,17,40,-6,19,-45,-26,-36,59,28,-5,-4,55,-20,17,-101,1,0,70,53,18,-28,6,-53,37,-50,125,18,-15,50,18,-50,94,45,-46,49,65,-36,-36,39,-1,28,39,-12,56,35,-32,1,-50,-22,5,31,62,-27,39,-38,69,6,-29,-22,-14,71,40,3,24,66,-84,40,11,-43,4,-39,-55,-2,15,22,8,16,-24,7,-4,-3,-58,74,-23,-15,15,25,31,-41,7,36,-12,8,37,49,24,72,-43,-9,68,-25,3,-29,-7,-11,26,75,-19,21,-1,30,13,-9,-10,-4,30,4,2,-18,-60,7,-9,7,20,42,57,-6,-10,16,50,21,36,9,-47,50,-27,-42,21,29,26,58,-39,-58,-4,-23,80,29,78,-2,42,-73,26,-28,18,49,-20,25,12,-39,-33,-53,-14,2,-63,12,-99,-34,18,27,-29,-29,-23,19,4,21,-34,63,-33,-31,2,-75,65,-16,2,9,-58,-2,-42,-35,-46,38,21,-12,8,-33,32,26,-41,-4,-7,21,0,-81,29,17,15,24,-6,24,-25,57,5,47,49,9,-57,13,-20,-43,19,22,-31,8,16,17,35,-49]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.9","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 1 in place, brief CBT can be used to enhance adjustment. Issues that may be addressed in primary care with brief CBT include, but are not limited to, diet, exercise, sleep, pain, medication compliance, mental health issues associated with a medical condition, and coping with a chronic illness or new diagnosis (Cully et al., 2017).","e":[11,31,-167,-55,35,-10,18,4,53,-32,11,8,27,21,-21,7,-9,-52,-21,3,-45,-35,10,-6,-8,59,52,50,-27,3,38,-25,15,-45,-36,-64,81,48,-27,-2,33,-16,34,-75,21,0,86,52,-16,4,17,-55,26,-22,122,3,4,16,28,-55,83,35,-65,72,32,-47,-20,38,-15,3,58,-26,38,53,-23,-21,-41,-26,-10,34,30,-4,77,-34,43,-4,-7,-13,8,74,14,19,11,52,-87,24,16,-24,12,-32,-60,6,18,6,-8,30,-14,31,-10,3,-76,48,1,-21,-7,-23,27,-45,36,59,-19,-27,26,76,21,52,-59,-31,39,-32,9,-30,-18,1,15,37,5,29,-8,28,19,-19,12,13,13,-6,5,-22,-36,11,-4,21,25,22,59,-3,-25,4,65,16,47,5,-41,47,-9,-34,6,43,22,52,-32,-53,-23,-18,62,51,78,-26,42,-66,22,-24,1,68,-8,4,4,-45,-51,-24,-18,27,-50,-2,-87,-76,3,-17,-2,-50,-5,16,6,38,-14,62,-37,-18,-5,-91,102,-14,-1,14,-44,-7,-40,-28,-47,26,15,-6,-3,-14,16,11,-24,-10,-29,44,-1,-98,46,48,27,25,3,26,-9,56,23,49,51,18,-66,32,3,-28,-9,29,-10,14,19,13,39,-26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.9","t":"Other problems may not be suitable for the use of brief CBT or may complicate a straightforward application of brief CBT. Axis II disorders, such as Borderline Personality Disorder or Antisocial Personality Disorder, are not typically appropriate for a shortened therapeutic experience, because of the pervasive social, psychological, and relational problems individuals with these disorders experience. Patients exhibiting comorbid conditions also may not be appropriate because the presence of a second issue may impede progress in therapy. For example, an individual with substance dependence secondary to major depression may not be appropriate because substance use requires a higher level of care and more comprehensive treatment than is available in a brief format. However, brief CBT could be used with Axis II and comorbid concerns in dealing with specific negative behaviors or in conjunction with more intensive treatment.","e":[81,44,-145,-44,-13,21,40,-35,8,-33,27,37,51,-25,4,-32,-3,-30,-38,14,-72,6,9,-23,17,79,7,13,-39,17,68,17,20,-61,-9,-59,53,33,9,25,54,5,31,-98,7,-7,114,74,1,-41,65,-58,43,-31,108,1,-23,20,-28,-59,62,35,-33,54,70,-41,-42,20,-24,-33,74,-5,51,52,-33,2,-26,-16,12,57,29,-5,30,-42,93,14,-17,8,6,57,19,2,20,48,-55,38,7,-22,-12,7,-57,-6,-7,42,8,23,5,-7,6,-4,-62,65,-34,-27,27,5,40,-57,11,45,-37,-49,36,67,4,42,-72,-18,52,-62,-39,-21,-17,-1,1,37,-10,-12,-29,17,23,0,9,26,-9,24,11,-36,-42,7,-8,24,10,47,38,-33,0,28,50,-8,28,-5,-59,29,-23,-42,22,54,8,36,-62,-34,12,-16,59,50,37,-44,19,-54,1,-4,-11,36,0,10,25,-26,-43,-38,23,26,-65,-7,-114,-51,31,-3,-19,-29,-7,34,-24,38,-45,56,-54,11,0,-49,82,-25,-19,-3,-60,-25,-10,-16,-43,34,9,-16,22,-45,41,16,-47,-20,-30,-1,-25,-121,69,1,2,-4,1,14,-13,45,-13,43,46,34,-56,7,-7,-32,25,29,-36,-3,8,1,46,20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.10","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 1 The following are general provider skills and abilities required for brief CBT: • Capability to establish a strong working relationship quickly • Thorough knowledge of the treatments used • Ability to integrate and use treatment manuals • Thorough and quick assessment of patient concerns • Skill in structuring sessions and homework material to address problems • Skill in presenting material clearly and concisely with specific examples for each patient issue • Provider interpersonal/personality variables: ability to be assertive, directive, nonjudgmental and collaborative 10","e":[-46,2,-141,-50,72,6,42,1,27,-12,-25,-18,16,-9,-24,-13,12,-67,-11,23,-62,-49,25,-17,11,34,-2,27,-38,-39,26,-31,19,-57,-28,-60,70,23,-43,19,22,-28,20,-81,36,23,108,45,-6,14,-10,-54,41,-21,142,21,2,19,1,-50,79,37,-100,70,-3,-43,-35,38,-46,-16,50,-10,52,34,-15,-17,-78,-25,11,34,52,-16,74,-16,33,-3,-23,-6,21,55,17,31,-17,66,-49,34,-36,-38,4,-18,-41,-18,33,-21,5,32,-8,-6,-12,1,-48,55,-19,-17,-24,-35,29,-25,30,79,-24,-16,16,67,38,43,-49,-23,7,2,23,-16,-38,10,4,26,42,17,25,44,15,17,-4,17,-32,-29,-1,-17,-35,4,6,29,34,39,49,-46,-5,-23,74,8,49,20,-60,35,-1,-51,17,6,24,40,-17,-41,-7,-3,47,34,70,-13,24,-71,21,-14,16,53,-7,-8,3,-44,-17,-10,6,45,-32,-8,-69,-94,23,-37,28,-65,-7,29,9,52,-29,76,-47,21,-9,-42,92,-38,-4,3,-27,-14,-41,-30,-61,2,44,19,7,-14,-15,42,3,11,8,47,-3,-64,30,14,26,44,9,20,-2,51,21,34,59,14,-91,17,-14,-33,-3,44,1,-14,23,0,17,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.11","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 1 ASSESSING THE PATIENT It is necessary to collaboratively engage patients appropriate for brief CBT versus traditional CBT or other types of therapy. Below are important points to consider in selecting patients for brief CBT. This assessment should precede the treatment phase. It may be based on the intake assessment, input from the referral source, or a review of the medical chart. Highlight 1.1 Things to Consider in Evaluating Patients for Brief CBT","e":[-5,6,-146,-53,55,17,42,6,3,-7,-9,19,26,9,-35,-41,2,-52,-23,26,-71,-23,-8,-9,10,20,8,36,-53,-7,25,0,40,-50,-53,-85,67,43,-54,-17,14,-22,27,-88,29,16,114,35,-15,13,18,-30,22,-17,136,23,-20,13,22,-32,80,53,-73,74,38,-41,-29,47,-30,-18,28,-15,62,37,-32,2,-25,-21,-4,27,40,-30,90,-33,28,-2,-26,-18,-1,57,9,25,22,69,-105,49,-30,-36,-7,-31,-51,-2,-2,-29,19,15,-17,11,-13,-36,-46,24,-26,-17,3,-13,47,-15,15,70,-6,-27,24,75,30,54,-56,-6,15,-18,-5,-11,-33,-31,0,52,24,6,-2,15,7,18,-5,29,-9,-8,20,-25,-29,9,9,43,35,40,27,-45,-22,-14,61,10,49,11,-34,34,-25,-31,29,1,36,17,-24,-38,6,-27,54,48,72,-28,18,-45,13,-25,14,49,-13,-25,16,-23,-28,-36,25,43,-36,-18,-72,-68,12,-14,19,-60,-10,26,-30,67,-71,92,-31,-4,-31,-74,73,-15,-10,21,-41,17,-29,-25,-44,18,42,18,-2,-8,-5,21,-36,11,-4,37,-11,-83,10,18,12,39,-6,27,3,50,21,36,66,23,-91,11,-1,-37,12,26,-31,2,11,10,27,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.11","t":"1. Strong Motivation to Change a. Increased distress is often associated with increased motivation to change. b. Positive treatment expectancies (e.g., knowledge of CBT and perceived benefits of treatment) are associated with improved outcomes. Alternatively, the patient does not have negative self-thoughts that might impede progress or change (e.g., \"Seeking care means I am crazy”; \"Nothing I will do can change things\"). c. Patients who have clear goals for treatment are good candidates. 2. Time Commitment a. Patient is willing to devote the time needed for weekly or biweekly sessions. b. Patient is willing to devote energy to out-of-session work (e.g., homework). 3. Life Stressors and Social Support a. Too many life stressors may lead to unfocused work and/or frequent \"crisis-management\" interventions. b. Patients supported by family and friends are more likely to benefit. 4. Cognitive Functioning and Educational Level a. Independent homework assignments and reading materials may require adjustment according to patients’ cognitive status and educational level. b. Patients able to work independently are more likely to carry out between-session work. c. Patients who are psychologically minded are more likely to benefit from short-term therapy. 5. Severity of Psychopathology a. Patients with comorbid psychopathology may be more difficult to treat in short-term therapy. In addition, some conditions such as substance abuse or serious mental illness require focused and more intensive interventions. b. Patients with an Axis II diagnosis are also less likely to benefit from short-term CBT. Long-standing interpersonal issues often require longer treatment durations.","e":[22,30,-153,-24,64,-10,47,9,47,-17,-26,3,48,11,25,-18,16,-27,-21,49,-61,-34,-3,-41,-26,68,-15,42,-21,24,81,-9,18,-43,-51,-24,100,55,43,4,56,-26,49,-101,5,-51,96,20,23,-27,5,-61,8,-16,118,41,-28,54,-17,-67,72,21,-46,65,58,-23,-28,46,-54,-6,55,11,3,78,-27,-1,-59,-6,8,16,54,-9,32,-69,79,-4,28,30,7,58,-9,9,3,53,-91,16,11,-29,-11,-28,-67,-38,-10,12,-8,19,1,-14,-23,11,-76,21,-32,-15,-4,2,51,-24,18,53,23,-15,-1,44,3,36,-44,-3,65,5,-14,-22,-42,28,-9,45,19,4,-11,18,67,13,45,34,-18,-35,-3,-25,-33,7,13,19,19,41,34,-52,-20,9,20,37,35,-9,-60,45,-10,-43,20,35,7,57,-30,-57,6,5,71,16,84,-11,18,-45,37,-28,40,34,30,21,24,-49,-45,-23,48,-1,-56,-7,-82,-59,15,-19,-9,-68,-23,52,-23,28,-43,71,-7,-7,-21,-49,67,-26,-33,16,-35,1,-4,-22,-28,26,49,-31,11,-23,1,26,-30,-14,7,37,-20,-64,72,9,2,32,11,-5,34,68,-6,22,35,-6,-58,1,-16,-42,-32,36,23,14,33,-3,23,-12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.12","t":"SUPPLEMENTAL READINGS Beck, J.S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press; Chapter 1. Bond, F.W. & Dryden, W. (2002). Handbook of brief cognitive behavioral therapy. San Francisco: Wiley. Cully, J., Stanley, M., Petersen, N., Hundt, N., Kauth, M., Naik, A., Sorocco, K., Sansgiry, S., Zeno, D., & Kunik, M. (2017). Delivery of Brief Cognitive Behavioral Therapy for Medically Ill Patients in Primary Care: A pragmatic randomized clinical trial. Journal of General Internal Medicine, 32(9), 1014–1024. Hofmann, S., & Otto, M. (2017). Cognitive behavioral therapy for social anxiety disorder : Evidence-based and disorder specific treatment techniques. Routledge. Lepping, P., Whittington, R., Sambhi, R., Lane, S., Poole, R., Leucht, S., Cuijpers, P., Mccabe, R., & Waheed, W. (2017). Clinical relevance of findings in trials of CBT for depression. European Psychiatry, 45, 207–211. Shatkin, J. (2018). 14.2 Sleep hygiene and CBT for insomnia (CBT-I). Journal of the American Academy of Child & Adolescent Psychiatry, 57(10), S21–S21.","e":[32,12,-149,-38,-2,9,35,-9,47,-17,-10,1,52,12,-16,-60,-19,-18,-12,8,-41,-3,-28,-39,-6,77,-19,25,-56,-10,42,11,-12,-41,-68,-22,106,20,-47,21,41,14,37,-103,3,-22,80,29,23,-11,10,-22,42,-53,113,3,-36,16,-13,-41,88,27,-64,26,42,-32,-39,74,-45,-10,64,-9,45,28,-49,-21,-33,-35,-10,23,63,-5,48,-40,37,-2,-52,2,-4,54,14,18,-23,30,-17,32,-4,-91,-41,-55,-50,-12,42,33,39,19,-19,-25,-61,11,-80,44,11,-1,16,1,59,-29,29,37,-14,-2,40,38,-5,45,-75,-2,18,-22,-19,-13,-23,16,-17,36,9,16,5,7,32,6,7,10,27,3,3,11,-46,16,-16,3,11,43,20,-41,-17,5,50,56,42,14,-45,73,13,-36,1,27,28,41,-82,-49,5,2,62,29,69,-15,14,-27,34,-26,57,35,6,-27,-3,-2,-47,-18,-8,3,-85,8,-85,-60,54,-35,52,-48,-16,25,-23,33,-35,80,-26,-20,-4,-41,15,-20,35,7,-14,-2,-12,-26,-61,14,0,13,4,-8,25,23,-43,32,22,69,-36,-102,9,6,43,41,-2,37,6,75,6,55,31,3,-54,-3,-18,-26,8,31,-10,15,18,30,44,7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.13","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 2 Module 2: Using Supervision OBJECTIVES • To discuss the importance of supervision/consultation in CBT training • To provide information on how to use clinical supervision and consultation in CBT training • To outline various models of supervision/consultation in CBT training • To provide tips on selecting a supervisor/consultant Introduction","e":[-24,-21,-139,-40,58,-6,44,-9,7,-2,-26,13,39,11,-23,-39,22,-53,-33,-24,-38,-39,49,-5,54,45,20,-5,-57,-35,19,-8,19,-42,-38,-74,67,46,-66,-32,6,-18,25,-91,18,-33,103,1,1,-11,34,-35,12,-1,148,16,8,-4,23,-19,99,42,-70,62,8,-54,-61,39,-44,1,34,-28,47,8,-24,-28,-19,-27,19,51,32,-28,67,14,0,15,-35,6,-7,50,11,25,18,43,-97,42,-13,-13,13,-13,-43,-16,34,-19,23,41,24,0,6,-8,-19,65,-17,-12,-12,-25,61,-47,10,65,16,-12,-2,78,61,58,-48,-7,-10,-22,21,-18,-28,-20,2,28,1,2,36,-9,13,-10,-24,22,-36,-57,42,-15,-46,3,-14,29,19,34,34,-46,-28,-39,80,8,82,10,-30,23,-35,-22,29,7,43,41,-36,-47,19,11,64,47,53,-3,6,-46,4,-32,14,34,-14,-21,35,-64,-38,19,10,61,-29,-43,-79,-47,4,-15,6,-36,-6,2,-27,24,-59,38,-13,36,-31,-20,50,-30,20,-7,-41,-20,-32,0,-57,9,19,27,24,22,-16,15,-29,-10,1,35,-18,-107,20,29,3,51,-10,57,37,57,45,24,58,29,-64,25,13,4,11,8,17,2,-7,10,32,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.13","t":"Knowledge about psychotherapy can be broken down into two broad domains, 1) knowledge of concepts and 2) knowledge of how to apply concepts. Information contained in this manual will provide you with basic knowledge of CBT concepts and attempt to provide you with practical tips on how to use these concepts. However, because the provision of CBT is highly variable, depending on the provider, patient, and treatment setting, applications of CBT will need to be customized and practiced in real- world settings. This manual is, therefore, only the first step toward CBT competency. Supervision and consultation are two methods to advance CBT practice skills through routine feedback and interaction with a knowledgeable CBT provider who can serve as a trainer/consultant.","e":[21,16,-146,-42,86,11,55,13,36,-15,-14,-13,53,-7,-21,-63,-4,-54,-17,21,-61,-27,-7,-34,-10,16,-38,-3,-18,-43,40,-8,13,-16,-50,-61,92,32,-31,-12,69,0,23,-70,13,-28,62,11,-23,-18,29,-41,17,-12,124,10,10,40,19,-104,105,69,-93,76,27,-28,-77,62,-36,-12,47,-12,58,26,-36,-43,-32,-27,5,52,54,-22,67,-8,29,32,-29,14,13,76,10,42,13,56,-72,47,-37,-21,-23,-24,-48,-13,15,-9,11,46,18,-34,-21,22,-70,20,-49,2,-31,-10,49,-30,17,60,10,2,4,63,39,64,-40,-10,-3,-1,-14,-26,-7,15,-18,59,30,-10,7,23,49,-2,-10,-2,-1,-40,20,-34,-27,18,18,55,5,3,55,-45,-4,-9,59,-2,51,21,-50,15,5,-44,16,-15,10,29,-39,-24,-18,10,74,38,69,-19,35,-23,19,-19,0,38,8,6,1,-79,-38,-29,11,44,-32,-18,-74,-49,31,-10,19,-38,-16,52,-17,52,-44,91,-28,23,-18,-27,67,-44,25,12,-12,-14,-22,-22,-63,11,8,7,26,-3,-15,20,-40,21,21,34,-23,-104,56,23,14,35,-17,11,7,67,1,22,59,34,-70,-9,20,-33,-5,32,4,36,41,15,21,-4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.13","t":"What is Supervision, and Why Is It Important to CBT? Supervision is designed to a) foster the supervisee's development and b) ensure patient welfare and safety by monitoring patient care. Supervision is NOT therapy; although supervision may involve an exploration of a provider’s personal experiences, such a focus is restricted to issues that influence the provider’s professional work (see following table.) Table 2.1 Goals and Focus of Supervision","e":[10,40,-122,-44,48,2,70,-22,34,-40,-35,12,69,-11,-1,-59,-1,-23,-13,-27,-7,11,9,-9,24,62,-12,3,-22,4,63,25,22,-20,-26,-65,65,64,-36,-21,27,20,-26,-137,15,-56,68,6,21,-46,17,-54,-30,-25,142,1,20,20,-22,-28,78,58,-82,67,14,-61,-60,27,-27,31,17,-22,38,42,-55,-23,-33,-2,24,24,62,-25,-13,13,20,2,-62,-5,-21,58,51,-32,36,39,-83,12,2,-7,13,-9,-62,-47,18,-15,46,23,11,-3,29,-26,-9,40,-34,3,-23,24,79,-14,22,47,41,36,-7,45,11,82,-38,23,39,-24,-4,-21,-22,-11,15,53,-44,6,27,-29,43,22,-24,23,-9,-49,32,-8,-33,24,20,27,-19,23,45,-29,-14,3,70,27,81,-15,-54,18,-31,-29,13,-10,25,27,-33,-47,15,31,83,36,57,4,9,-66,-29,-67,19,0,-11,12,5,-117,-17,-8,48,24,-31,-3,-86,-18,34,15,5,-26,-12,6,-48,21,-42,45,-36,-1,-36,-32,42,-19,-4,6,-39,-34,-2,10,-72,20,9,-7,47,-19,-46,9,-36,-35,-1,24,-17,-55,31,56,-4,56,-6,11,41,47,15,17,35,-29,-53,4,55,-40,-8,-13,21,10,50,-18,56,-33]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.13","t":"• Provides provider performance feedback • Provides guidance and acquisition of alternative viewpoints For the • Contributes to the process of forming a provider’s identity Supervisee • Serves as a secure base to explore applications and therapeutic principles • Ensures that patients receive acceptable care For the » Providers do no harm Patient » Providers possess sufficient skills » Those who lack skills are provided with remediation 13","e":[-23,13,-172,-47,103,-5,73,48,75,-11,-29,-11,42,18,12,-15,4,-53,-14,27,-74,-56,-23,-8,33,52,21,-27,-34,-28,14,-17,15,-20,-8,-61,63,30,-48,-11,-2,9,0,-83,4,-5,16,-7,26,-7,19,-70,-5,41,128,-16,14,36,-18,-21,78,79,-91,69,44,-33,-38,45,-16,12,9,0,30,29,-47,1,-39,-4,-14,40,84,0,90,-7,44,26,-15,14,-36,77,30,34,1,40,-102,7,-37,5,-12,-26,-45,7,54,-34,51,65,20,29,18,8,-12,7,-37,-11,17,-37,71,-24,-7,66,19,24,-4,48,36,54,-35,-17,-8,-5,20,-66,-48,-1,2,31,-8,-22,14,16,38,43,-14,-32,10,-43,51,-8,-32,14,-9,31,-9,46,47,-48,1,-16,34,-7,85,21,-36,56,-18,-60,27,-16,16,29,-5,-41,13,25,71,-2,16,-43,8,-47,0,-74,51,33,0,-41,36,-44,-62,-39,4,65,-29,-27,-58,-30,-5,-36,33,-32,5,11,-48,29,-30,33,-46,29,-22,-9,94,-34,44,-7,-25,-4,-8,-35,-15,32,0,-36,-20,-15,-17,15,-46,9,-15,24,0,-94,53,24,13,10,14,50,20,52,-8,50,9,-15,-81,22,-3,-41,4,34,21,13,36,-25,34,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.14","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 2 SUPERVISION VERSUS CONSULTATION There is a difference between supervision and consultation. Whereas supervision involves the direct oversight of clinical cases over a period of time (often involving evaluation of the provider), consultation refers to a relationship designed to assist in professional development that does not involve formal oversight of clinical cases and may or may not continue over time. In essence, consultation involves a growth-oriented discussion of cases or issues without oversight or evaluation. When? (Indications/Contraindications)","e":[30,25,-117,-57,36,43,47,-1,47,-21,5,-17,43,-7,-10,-68,31,-58,-40,5,-56,-6,4,6,37,8,-15,-24,-50,-24,54,56,48,8,-51,-107,67,46,-34,-36,20,20,21,-119,6,-73,20,-8,12,-56,31,-10,-53,38,94,28,70,39,12,-35,99,28,-73,70,29,-63,-75,29,41,-54,17,-36,30,16,-28,-23,6,-31,39,9,42,-56,59,3,14,36,-62,-6,7,64,35,37,21,25,-95,50,-6,4,11,-25,-35,-26,22,3,65,8,-6,-19,-45,-10,-7,20,-32,-19,27,-35,68,-21,27,51,-21,-1,-9,68,52,40,-25,22,-19,-18,25,-15,-23,19,-22,46,-16,-15,6,-38,47,9,-13,-5,-38,-65,59,-22,-11,26,47,38,-8,35,11,-33,-32,-8,78,24,71,4,-13,40,-20,-16,34,6,6,-20,-12,-30,22,35,82,33,65,-47,31,-24,-22,-37,-16,-1,25,-13,24,-101,-27,-1,-7,7,-44,-23,-56,-38,14,9,12,-31,-13,-5,-48,22,-58,78,-15,-11,-36,-21,41,-36,33,17,-13,-46,-36,19,-66,4,7,5,45,-2,-7,-1,-26,13,17,52,-40,-96,20,45,8,46,-1,44,47,43,16,22,24,17,-39,-10,48,19,5,5,6,43,30,-27,59,-2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.14","t":"Ideally, supervision or consultation occurs on a regular basis. Typically, for providers learning CBT, supervision/consultation should occur every week or every other week. Monthly consultation meetings may be appropriate for licensed practitioners in a more advanced stage of psychotherapy training. Supervision and/or consultation may also augment workshop-based training, with the workshop building initial skills and consultation/supervision helping the provider to deliver high-quality care during real- world applications. How? (Instructions/Handouts)","e":[-28,-5,-160,-58,39,-14,54,-5,63,-26,-4,-9,37,6,-9,-56,-15,-65,-68,29,-47,-6,11,-12,6,48,-21,15,-2,-24,45,11,27,-28,-36,-61,81,26,-25,-27,78,7,27,-90,34,-70,77,5,-14,-35,13,-51,-20,1,118,46,23,34,-21,-48,141,33,-76,77,27,-20,-83,70,-13,-13,17,-50,43,34,-29,-5,-40,-37,-8,27,19,-28,59,-26,23,16,-27,28,9,89,57,15,13,34,-62,15,-1,-13,-40,-34,-62,-14,20,-15,18,29,-9,-17,-4,-5,-52,26,-43,-28,-9,6,40,-35,6,74,-23,-31,-31,53,33,73,-29,1,7,-24,-1,-10,-15,20,2,42,-9,17,26,-11,36,-13,4,11,-2,-46,29,-48,-15,48,13,42,1,8,45,-33,-50,-9,94,7,58,-15,-39,29,-28,-25,13,9,29,15,-39,-51,-12,13,60,23,47,-25,14,-41,1,-61,14,9,16,7,2,-79,-3,-30,7,17,-55,-29,-70,-35,57,3,-15,-32,2,6,-48,30,-39,68,1,-12,-38,-12,71,-28,-22,21,-26,-15,-23,9,-46,46,35,-2,3,-34,2,12,-22,4,23,58,-6,-73,15,17,-4,30,10,19,36,39,63,33,37,34,-67,-14,25,18,-4,-14,36,16,41,2,30,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.14","t":"The following table outlines the most common formats for supervision. The usefulness of each procedure will be determined by the goals of supervision and the supervisee’s level of training and developmental needs. Exposure to multiple training modalities is seen as most effective. 14","e":[-10,33,-159,-27,39,-43,48,-7,17,-17,6,-36,75,48,9,-40,33,-85,-13,7,-16,-44,-3,-44,30,48,5,-59,-37,-27,34,-4,59,-40,-18,-106,29,17,-15,-15,29,20,-13,-58,40,-30,55,-20,29,-35,22,-25,-19,2,103,19,-11,32,5,-42,104,77,-122,27,47,23,-55,71,-3,5,36,-11,59,36,-71,-11,0,-37,24,68,36,-8,75,-22,14,31,-3,25,-40,55,38,21,32,33,-100,24,16,23,-36,-28,-19,-22,54,-13,53,45,43,-19,-3,-7,-58,82,-24,38,-6,-23,62,-28,13,47,-7,-2,-1,47,-12,31,-55,4,34,-38,42,-24,-41,-31,-15,85,-38,-11,27,-3,51,-8,-26,-24,6,-50,24,6,-23,14,22,8,15,38,12,-55,-7,-5,36,34,65,-15,-46,31,-36,-58,26,19,25,0,-14,-68,46,13,64,-9,80,-36,-6,-33,17,-35,0,4,-8,-34,31,-60,-75,2,9,21,-12,-45,-79,-51,7,-6,0,-32,-16,-25,-76,13,-42,51,-28,20,-45,-8,46,-8,-27,1,-41,-17,-28,-2,-52,35,1,-9,27,-19,1,19,-52,3,31,31,-34,-75,25,32,-28,-11,-1,47,53,41,1,-6,26,-49,-46,4,-4,-9,25,43,-3,40,8,6,15,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.15","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 2 Table 2.2 Common Formats for Supervision Format Description Advantages Disadvantages Verbal Providers verbally • Less threatening to • Subject to provider recollection Report report the details of a providers (errors and omissions) given therapy session, • Allows free-flowing • Limited ability for supervisors or case, to the discussion between to monitor and provide supervisor. provider and feedback on the “process” of supervisor therapy","e":[11,3,-154,-66,44,-1,39,14,11,-25,-17,-17,48,42,8,-31,37,-74,-33,-4,-33,-53,-13,-4,44,58,10,-47,-79,-24,28,6,22,-26,-21,-63,49,18,-56,-17,28,-8,1,-77,11,-26,74,24,6,5,34,-53,-1,23,119,-25,-19,18,23,-29,83,45,-94,53,36,-29,-55,71,-34,-19,48,18,16,15,-33,0,-24,-52,19,56,46,12,76,-24,15,8,8,37,-9,55,-7,13,12,44,-111,49,-21,-4,-21,-3,-32,-20,81,-29,54,43,3,-24,-6,13,-16,83,-20,-8,8,-74,78,-57,12,55,-12,-5,-22,82,38,50,-34,3,10,-43,39,-28,-52,-1,3,47,11,-14,35,-2,41,22,-26,-2,-8,-76,42,-26,-30,-8,13,23,-11,81,10,-39,-4,-25,58,30,65,17,-25,44,-23,-49,28,20,0,-16,-17,-33,25,3,55,33,45,-31,15,-37,-6,-32,5,37,5,-49,11,-38,-54,1,-19,50,-41,-42,-76,-93,-16,-25,20,-50,-5,-3,-46,11,-46,43,-48,13,-55,-32,68,-23,-4,12,-12,-4,-36,-13,-45,9,14,7,21,-15,-24,17,-21,21,-7,8,-36,-89,20,22,-3,18,-27,71,31,43,18,27,24,-16,-70,15,25,-11,27,48,-2,27,24,-4,22,10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.15","t":"Process Providers write down • Less threatening to • Subject to provider focus and Notes and recount issues providers recollection identified in session • Provide a more • Limited ability to monitor along with their own detailed recount and provide feedback on the personal reactions and of the session process of therapy feelings encountered in (compared with the session. verbal report alone) • Begin to identify provider issues during session (process)","e":[51,-8,-149,-88,58,-59,23,10,45,-23,-26,-7,53,28,22,-60,31,-65,-23,-9,-58,-34,-90,10,12,35,10,-64,-42,14,56,-2,8,-20,-3,-72,41,-17,-34,1,40,-10,27,-106,3,-22,47,37,-19,-17,43,-83,-45,10,88,-5,-11,52,26,-30,111,42,-52,83,63,-51,-43,69,4,-16,58,21,22,23,-2,-6,-34,-36,-5,27,26,3,88,10,38,33,6,45,-11,98,-11,-4,15,38,-103,22,-12,-17,-37,-34,-40,-15,17,-56,95,30,-1,26,9,11,2,67,-52,-26,28,-32,109,-22,6,41,-9,-10,-14,52,18,50,10,6,10,-9,4,-15,-46,28,35,42,-23,-37,1,11,43,-2,-19,-5,2,-19,41,-50,4,1,37,9,-54,34,48,-20,-36,-3,49,72,43,14,-34,55,-20,-42,3,4,-3,-24,-11,-45,20,-22,85,66,55,7,19,-49,16,-30,40,36,23,-23,40,-66,-30,-64,-18,49,4,0,-63,-66,-7,-33,6,-36,-3,32,-44,28,-22,83,-46,-7,-60,-45,80,-27,-22,17,7,4,-4,-10,-32,6,12,-18,19,-25,-10,28,-27,26,-3,-4,-57,-67,16,-4,44,-23,-27,50,23,44,-7,4,25,-26,-70,0,14,-41,21,37,9,4,45,-3,39,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.15","t":"Audio/Video Actual sessions • Provides access to • Can be intimidating to Recording are audio or video objective and process providers (and sometimes to recorded and reviewed content of sessions patients) in supervision. • Serves as an excellent • Logistical issues – specific learning tool informed consent for patients, availability of equipment","e":[13,38,-143,-42,37,-16,7,0,37,4,20,32,43,36,13,-84,-30,-70,-40,4,-45,-42,-16,12,13,-4,18,-12,-43,8,50,-30,41,10,-21,-101,25,33,-38,-4,36,-24,-37,-52,-2,-15,7,-2,24,-9,19,-58,-49,32,175,14,7,70,18,-29,76,50,-50,62,47,-18,-26,47,23,7,58,-14,33,8,-38,-13,-34,-13,-21,36,23,-57,59,1,45,4,-6,25,27,84,10,10,56,25,-95,13,-30,68,-5,13,-24,-18,41,-50,44,32,20,5,-24,3,19,102,-4,6,17,-30,59,-37,10,48,46,5,-4,39,23,41,-8,-1,-21,1,-25,-23,-20,-9,37,54,-4,-26,-1,8,30,22,-50,-3,-15,-46,29,-22,-28,6,48,23,-6,24,6,-54,-21,7,45,76,30,8,-76,34,-28,-36,19,3,52,14,-27,-39,-7,35,46,54,72,-28,20,-78,28,-40,-2,-40,-10,-40,41,-59,-31,-11,-39,24,-15,-35,-80,-51,34,10,44,-59,10,-9,-54,22,-14,110,-51,-28,-64,-4,50,-5,27,18,-34,-27,-1,-29,-27,29,40,14,7,-17,4,-42,-28,1,-19,47,-40,-77,16,30,-5,-10,-2,20,8,26,-2,2,17,-24,-87,17,13,-44,-5,-22,32,17,16,-30,58,7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.15","t":"Live The supervisor is in • Provides the • Possibility of missing nonverbal Supervision the room (connected supervisor with real- cues during the consulting through audio/visual time evidence of encounter if connected by technology) with the supervisee’s clinical telephone. supervisee and patient skills development • Possibility of novice providers or watching through a • Allows the being threatened or anxious double-sided window. supervisee to • Possibility of patient The supervisor does enhance therapeutic discomfort with this approach. not engage in direct approaches and/ therapy, but instead the • Possibility of reduction in or learn alternative supervisee consults with credibility of novice provider approaches in real- the supervisor in the with patients if the intent for time with a patient presence of the patient. this modality is not adequately explained at the outset","e":[4,6,-175,-42,55,25,41,10,36,-39,-38,-8,37,55,-7,-49,42,-73,-7,-46,-16,-26,4,-9,14,61,18,-11,-46,-30,39,37,65,-26,-29,-43,69,40,-26,1,-16,-15,-5,-111,6,-42,32,12,61,-39,-11,-37,-23,44,135,5,34,47,-12,-29,82,34,-45,62,54,-35,-73,55,-24,5,27,-7,33,1,-55,51,-29,-39,5,42,58,-26,79,-14,27,3,-42,-4,-38,59,44,15,34,40,-113,27,-40,24,-11,-41,-32,-24,44,-29,38,58,37,-30,-11,-15,8,27,-26,-7,49,-9,71,-48,15,58,27,22,-29,43,31,82,-54,5,32,-34,25,-9,-67,-5,21,30,-19,-19,18,-19,50,25,-13,-4,-50,-66,82,-7,-14,16,4,22,3,55,38,-55,-35,4,45,10,78,-18,-45,45,-20,-71,38,6,5,-6,-31,-46,40,12,56,16,25,-50,-26,-61,1,-55,2,-20,3,-38,1,-63,-29,-17,5,21,-22,-31,-38,-71,25,-19,51,-66,-13,-7,-25,0,-25,44,-21,-30,-46,-14,46,-47,11,-53,-12,-11,-27,15,-47,21,27,4,14,-2,-16,12,-62,4,0,51,-35,-90,6,25,11,28,-6,35,33,39,-3,28,15,15,-65,24,27,-2,0,44,22,29,32,-14,23,-26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.16","t":"SELECTING A SUPERVISOR / CONSULTANT The following are characteristics to seek out in selecting a CBT supervisor or consultant: 1. CBT knowledge and practice experience • Ideally, CBT supervisors and consultants have received formal training in CBT and use CBT in their daily clinical practice. 2. Availability • For those first learning how to apply CBT, it is highly recommended that you identify supervisors/consultants who are available for weekly or bi-weekly meetings that involve anywhere from 30 to 60 minutes per meeting. The actual length of meetings can be determined by the number of cases being reviewed. • Consider logistical issues in scheduling. Would the supervisor/consultant be available for in-person or telephone sessions (in-person is more effective)? Consider proximity, travel, and availability of resources (e.g., audio/video recording). 3. Experience with a patient population similar to those you will be serving, as well as considering experience with brief or longer-term therapy.","e":[-12,23,-152,-30,47,-20,58,-18,43,11,-26,-23,23,14,-11,-51,2,-94,0,2,-38,-34,7,-26,26,47,-25,27,5,-15,20,9,22,-49,-32,-63,63,12,-18,0,62,-16,11,-136,36,-46,79,44,11,-25,-32,-50,-36,-8,72,19,-20,95,-17,-39,72,30,-60,80,26,-38,-42,63,-31,-3,19,-19,54,28,-30,2,-66,-24,31,42,61,-10,94,-21,8,10,-30,25,8,63,9,11,26,68,-72,28,-11,-29,-15,-48,-50,-7,-8,8,-7,38,14,-38,1,-34,-51,33,-46,-1,-3,22,38,-10,-6,82,-1,-14,-26,31,38,84,-55,-6,45,-4,8,-23,-15,4,0,35,-18,18,23,-25,40,11,10,4,-25,-33,13,-26,-29,55,13,35,20,35,38,-56,-25,-2,41,13,71,-25,-51,60,-15,-48,-8,35,34,25,-22,-64,28,22,73,11,60,-4,2,-48,36,-43,8,57,-7,-21,21,-90,-6,-9,39,6,-44,-37,-78,-56,43,-34,-21,-76,-1,31,-4,51,-30,50,-10,12,-33,-10,34,-14,-8,-16,-34,1,-21,5,-32,16,58,-22,23,11,-11,3,-27,5,8,17,-11,-64,43,41,-1,39,7,3,45,70,8,22,66,23,-97,-26,14,-4,16,9,25,28,22,17,11,-23]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.17","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 3 Module 3: Therapeutic Skills in Brief CBT OBJECTIVES • To better understand the need for a strong therapeutic relationship in brief CBT • To understand the factors associated with a strong therapeutic relationship • To learn strategies for developing rapport and maximizing nonspecific factors What are Therapeutic Skills, and Why Are They Important to CBT?","e":[-18,4,-137,-52,66,-2,42,-20,12,-27,-42,-5,51,-17,-36,-14,1,-48,-13,19,-62,-41,17,-4,21,26,12,8,-45,-18,21,-33,-12,-55,-53,-74,72,62,-55,-28,21,-26,26,-65,25,-11,87,14,-16,-7,34,-45,30,-31,150,24,9,-4,-2,-34,73,44,-82,58,21,-54,-50,48,-47,-20,59,-10,41,22,-34,-23,-36,-26,4,38,36,-20,58,-15,3,10,-12,-27,-3,53,1,47,20,29,-116,40,-15,-17,8,-12,-36,-9,48,-22,25,32,15,0,0,1,-56,58,-19,-13,-13,-27,35,-30,24,71,-3,-18,-2,55,33,51,-43,-2,-1,-14,9,-11,-48,-9,24,64,20,4,14,64,11,8,-21,21,-43,-32,1,6,-38,-1,-5,16,30,19,31,-47,-14,-35,67,21,40,26,-33,30,-22,-28,24,-2,23,40,-38,-25,10,-14,62,37,56,0,7,-64,11,-19,24,40,-23,-1,44,-34,-33,7,5,63,-41,-43,-67,-68,3,-16,34,-46,-15,5,-12,52,-45,55,-23,44,-18,-40,52,-29,-1,-1,-42,-18,-41,-19,-60,2,18,10,-28,7,-10,8,-15,-8,-9,31,-23,-87,24,32,9,35,8,25,7,81,46,33,61,21,-68,32,-13,-44,4,19,-5,9,8,5,-2,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.17","t":"CBT is structured and goal-directed. The context is supportive, and the techniques are paired with a collaborative therapeutic stance. Therapeutic skills refer to the relationship components of therapy (e.g., rapport, installation of hope, trust, collaboration) and are comparable with treatment-specific skills that refer to the technical aspects of the psychotherapy orientation (e.g., the actual techniques such as guided imagery, thought challenging, etc.). Therapeutic skills are common within all psychotherapies and serve as the foundation for patient improvement. Refer to intervention techniques unique to the type of therapy being provided (e.g., CBT, psychodynamic, interpersonal). Studies show that therapeutic skills are responsible for a large percentage of the change associated with psychotherapy treatments.","e":[29,8,-133,-52,79,-21,71,6,29,-28,-21,-26,63,-39,-16,-30,-23,-40,-35,38,-71,-32,18,-20,-23,34,-33,15,-41,-40,50,-1,32,-37,-59,-44,68,22,2,-12,27,6,5,-104,19,-40,54,7,-4,1,29,-31,20,-54,169,12,16,25,-32,-56,77,71,-96,58,54,-21,-57,50,-10,-29,63,-10,52,39,-37,-34,-36,-14,6,17,37,-57,27,-35,37,15,11,25,-19,72,8,29,10,23,-99,9,-27,-39,-17,-26,-50,-17,34,-14,22,34,-5,-31,-30,10,-39,24,-37,4,-32,-25,43,-45,19,29,34,2,-19,35,-3,72,-74,-21,24,-6,-8,-11,-35,-6,-27,71,18,-32,-5,41,32,-1,-7,9,4,-28,1,-10,-31,5,24,30,1,17,33,-38,-14,18,63,44,37,39,-49,-15,-16,-59,7,3,25,38,-56,-40,-22,15,87,38,79,0,5,-58,-2,-14,22,33,-3,-8,37,-78,-16,-37,31,40,-56,-9,-64,-75,18,0,55,-38,3,34,-45,57,-33,81,-20,21,-15,-23,54,-26,5,11,-54,-12,-29,-6,-77,14,19,-1,-33,-17,-9,2,-47,16,36,52,-19,-59,11,29,31,30,-6,1,13,75,30,38,17,17,-58,31,12,-30,6,38,-8,23,25,-28,-4,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.17","t":"When? (Indications/Contraindications) Therapeutic skills are critical during the early stages and important at all phases of treatment. Strong therapeutic skills aid in engaging and retaining patients in psychotherapy and also strengthen the technical components of treatment. Patients who perceive the therapeutic relationship to be collaborative, safe, and trusting are in a better position to obtain benefit from the treatment, will likely be less resistant and more open to exploration and change. As treatment progresses, the therapeutic relationship should become stronger, allowing the provider and patient to gradually move into more complex and meaningful therapeutic issues.","e":[33,19,-163,-30,37,0,50,10,36,-7,-36,-10,41,-33,-8,-17,19,-46,-27,18,-60,-32,-4,-43,1,44,-14,-13,-26,-9,61,-9,23,-51,-47,-82,68,31,-6,-40,38,5,14,-91,21,-34,29,5,-10,-21,52,-58,-21,-12,165,48,22,27,-9,-70,80,61,-95,24,58,-14,-48,19,0,-11,43,-43,44,23,-20,-13,-23,-2,-14,29,36,-29,81,-51,17,36,14,-11,-6,90,41,25,-9,32,-104,-4,-26,-24,-31,-32,-10,3,15,-25,24,40,11,-16,-42,2,-28,49,-26,-39,5,-25,62,-45,27,29,-10,-3,-10,64,13,37,-52,-14,3,-4,-20,-11,-25,32,-3,90,28,-42,-3,43,51,51,2,9,-26,-48,1,-10,-32,4,17,39,-16,19,18,-60,-19,6,77,2,55,37,-41,37,-23,-37,17,38,0,36,-43,-1,21,-24,77,19,85,-12,16,-35,-17,-42,7,-13,-33,-28,46,-57,-44,-42,5,51,-68,-14,-63,-71,18,-22,48,-34,-38,8,-53,39,-48,85,-29,18,-38,-17,46,-19,35,17,-32,-46,-31,-34,-47,11,37,15,-30,1,-19,5,-47,33,4,51,-27,-32,41,28,21,-2,-15,15,33,71,11,32,18,33,-78,32,-9,-60,-18,37,-1,18,21,11,-7,8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.17","t":"How? (Instructions/Handouts) Borrowing from person-centered therapy, this module focuses on four factors (Figure 3.1) important to the development of a strong therapeutic relationship. These factors are empathy, genuineness, and positive regard. These concepts are defined and discussed and represent general characteristics that all providers should attain in working with patients. Following a discussion of these principles, active listening is introduced as a technique to better attain a solid therapeutic relationship.","e":[38,-5,-194,-81,43,16,68,-21,24,14,-9,-8,45,4,11,-11,10,-33,-31,44,-73,-56,-46,-23,35,32,-8,21,-43,-21,26,-39,10,-36,-52,-12,63,90,-3,20,-3,14,15,-59,16,-74,17,-26,50,8,-7,-47,-6,2,117,25,7,89,0,-81,81,55,-78,59,45,-15,-29,43,-42,-17,46,-46,24,27,-1,19,-35,-32,35,21,67,-18,56,-60,42,4,0,9,-21,56,31,26,31,34,-110,3,-35,1,-24,-40,-28,-14,3,-3,20,17,24,13,-33,26,-45,60,-35,-33,-5,-54,70,-26,7,44,14,-27,19,47,-8,32,-50,-13,-9,-14,8,-41,-24,-33,18,74,11,-44,-5,12,28,16,-9,3,-7,-26,-8,-19,-10,22,30,50,-14,34,-11,-58,-32,-36,38,24,33,24,-26,24,5,-37,10,41,21,32,-35,-41,12,2,68,8,88,-32,15,-31,16,-70,11,20,-30,13,34,-42,-37,-3,-13,23,-59,-22,-49,-61,10,-15,55,-36,-26,5,-33,39,-36,85,-13,22,-24,-32,57,-20,-33,4,-16,-47,-54,-19,-60,28,38,-15,-4,-8,-28,-28,-41,10,-24,5,-43,-63,52,58,6,-6,-14,25,-2,23,2,57,18,13,-75,25,-6,-55,-21,30,1,39,17,-13,7,3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.17","t":"EMPATHY (VALIDATING THE PATIENT'S EXPERIENCE) Empathy is the ability to understand experiences from another person’s point of view. Empathy is an important part of building rapport and facilitates feelings of trust and mutual respect between the patient and provider. It is impossible for a provider to be knowledgeable about every patient's unique background. Empathy, which at its core 17","e":[40,60,-138,-100,98,50,28,18,26,45,13,3,50,-2,25,-13,33,-47,-17,25,-72,-26,-13,-3,29,30,-7,-5,-86,-18,4,6,58,-24,-37,-44,26,66,20,2,-5,9,60,-62,45,-1,23,28,51,-47,-45,-34,-9,34,144,31,27,57,-11,-17,49,38,-38,78,49,-17,-57,-8,1,-35,68,-32,-18,57,-31,-12,-29,15,18,49,76,1,15,-10,43,-45,-42,9,-27,79,24,24,47,12,-99,30,-22,34,-16,-24,-48,-10,33,-28,88,24,-33,44,25,-5,-18,29,-6,-7,21,-33,54,4,23,50,58,33,-19,71,23,33,-33,-24,1,6,13,-25,-6,-11,3,29,40,-30,8,26,35,30,-6,-23,-13,-49,-11,-22,-32,48,30,50,-10,43,-4,-49,-18,11,82,23,62,47,-60,24,5,-20,11,-39,20,4,-33,-6,35,-7,20,-2,45,-30,7,-47,8,-72,65,-11,-29,-49,15,-86,-16,-44,37,17,-22,-30,-40,-44,12,16,48,-58,-4,31,-21,47,-50,57,-13,-11,-28,-39,40,-37,-3,2,8,31,-6,-8,-32,0,58,-17,25,6,-52,1,-32,-13,-18,16,-51,-67,52,12,15,40,-21,21,19,28,26,30,-8,28,-78,-13,35,-78,20,34,-7,-1,24,-40,40,-23]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.18","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 3 consists of asking questions in a respectfully curious manner and expressing emotional understanding of the answers received, is a solid first step towards understanding patients' unique life background. Additional reading about cultural differences may facilitate more informed questions and better prepare the provider for additional questions and/or rapport development.","e":[2,10,-174,-55,69,57,42,-11,20,-7,-9,-14,28,23,-44,-30,31,-74,-26,41,-77,-26,3,4,39,18,12,11,-36,-31,23,-34,-1,-23,-51,-80,37,67,-85,10,25,-30,23,-51,32,10,60,-9,2,-13,25,-54,16,21,123,37,18,6,44,-29,83,46,-72,45,5,-39,-40,60,-39,-30,61,-26,64,16,-46,-1,-39,-27,30,36,33,-23,80,-30,-1,10,1,-18,2,59,-16,17,1,28,-112,51,-22,7,-4,-34,-18,-25,39,-38,9,32,-3,9,-20,6,-47,64,-21,-32,-1,-26,46,-30,35,45,-12,-11,10,72,36,40,-21,-28,-27,18,11,-14,-66,-24,-6,25,30,-13,26,40,29,7,-7,8,-19,-45,23,-26,-10,-24,-9,45,48,9,25,-52,-16,-33,77,24,52,4,-33,60,11,-48,29,22,21,8,-32,-27,18,-33,49,9,61,-64,43,-43,-6,-29,25,28,-19,-19,14,-21,-38,-25,-26,91,-21,-21,-55,-75,-18,-29,29,-43,-24,8,-11,39,-51,75,-10,26,-27,-37,86,-38,29,11,-19,-3,-16,-25,-45,9,0,8,-20,2,-15,5,-28,-16,-12,37,-27,-119,52,10,24,31,-27,38,28,47,35,20,74,35,-51,28,2,-10,-15,13,-21,-9,-1,-2,3,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.18","t":"Showing empathy to patients helps to validate their experiences. Being critical, even subtly, of what patients are sharing in therapy often makes them feel judged and unwilling to disclose additional information. Use validating responses to show empathy towards a patient. Validating responses are simply statements of understanding of your patient’s viewpoint. Validating responses usually entails the provider’s describing what the provider heard the patient say, in a nonjudgmental manner. Figure 3.1 Developing a Strong Therapeutic Relationship EMPATHY (Validating the Patients’ Experience) RELATIONSHIP THERAPEUTIC STRONG GENUINENESS (Being Authentic) POSITIVE REGARD (Respect) ACTIVE LISTENING","e":[53,42,-149,-98,101,7,40,11,63,21,-3,8,60,9,-3,-27,44,-98,-32,18,-74,-47,-51,-6,21,9,-12,27,-86,-14,3,18,45,-36,-47,-28,40,67,-16,-19,19,11,34,-62,3,-16,44,14,-1,-43,-6,-60,-12,17,142,25,7,78,3,-54,72,49,-31,45,66,-17,-37,-1,-15,-3,71,8,21,24,-27,-3,-41,-4,-1,38,60,-11,48,-56,54,7,-21,16,-15,75,37,2,44,34,-128,24,-35,5,-38,-44,-43,17,21,-29,46,40,3,59,8,-10,-35,20,-31,-11,5,-17,58,-44,13,66,48,38,-22,40,-2,23,-45,-9,4,7,11,-36,-25,-7,3,53,42,-37,13,-12,21,31,-7,-18,-12,-49,27,-21,-20,32,29,63,14,23,15,-87,-8,-16,61,26,63,22,-48,16,-26,2,6,-11,26,17,-51,-14,21,-15,52,-19,67,-42,-6,-49,16,-70,73,-9,-19,-27,37,-52,-34,-30,5,38,-42,-31,-63,-40,1,5,57,-43,-16,7,-45,43,-42,42,-33,-17,-30,-46,30,-23,3,7,-10,31,-16,-21,-34,34,30,-11,-7,3,-32,15,-48,10,-20,14,-46,-75,33,-6,31,20,-40,22,13,42,11,40,29,47,-62,3,26,-59,2,26,1,14,14,-27,35,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.18","t":"GENUINENESS Genuineness is the ability to be authentic and free of deceit or judgment. You can be professional and express who you are at the same time. Genuineness helps build rapport and solidify a therapeutic relationship by allowing the patient to view the provider as a human being. Patients often assess the genuineness of the provider for credible feedback about progress in their functioning. 18","e":[56,51,-195,-53,69,3,22,32,19,-16,-42,10,12,13,1,6,4,-77,13,45,-76,-31,-17,-6,26,26,-4,17,-27,-35,-1,13,53,7,-19,-23,22,83,68,-28,0,19,3,-69,6,29,32,3,52,-21,15,-51,9,28,113,21,21,83,-2,-43,52,69,-70,82,69,-41,-25,45,-8,-36,14,-24,11,49,-34,-1,-35,17,-1,28,43,-46,65,-12,69,6,12,-20,-9,100,53,17,0,28,-76,4,-15,6,0,-62,-33,0,31,-4,29,18,2,57,-25,8,-9,55,-23,-18,30,-7,69,-68,17,65,15,-13,15,97,2,48,-14,-13,23,-10,-3,-31,-29,2,-7,90,35,-21,-10,30,28,9,-13,-21,-35,-83,-4,-25,-17,39,40,17,15,38,-11,-42,-27,-6,43,1,50,16,-47,17,-3,-25,-18,27,16,33,-20,-15,6,14,54,-40,29,-43,-4,-34,24,-31,23,8,-22,-16,51,-68,-12,-38,14,25,-16,-5,-53,-84,0,14,33,-51,-13,5,-23,26,-50,47,-26,-7,-21,-26,56,-7,-6,-16,7,-39,-29,-36,-33,-7,44,0,30,0,-4,-18,-17,26,-16,3,1,-100,58,28,17,31,-47,47,22,23,-15,57,-32,5,-67,34,1,-70,18,1,3,9,16,-16,-6,-1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.19","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 3 Genuineness consists of a wide variety of concepts ranging from nonverbal behaviors to overt statements. Examples of factors related to genuineness include: Supporting nonverbal behavior: Providers should be aware of their own nonverbal behaviors like keeping eye contact, giving a patient your full attention like substitute such as for like keeping eye contact, giving a patient your full attention, and nodding in agreement or understanding. It’s important that these nonverbal behaviors match what is going on in the conversation, so as not to seem unnatural or inauthentic.","e":[42,35,-182,-57,80,22,53,-11,19,1,-36,-13,-7,68,-18,0,17,-70,-3,71,-73,-13,21,-18,20,16,15,30,-24,-57,-3,-1,3,-31,-28,-44,22,89,-21,15,5,10,9,-35,-6,8,57,12,23,12,42,-27,38,13,143,22,16,50,8,-44,57,63,-76,58,31,-36,-68,62,-39,-44,28,-8,0,40,-16,0,-43,-9,-2,49,30,-53,81,-18,56,10,11,-17,-7,59,16,1,-1,15,-92,25,-28,7,-16,-48,-35,-15,17,-13,11,8,32,42,-24,19,-18,79,-16,-27,20,-24,46,-61,35,61,18,-40,-17,68,18,30,0,2,-10,-4,17,-17,-61,-26,-7,61,30,0,2,24,17,17,-22,3,-38,-72,3,-35,-3,-4,4,43,26,16,0,-38,-50,-59,46,11,48,-9,-24,39,4,-34,-11,18,25,14,-39,-14,23,-1,45,1,42,-67,-3,-33,23,-32,11,36,4,-1,21,-26,-63,1,-31,63,-15,-18,-52,-76,-20,-33,9,-58,-35,-12,-21,48,-70,60,-22,28,-35,-28,61,-20,12,-24,-9,3,-25,-32,-61,13,24,20,25,15,-6,-2,-25,20,3,14,-14,-98,33,21,11,24,-46,30,51,5,14,49,35,15,-50,26,-30,-39,6,26,-22,22,12,-20,11,16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.19","t":"Role behavior: CBT providers encourage patients to be active and empowered and subsequently attempt to facilitate this development through their behaviors in therapy. Providers that stress their authority in and between sessions with patients can cause a patient to feel inferior or intimidated. It is important to remember that the therapeutic relationship is one of partnership and the provider and patient work together to alleviate concerns, fears, and problems in the patient’s life.","e":[-1,51,-153,-48,65,2,41,-21,66,3,-47,24,28,6,44,-25,8,-50,-60,1,-87,-22,-7,7,21,62,-1,6,-11,-26,70,35,52,-18,-35,-26,93,47,-42,11,44,-21,-9,-95,-1,-77,75,40,0,-4,11,-99,-1,-24,154,18,-1,55,-47,-68,102,46,-60,72,53,-35,-45,44,-39,-13,31,-11,52,49,-27,-8,-43,-20,15,33,75,5,49,-30,47,3,23,-10,-23,82,34,-13,21,20,-92,2,-20,-47,-33,-16,-53,12,24,0,-11,41,21,5,-11,9,-46,49,-29,-36,-23,9,60,-56,-3,32,22,18,-24,25,-9,75,-45,-5,25,3,-11,-31,-32,-1,16,38,2,-13,30,20,25,24,6,-4,17,-33,7,-17,-40,19,19,16,-23,42,50,-24,-19,-3,47,15,52,1,-55,9,-9,-44,22,27,17,44,-26,-55,-18,-10,76,22,45,4,18,-61,-8,-24,22,5,-2,-7,17,-41,-41,-87,6,44,-32,-12,-91,-55,7,-9,16,-40,-7,-7,-9,7,-39,46,-53,3,-30,-60,43,-36,-17,34,-75,-22,-1,-1,-46,41,23,-22,0,-33,-24,1,-24,-4,-37,4,-24,-40,28,30,36,23,-9,42,1,29,18,71,36,35,-46,13,-10,-58,18,23,17,0,39,-25,34,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.19","t":"Congruence: Making sure that your words, nonverbal behavior, and feelings match each other is referred to as congruence. Not demonstrating congruence of your feelings and thoughts can become confusing or misleading to a patient. Spontaneity: This concept deals with the way the provider speaks and the timeliness of responses. Responses and feedback provided \"in the moment\" are more valuable than feedback provided at a later time. Patients are more likely to receive spontaneous messages as genuine.","e":[49,0,-184,-96,51,-18,42,-30,48,-14,1,7,23,91,-11,-44,26,-43,-38,90,-57,25,-45,-18,23,16,-28,-27,-55,-2,24,6,37,-21,-62,-39,13,17,17,-23,49,30,29,-79,49,8,45,9,25,-40,-20,-75,2,-12,92,52,49,54,12,-42,85,30,-52,78,61,-17,-58,57,-27,-19,50,6,32,15,-37,15,-41,17,0,12,42,-47,75,2,99,18,6,-18,-29,108,11,-16,12,22,-118,4,-30,9,-29,-55,-86,-4,-10,-20,-8,51,-8,9,-42,0,-32,42,-44,-5,10,13,96,-22,11,59,13,-7,5,54,-12,63,-20,2,18,-22,-13,-7,-22,-12,2,30,17,-28,16,22,62,2,26,-10,-20,-72,6,-43,-40,20,8,17,27,9,-16,-30,-25,-14,23,4,55,8,-39,38,-13,-51,-3,19,-26,-2,-53,-20,18,3,79,37,74,-82,-20,-66,3,-20,1,9,-21,-12,34,-15,-65,-19,11,10,-60,6,-60,-57,17,1,37,-39,-35,12,0,45,-28,59,-28,19,-16,-10,94,-27,-22,2,-13,-3,-11,24,-60,42,27,-27,17,-31,7,-25,-32,18,-44,-9,-9,-80,17,-15,28,53,-20,26,20,13,-16,42,19,7,-76,26,24,-40,-2,32,12,-27,21,-27,38,-2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.19","t":"POSITIVE REGARD Positive regard simply means showing all patients the respect they deserve. It’s essential to show patients that they are valued and that what they have to say is important. Patients who feel that their thoughts and feelings are acknowledged and understood often share more and feel more connected to the provider and the therapeutic process.","e":[50,26,-151,-82,68,26,22,0,36,25,10,22,28,35,91,-14,8,-50,-23,29,-88,-34,-80,-3,47,35,-14,14,-64,9,3,-8,15,-42,-24,-5,28,48,-6,-25,35,3,-20,-45,42,8,22,-25,46,-19,-2,-66,-25,20,133,38,52,41,-31,9,72,51,-59,26,57,-5,-22,3,-34,25,22,13,25,36,-44,30,-56,10,4,-26,54,-21,55,-20,47,-4,24,2,-28,70,29,-11,18,38,-130,15,-8,3,-52,-51,-19,-21,1,-18,66,57,-9,60,-8,-25,-32,43,-39,-1,9,-18,100,-52,3,86,45,-9,8,61,21,49,-40,-29,18,0,30,-62,-29,-13,-23,38,51,-27,15,5,29,30,-12,5,16,-70,14,-18,26,26,36,31,-4,18,6,-58,-51,2,37,43,49,23,-46,26,-22,-37,15,-33,1,13,-4,-7,38,-42,48,-21,39,-22,-13,-46,-14,-56,67,12,-8,-25,47,-30,-42,-34,54,62,-17,27,-27,-25,18,-3,58,-40,-50,7,-44,48,-33,57,-13,1,-4,-47,8,-46,-20,21,20,-7,-33,-38,-36,33,24,-33,-6,-5,0,4,-29,-5,-14,23,-48,-75,7,29,15,33,-3,57,12,23,-24,37,13,34,-96,49,-14,-48,-9,12,46,-18,33,-16,54,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.19","t":"Communicating positive regard may be harder than it seems, especially if you hold some negative beliefs about the person you are trying to help. Sharing any negative feelings or beliefs about your patients with your supervisor or consultant can be an excellent method to ensure that you develop and demonstrate genuine positive regard toward your patients. Commitment to the patient means that you are dedicated to working with patients on whatever issues they are bringing to therapy. This includes being on time, avoiding canceling patients’ appointments, and using all efforts to help patients work through these issues.","e":[42,38,-147,-82,73,34,9,-17,13,9,-30,14,20,39,51,22,39,-74,-45,39,-67,-34,-44,-18,12,38,-5,4,-70,30,16,1,11,-62,-34,-24,4,42,15,-19,17,1,-3,-103,34,-32,49,-12,62,-31,4,-67,-39,27,111,33,10,75,-27,-30,110,45,-25,58,50,-19,-42,29,-42,24,11,28,44,12,-44,41,-20,-22,7,-9,49,-49,63,-22,44,34,13,25,-35,96,15,-16,-3,30,-113,39,-45,-5,-28,-53,-49,-18,9,-1,6,49,-1,28,23,10,-5,29,-63,-24,19,-15,70,-64,11,19,39,-16,4,71,13,36,-40,-25,22,0,11,-46,-40,10,-51,42,32,-40,10,-1,37,28,12,3,-12,-45,27,-58,27,16,27,35,-7,14,42,-75,-43,-11,34,15,74,8,-41,15,1,-43,14,40,1,28,-29,-26,26,-8,82,8,9,-15,-22,-34,-5,-33,24,15,-1,4,54,-63,-43,-35,6,44,-12,14,-56,-57,16,-13,55,-37,-41,30,-43,61,-26,56,6,-5,-35,-48,32,-29,-15,-5,14,-32,-8,-4,-65,30,30,-20,48,-3,11,-11,-47,28,-11,1,-51,-57,10,49,17,32,-19,46,8,27,-13,20,16,26,-83,37,18,-16,-25,43,27,0,17,-22,37,1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.20","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 3 Displaying warmth towards patients is a vital part of building rapport. Warmth can be displayed through tone of voice, facial expressions and body postures, or the thoughtfulness of your responses. The following section addresses the concept of active listening. Active listening is a useful technique to communicate the nonspecific factors of empathy, genuineness, and positive regard.","e":[34,-21,-216,-93,39,21,75,12,9,16,6,24,23,53,-5,-2,8,-47,-37,31,-66,-34,5,-24,49,47,15,24,-61,-42,5,-20,7,6,-64,-17,59,62,-39,28,5,-19,45,-21,37,-12,37,-23,17,20,-16,-46,-3,-15,122,-4,12,40,5,-33,92,68,-73,28,40,-18,-23,25,-41,-18,56,-14,34,-11,-2,15,-43,-25,10,44,48,-45,75,-30,77,1,-8,1,-33,34,3,11,30,24,-100,57,-16,9,-31,-41,-24,-14,21,-5,26,25,-11,-13,-16,1,-20,64,-30,-51,-5,-46,52,-51,13,63,40,-10,-7,47,23,55,-34,-22,-12,-26,29,-2,-63,-29,11,43,22,-39,24,44,38,-1,10,-2,-22,-41,-5,-61,-6,9,4,37,18,6,-8,-58,-31,-8,55,30,72,23,-29,12,18,-35,-5,34,38,10,-45,-1,2,-19,15,-17,78,-50,9,-56,-6,-44,31,-11,-12,-19,13,-39,-26,-6,-37,49,-50,-25,-40,-38,-8,-8,66,-21,-17,-8,-5,15,-63,86,1,20,-25,-41,87,-25,22,-23,-2,2,-42,-43,-39,-2,53,27,-25,-18,-23,-31,-61,-17,-34,7,-61,-82,41,35,-2,6,-1,36,8,23,10,42,10,28,-75,59,-14,-29,-42,24,1,33,-7,-11,33,5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.20","t":"ACTIVE LISTENING Listening to your patients is the foundation of all therapeutic approaches. Listening is made up of three steps: receiving a message, processing it, and sending it back. Providers should attempt to remain open to all messages from their patients (both verbal and nonverbal) and attempt to process as many messages as possible.","e":[32,-13,-183,-84,64,-20,71,-9,31,4,-4,4,46,38,-25,-35,-9,-40,-44,-2,-34,-25,-38,-45,31,43,3,26,-58,23,15,-34,45,12,-34,-48,42,87,-17,12,0,-12,4,-57,44,-71,50,3,30,-31,-8,-48,-56,33,95,43,8,64,-6,-42,107,1,-72,43,46,-12,-29,45,3,-6,76,-5,50,-20,-5,12,-26,-24,15,41,46,-52,114,-50,56,1,-15,16,-10,68,3,-27,38,16,-128,9,-49,29,-42,-68,-49,-8,12,-38,48,44,16,-9,-7,14,-26,47,-16,-55,-9,-42,77,-13,1,31,20,-35,-5,33,-1,59,-50,-20,1,-7,15,-6,-36,-17,41,42,-5,-50,18,11,6,-24,9,11,-14,-13,19,-23,-17,23,18,37,20,13,20,-52,-14,24,20,47,67,11,-58,40,-7,-30,-27,47,42,14,-62,-12,25,13,59,30,73,-54,-4,-33,-1,-41,2,0,-28,-10,18,-57,0,-11,-8,27,-45,-27,-39,7,12,-19,108,-38,12,5,-39,-10,-17,109,-10,0,-29,17,70,-8,3,-19,-26,-14,-27,-21,-36,21,68,-7,-16,-50,-5,-32,-42,-3,-32,7,-30,-86,29,37,14,-5,-20,17,-9,29,9,55,39,32,-91,30,-1,-30,-54,27,16,19,10,-19,40,-1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.20","t":"Clarification: Since we all speak from our own frame of reference, messages we send to others may not be received in the way we intend. Clarification is a useful and necessary tool for all providers. Clarification can be used to help simplify a message that is being sent by patients or to help confirm the accuracy of what providers think they have understood. In-Session Example 3.1","e":[49,30,-120,-75,68,-11,15,0,18,-5,10,3,55,83,29,-68,4,-63,13,44,-41,-5,-26,-14,11,6,4,6,-38,26,56,21,2,-37,-33,-48,32,29,0,1,60,25,6,-77,50,7,82,25,27,-65,9,-56,5,78,123,43,39,24,11,-68,92,87,-32,60,67,-24,-80,35,4,-5,40,-33,38,40,-76,19,-53,-7,7,35,74,-42,80,-22,30,65,-43,5,31,64,19,-15,43,34,-83,23,-38,5,-15,-21,-39,6,37,-23,34,59,7,15,0,-18,-8,46,-52,6,-31,-7,74,-26,40,29,-12,17,-10,41,16,41,5,11,40,-61,-30,-3,-20,11,31,45,-34,-8,21,40,44,3,6,-58,-12,-47,-25,-35,9,29,3,18,-20,22,32,-8,0,-26,23,-7,71,-3,-75,50,-36,-20,21,10,16,15,-50,-10,24,-13,63,30,56,-31,-2,-31,-23,-32,16,-14,-42,-22,49,-66,-17,-34,-21,-2,-32,-14,-46,-27,29,11,11,0,-44,10,-37,26,-18,65,2,5,-20,-10,76,-15,37,11,-20,-36,30,-30,-51,20,38,8,26,-15,2,13,-47,26,-64,9,-17,-78,36,20,38,-23,-1,24,11,81,9,17,2,-23,-83,0,32,-75,-7,18,-24,15,29,10,40,-24]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.20","t":"Patient I just do not feel like trying any more. Provider: Tell me more about what you mean. Patient: I just feel like giving up Provider: Do you mean giving up on your goal to complete college; or are you referring to something different, like giving up on life and possibly harming yourself? Patient: I am not referring to suicide, if that is what you mean; but I am feeling really depressed. Each day seems like such a struggle, and I often just feel like staying in bed. When I said “give up,” I guess I was referring to not wanting to face all the struggles I face in life … my school work, financial problems, relationship problems, etc.","e":[20,37,-128,-59,33,56,-25,-26,52,-18,-37,25,27,35,14,-23,51,-88,-45,31,-59,-58,-55,-3,-2,57,-29,4,-87,80,15,-9,81,-8,-54,-35,22,41,32,22,21,-25,19,-109,-2,-47,41,28,31,-50,-4,-73,-17,-2,74,43,-4,27,5,-8,104,18,-8,94,90,-38,-56,16,-25,-21,69,11,16,20,-51,62,-24,-45,34,-18,28,-29,45,-17,30,42,-10,16,-38,94,-21,9,-2,20,-89,-2,-23,10,-22,-77,-79,-4,-18,-26,64,35,5,33,0,-12,-3,45,-28,-46,20,31,41,-62,43,34,4,30,39,50,29,53,-2,1,16,42,44,-38,-39,44,-12,61,-35,-62,-19,0,44,-32,23,11,-10,-28,32,-21,-27,10,38,15,43,10,33,-56,-9,18,33,-26,34,23,-37,53,6,-48,-15,45,16,47,1,-48,30,-21,67,39,41,25,-23,-65,52,-18,67,6,56,-18,34,-18,-34,-71,-15,34,20,14,-68,9,30,-43,21,2,-13,30,-34,7,-44,59,-61,1,-35,-7,57,-56,-42,15,-48,-5,9,-19,-60,61,47,-38,22,-24,14,11,-27,-3,4,-8,-6,-86,43,8,15,26,-27,50,-28,44,-22,28,6,16,-52,7,0,-22,6,18,36,9,18,33,72,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.20","t":"Notice that the clarifying statement and question helped the provider and patient to more fully explore her feelings and thoughts. Given this new information, the provider is in a better position to explore the patient's concerns and to set up targeted efforts and strategies for treatment. Paraphrasing and Reflection: These techniques involve restating the patient’s main thoughts in a different way or reflecting back the emotions the patient is currently experiencing to gain depth or clarification. 20","e":[51,48,-141,-77,77,-15,32,-14,59,-13,-18,11,58,59,8,-28,44,-80,-20,37,-78,-26,-31,-2,16,20,-18,4,-43,5,54,22,6,3,-45,-64,37,45,-34,-29,66,0,20,-88,19,-65,53,-12,16,-81,-4,-13,-9,-3,106,25,-1,44,42,-53,69,57,-63,71,31,-68,-56,48,-38,3,78,8,21,29,-70,-12,-26,-1,9,24,54,-38,75,-18,54,34,-9,-9,9,74,11,-3,16,62,-105,4,5,-9,-15,-30,-90,-10,29,-29,62,19,7,43,2,4,-22,25,-51,-2,-4,22,62,-22,11,58,7,32,-3,85,22,59,-44,-17,28,-20,-10,-23,-35,22,-3,34,-39,-7,11,11,50,32,-6,-30,-27,-68,8,-26,-8,23,15,41,18,21,36,-33,7,3,45,15,76,7,-46,67,-18,-33,2,3,-5,0,-45,-32,13,-25,79,11,62,-59,23,-21,-6,-26,25,19,-8,-29,32,-51,-43,-35,-18,54,-52,11,-74,-22,54,2,10,-7,-41,0,-52,30,-12,71,-28,-8,-44,-36,58,-2,10,2,-4,-13,8,-10,-24,45,2,-6,-4,-6,-6,19,-31,12,-50,20,-33,-122,59,13,49,-7,-19,16,-2,42,28,23,35,7,-60,48,56,-45,13,27,12,11,15,-5,46,-47]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.21","t":"Patient: Since my fiancé’s death, I feel like every day is a struggle; and I often question whether my life will ever get better. I just miss him so much that I think about him constantly. I don’t know what to do, but the pain is getting to be too much. Provider: You are really struggling to feel better, and much of your pain comes from the grief and loss you feel from losing your fiancé. You may even be questioning whether or not this pain will subside because it is getting unmanageable. Patient: Yes, that is correct. I do not want you to think that I think only about the pain of losing him. The pain I feel comes from my intense feelings of loss, but this pain is also because I miss all the things he meant to me and the joy he brought to my life. I am really struggling because I do not want to let go of him, but holding on hurts so much.","e":[43,-2,-120,-42,18,30,-19,-11,66,-32,-47,14,26,-9,39,-6,26,-52,-40,61,-51,-52,-34,22,21,47,-28,5,-70,67,57,-4,21,-57,-51,-45,10,79,51,39,89,-61,30,-79,72,-58,40,45,27,-25,-7,-69,-44,-43,80,23,20,60,30,-22,121,3,-8,68,80,-70,-65,11,-5,-20,39,35,22,32,-47,64,-32,-13,33,-16,60,-21,70,-17,3,10,4,55,-18,113,17,-32,16,79,-64,27,-72,13,-36,-46,-54,2,-25,-24,32,36,-35,55,21,-36,-33,15,-34,-70,-6,26,69,-59,1,51,-56,48,22,64,50,67,-39,6,18,27,1,-47,17,51,12,48,-30,3,-21,20,48,-6,-1,-52,-52,-21,26,-54,-44,0,36,-10,33,32,48,-56,-23,52,49,4,15,-4,-4,47,64,-66,0,20,17,41,-10,-77,32,-20,82,15,-9,-11,4,-51,30,-3,40,-21,21,2,10,-3,-12,-44,-4,19,4,6,-67,-8,24,-60,24,-46,3,15,-8,-3,-32,27,-22,12,-20,-33,43,-34,-37,30,-58,-4,-13,-1,-36,47,36,-28,1,-23,3,-8,-27,-4,-44,-8,-17,-89,72,27,15,16,-23,56,-36,73,12,-1,16,4,-66,9,-4,-31,4,13,4,13,36,14,76,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.21","t":"In this example of paraphrasing, the provider gives back to the patient what he or she heard, which allows the patient to hear her own words and react with a more detailed response. The use of paraphrasing in this example facilitated a deeper understanding of the issue but also conveyed to the patient a feeling of being heard and understood.","e":[70,36,-148,-97,65,-17,-14,4,64,-17,-25,17,41,63,31,-12,16,-92,-27,26,-71,-33,-32,4,5,16,-22,2,-38,-34,17,15,53,-12,-82,-40,29,26,-28,-7,58,-2,2,-18,57,-81,46,26,-8,-67,-4,-55,-26,-4,137,22,38,26,34,-42,65,52,-64,27,77,-20,-60,61,-25,6,66,22,4,-8,-34,-14,-45,8,-3,54,65,-25,48,-6,44,35,16,-9,-20,66,9,0,14,38,-89,16,-21,-17,-16,-29,-78,-12,55,-48,68,45,37,41,-22,-1,-11,28,-50,-45,-6,4,76,-37,2,64,-12,25,-51,55,8,57,-46,-12,-4,-5,27,-10,-34,28,17,25,9,-19,47,9,44,0,15,-36,-35,-44,20,-22,-21,49,21,29,32,54,24,-24,-15,14,18,12,63,18,-69,46,-49,-40,5,9,-2,-2,-32,-37,9,-2,55,7,64,-38,-21,-14,27,-36,23,-9,12,-42,34,-22,-43,-50,-27,38,-18,-5,-76,-22,18,-2,41,-14,-3,-3,-9,35,-8,62,-41,4,-25,-26,64,6,21,19,-17,16,-7,-13,-44,25,41,-28,10,-53,4,4,-33,28,-51,17,-2,-136,22,12,36,-23,-9,19,-16,15,14,14,8,6,-55,29,31,-52,-7,17,4,32,25,-10,70,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.21","t":"Listening for Themes and Summary Statements: Often, patients express thoughts, feelings and behaviors that become thematic across situations. Although novice providers may initially have difficulties identifying this thematic content, repetition over time (e.g., across sessions) usually helps to create a clearer picture of the salient therapeutic issues that require attention or focus. With experience, providers become more effective and efficient at identifying thematic content.","e":[2,12,-177,-94,44,-43,34,-31,0,-20,-21,8,47,64,-4,-35,3,-30,-18,35,-55,-38,-13,-34,-4,77,14,-11,-64,15,18,9,9,-28,-38,-76,22,41,-18,23,30,14,0,-60,30,-42,35,1,10,-48,2,-47,13,18,104,31,-17,49,28,-46,78,68,-62,47,27,-35,-42,37,-35,5,57,13,13,29,-21,3,-18,17,-7,63,67,-38,57,-8,49,30,34,-1,-30,90,34,-17,-11,54,-132,-3,-17,-8,-35,-35,-106,-12,17,-47,51,28,-10,44,1,-5,-13,72,-50,-15,-10,-27,87,-19,-12,44,-25,-28,9,71,14,42,-5,-43,5,-16,-17,-25,-59,-16,30,39,-7,-31,12,39,31,9,-24,-34,7,-55,6,-41,-20,11,25,52,-11,39,36,-35,-25,7,25,2,58,8,-2,31,-2,-36,7,32,-2,19,-20,-36,-2,-1,98,33,95,-7,21,-26,-2,-34,15,-4,-10,-8,26,-26,-24,-47,-23,29,-51,-16,-66,-27,-17,-17,24,-69,-23,-6,-45,35,-55,84,-25,-22,-43,-27,90,-11,-47,36,-33,31,14,-43,3,32,28,-16,-13,-37,-11,-16,-30,-4,-43,11,-14,-69,69,25,33,-20,-4,-4,-7,27,-20,26,62,23,-41,12,28,-24,-1,61,5,7,5,-1,27,-47]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.21","t":"Once identified, thematic content can be a very powerful mechanism to influence treatment outcomes. Summarization is the technique that brings thematic content into the purview of the patient. Summarization is a condensed phrasing of the patient’s responses over a specific period of time (e.g., across the session, since the outset of treatment, since the onset of his/her current difficulties.) You should rephrase the themes, and repeat them back to the patient for clarification.","e":[26,21,-174,-110,-16,-47,43,2,3,-5,-1,-13,103,38,-4,-68,-1,-11,-48,37,-73,-21,-9,-13,8,42,6,-28,-39,28,-2,17,-39,4,-84,-79,21,34,-26,-5,12,34,15,-46,14,-33,27,-30,-2,-48,-13,-73,-15,-10,100,25,-3,-1,67,-52,88,73,-45,42,35,-35,-61,26,-18,-5,53,6,23,-1,-55,-11,-31,8,6,26,58,-65,60,-9,41,7,36,-13,-66,72,20,-12,-44,54,-123,2,-2,-21,3,-46,-111,-15,30,-11,40,60,1,39,19,-6,-18,11,-64,0,-12,-45,81,-8,-11,45,-21,-24,37,41,-4,37,2,-19,14,-28,4,-59,-48,8,28,48,-1,-29,-14,58,30,-10,-16,11,15,-43,37,-16,7,-37,41,60,-17,15,32,-13,-19,12,12,-7,59,4,-57,33,-8,-17,2,24,-3,-23,-22,8,16,-17,93,16,85,-1,26,-31,32,-28,18,-8,-2,-17,59,8,-12,-12,-4,44,-30,9,-74,-6,38,1,60,-76,-7,28,-61,33,-51,76,-22,9,-43,-11,64,-19,-4,18,-19,-4,-5,-53,-28,16,5,-17,-28,-22,2,3,-22,30,-57,16,-58,-84,50,6,23,-9,32,-7,7,42,-8,-3,39,-12,-42,37,13,-10,-5,51,-13,12,32,-21,33,-26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.21","t":"BARRIERS AND CHALLENGES TO BUILDING AN EFFECTIVE THERAPEUTIC RELATIONSHIP Setting limits in an empathetic manner is an essential tool for new providers. Many new providers desire to “make it all better,” in that they may coddle and console the patient and are distracted from working on deeper issues. A provider can create a holding environment through empathetic words and active listening. A holding environment is a setting in which the patient feels like he or she is being heard and that he or she is in a safe and secure place to voice thoughts and feelings without judgment.","e":[24,53,-176,-101,38,57,26,0,41,-1,11,-3,26,25,36,20,28,-55,-42,-10,-75,-18,-10,3,-5,60,59,-17,-64,4,16,-10,20,-6,-47,-80,60,69,-32,-7,28,3,24,-77,7,-47,48,14,45,-26,20,-51,-55,-7,144,-3,9,82,3,-29,88,43,-58,79,43,-14,-54,27,-15,-49,75,-3,23,-6,-24,28,-36,-3,31,28,49,0,56,-34,68,19,-21,15,-21,82,25,-16,-27,26,-77,37,-19,24,-35,-55,-34,-22,26,-17,-11,30,17,35,5,31,-6,41,-36,-37,19,-25,66,-25,28,56,29,54,0,24,49,40,-54,-25,14,-42,-14,-68,-34,-17,-5,2,-8,-19,-3,33,37,21,6,-31,-34,-26,40,-38,-9,-8,12,55,10,51,10,-50,6,20,49,13,57,44,-20,29,13,-43,21,16,3,0,-70,-48,5,20,36,38,79,-71,18,-35,22,-71,46,-7,-55,-2,5,-78,-6,-42,-8,24,-64,-8,-43,-27,26,-46,69,-34,10,52,-11,-1,-30,56,-27,-3,-27,-44,56,-44,-24,-6,5,1,-20,-20,-21,12,35,-37,9,-16,0,-8,-61,26,5,9,-52,-72,29,-1,12,16,0,27,-23,34,21,37,-12,28,-89,38,25,-39,2,16,20,-18,17,-57,30,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.22","t":"seamless. Often, however, patients and providers are not speaking the same language. For example, a provider may feel most comfortable when tackling a certain issue first; whereas a patient may wish to focus on a different problem first. When the provider and patient are not in congruence regarding goals, the move between rapport building and goal setting is strained. To overcome this issue, providers are encouraged to use motivational interviewing strategies (see Rollnick, Butler, and Mason – Chapters 3, 4, and 5). Primary techniques involve listening to the patient, following the patient's lead and/or motivation, and setting collaborative and mutually agreed-upon goals. A vital aspect to transitioning from rapport to goal setting involves assessing the importance, confidence, and readiness of the patient about specific treatment goals (see Goal Setting, Module 8).","e":[23,31,-175,-21,45,19,26,-7,11,10,-9,-22,54,66,33,8,36,-85,-35,66,-69,-21,20,-21,2,25,7,2,-60,13,58,22,29,-16,-69,-36,39,9,-31,-9,15,-17,33,-96,31,-26,50,-4,31,-29,-14,-27,-51,-13,74,30,-15,66,21,-50,109,45,-35,76,42,-22,-28,52,-33,-30,41,20,52,30,-57,17,-33,-7,-28,12,53,-58,36,-19,56,36,45,27,-62,89,-13,12,41,27,-114,43,-34,-14,-14,-44,-73,7,-2,-7,18,-7,25,22,-6,-3,-1,45,-26,-17,-15,23,85,-3,16,47,11,-38,3,31,22,43,-46,-32,50,50,12,-48,-60,2,-23,33,5,-32,25,2,34,22,23,-36,-15,-49,6,-47,-32,44,21,28,55,32,32,-42,-15,4,51,7,73,18,-28,45,26,-20,4,0,2,12,0,-56,14,-1,80,8,60,-10,-12,-46,39,-38,33,46,-21,-10,5,-23,-29,-64,-14,43,-25,-11,-58,-50,42,-32,70,-49,-52,22,-60,19,-56,75,-9,-11,-27,-26,53,0,-28,-18,-30,-6,3,-17,-42,49,-5,-52,3,-18,31,-47,-35,6,-12,2,7,-85,26,19,40,13,-4,59,16,40,-8,21,5,12,-64,7,17,-24,-5,39,20,0,12,-39,9,-40]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.23","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 4 Module 4: Case Conceptualization and Treatment Planning OBJECTIVES • To better understand the role of case conceptualization in cognitive behavioral therapy. • To develop specific case conceptualization skills, including: a. Assessing patient concerns/difficulties b. Establishing a treatment plan (goal setting) c. Identifying treatment obstacles What Are Case Conceptualization and Treatment Planning, and Why Are They Important in Brief CBT?","e":[17,9,-107,-41,64,9,44,8,-2,-23,-21,-26,62,28,-23,-49,-29,-32,-20,15,-29,-33,17,-6,30,41,4,8,-56,0,18,-9,8,-45,-63,-109,88,12,-70,-49,23,-24,27,-69,39,11,94,0,-4,14,47,-39,49,-32,117,31,-3,40,-16,-29,120,81,-63,75,2,-53,-45,46,-35,-34,47,-13,23,20,-39,3,-32,-4,-11,34,53,-39,77,-31,24,24,-11,-18,-18,54,-25,46,-6,28,-91,34,-39,-10,-12,-25,-58,-14,15,-7,1,53,-4,-5,1,22,-61,29,-34,15,-18,-10,47,-27,48,38,6,-18,56,21,57,56,-56,-20,2,-35,-7,-13,-27,-26,-10,39,18,-21,11,44,60,12,-1,31,-28,-24,20,-29,-34,-9,-29,31,32,2,58,-22,-24,-14,60,17,45,16,-46,45,-50,-50,30,10,-2,8,-14,-38,18,26,70,54,63,-26,2,-34,-12,-13,13,46,0,-21,51,-13,-15,-16,20,46,-45,-9,-79,-77,3,-16,32,-54,-12,23,-31,46,-41,61,-24,31,-24,-6,61,-39,21,26,-32,-8,-21,-17,-52,-4,12,15,2,25,4,45,-29,20,-2,26,-35,-90,27,23,21,40,-52,16,37,61,27,44,55,21,-49,29,-19,-30,-21,71,6,38,8,-9,52,6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.23","t":"Case conceptualization is a framework used to 1) understand patients and their current problems, 2) inform treatment and intervention techniques and 3) serve as a foundation to assess patient change/progress. Case conceptualization also aids in establishing rapport and a sense of hope for patients.","e":[57,31,-96,-73,70,18,21,10,-3,-50,20,-35,78,27,-25,-49,-37,-34,-30,47,-51,20,-12,-27,17,32,-7,6,-47,52,2,22,29,-14,-45,-94,54,14,-24,-51,26,27,51,-47,26,15,28,-42,-7,-14,23,-47,56,2,90,44,6,71,-16,-39,108,93,-47,84,7,-31,-43,44,5,-58,33,1,12,41,-52,35,-32,11,9,34,106,-62,58,-54,49,25,-11,-17,-23,38,-29,44,22,-9,-68,12,-38,27,-33,-17,-59,-29,9,1,7,78,-24,12,15,35,-59,31,-70,1,1,-25,64,-33,36,-8,12,0,56,8,51,28,-53,-39,20,-60,7,-23,-31,-20,-12,56,45,-48,-18,44,65,10,9,7,7,-23,16,-41,-16,34,-2,35,21,-17,57,-20,-20,29,44,0,39,16,-62,54,-38,-38,35,17,-29,-9,-1,-40,18,41,79,29,74,-57,-36,-13,-21,-18,0,25,12,-15,69,-4,-37,-24,21,19,-30,3,-74,-24,22,24,26,-51,-11,9,-45,34,-39,48,-8,3,-35,39,38,-39,4,18,-28,28,-19,-21,-57,-19,9,0,19,2,1,24,-56,43,-4,23,-39,-54,27,-15,15,7,-63,2,37,44,6,62,2,1,-28,-15,-14,-33,-44,63,24,33,16,-36,61,-25]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.23","t":"Case conceptualization is vital to effective treatment and represents a defining characteristic of expert providers. Using these skills, providers are better able to define a treatment plan using intervention techniques that provide the best opportunities for change. This focused and informed approach provides the roadmap for both patients and providers and should include a foundation for assessing change/progress using measurement-based care principles. Case conceptualization (Figure 4.1) is particularly important for short-term therapy, as it serves to focus both the patient and clinician on the salient issues to avoid ancillary problems that often serve as distractions to core goals.","e":[48,37,-115,-56,62,29,26,11,20,-31,16,-28,94,16,-14,-48,-6,-45,-17,60,-57,-8,-27,-45,13,11,13,15,-40,29,32,5,37,-19,-51,-100,83,3,-21,-44,31,17,39,-62,13,-15,29,-20,-9,-19,37,-60,40,-5,110,48,-1,73,-4,-44,102,94,-71,70,17,-50,-31,38,-6,-56,22,-9,5,42,-32,42,-26,5,4,31,76,-50,75,-67,46,33,-19,-13,-22,55,-21,55,-3,21,-88,5,-23,13,-26,-18,-56,-36,-4,-14,10,77,-16,4,5,29,-53,21,-61,6,-7,-21,76,-32,33,2,-1,-10,80,28,32,25,-68,-40,32,-35,-13,-31,-52,4,1,69,30,-40,1,44,62,23,13,0,-3,-19,8,-49,-9,21,9,42,21,14,42,-24,-19,32,43,-10,37,11,-50,45,-30,-27,28,-15,-28,7,-9,-43,23,23,105,26,84,-44,-13,-41,-34,-31,-10,22,14,-16,72,-22,-38,-47,21,26,-44,3,-77,-53,31,5,12,-65,-8,15,-49,55,-32,79,2,10,-48,16,62,-35,10,25,-31,11,-38,-9,-63,-6,17,25,26,7,-12,25,-68,32,4,-1,-36,-53,31,-9,23,-11,-34,16,27,55,10,38,27,-10,-44,3,-6,-26,-36,62,14,34,30,-43,61,3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.24","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 4 When? (Indications / Contraindications) • To better should begin during the first session and become increasingly refined as treatment progresses. • An assessment of current difficulties and the creation of a problem list should occur during the first session. • A treatment plan (including treatment goals) should be addressed early in treatment (sessions 1, 2). Early conceptualization and treatment planning may require modification as additional information becomes available. • Treatment plans and goals should be routinely revisited to ensure that the patient is improving and agrees with the flow of the therapeutic work. How? (Instructions/Handouts)","e":[13,-12,-161,-37,38,19,49,16,-2,-7,-31,2,25,38,-21,-34,30,-40,-29,21,-23,-44,-14,-33,23,40,-10,-7,-20,-17,46,-15,18,-58,-44,-97,77,37,-51,-45,22,-33,28,-64,25,-15,93,26,-19,7,57,-15,-9,-3,130,51,12,21,12,-51,116,54,-81,54,35,-43,-43,36,-17,-24,65,-33,30,22,-6,8,-15,-15,-24,28,12,-12,107,-70,32,16,11,-9,8,53,-11,30,-29,23,-103,5,-47,-8,-22,-36,-26,-18,18,-29,0,46,25,-8,-35,-15,-31,33,-7,-26,-16,-21,63,-34,34,63,-27,-29,20,78,58,24,-47,-20,6,3,-11,7,-27,12,0,51,48,-33,-7,29,48,23,4,16,-37,-58,30,-47,-20,4,-6,37,3,30,28,-57,-27,-2,76,-7,63,14,-56,56,-19,-32,5,41,10,23,-16,-9,2,-14,48,56,79,-43,21,-35,-3,-31,-3,33,-23,-17,22,-27,-41,-32,5,60,-54,-9,-47,-87,15,-45,30,-26,-22,24,-37,51,-58,89,-33,22,-5,-21,77,-28,22,22,-28,-19,-6,-10,-41,21,-1,32,-8,2,0,29,-29,7,-1,33,-23,-85,19,6,8,17,-20,10,34,45,22,34,56,47,-82,32,1,-29,-25,63,-1,13,13,22,33,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.24","t":"A) Using established self-report symptom inventories. A common practice in CBT involves the use of self-report symptom measures to assess baseline functioning as well as therapeutic progress. Frequently used measures for depression and anxiety include the Beck Depression Inventory – Second Edition, Patient Health Questionnaire-9 (depression), Geriatric Depression Scale, Beck Anxiety Inventory, and Generalized Anxiety Disorder 7-item scale.","e":[13,4,-189,-67,28,-11,61,-6,43,-15,-17,22,59,17,1,-59,-2,-36,-29,36,-22,-24,-48,-23,9,76,-23,33,-20,15,49,12,17,-28,-57,-27,45,28,29,38,55,-26,31,-83,27,-4,84,45,62,12,33,-65,40,-46,85,21,-27,43,22,-38,75,46,-43,44,76,-22,-28,45,-42,28,90,-20,50,59,-77,2,-28,-23,18,23,34,-29,81,-40,80,12,-16,15,-22,56,17,-9,10,60,-57,36,17,-21,-26,-56,-36,0,-27,4,9,-2,2,-38,-1,-13,-59,76,2,-28,25,3,58,-39,-43,44,-10,18,34,24,12,48,-35,21,25,-27,-8,-5,-17,-9,5,41,-29,22,-20,16,54,-19,-14,30,-4,-9,38,-31,-62,-1,-12,-3,20,29,26,-44,-51,28,57,33,37,-2,-32,54,-14,-65,3,63,42,80,-45,-52,-36,0,44,13,60,-3,43,-41,42,-23,56,18,-20,-13,33,-64,-14,-50,38,17,-53,-16,-86,-37,26,-1,17,-47,-14,30,-9,-8,-58,51,-1,-16,47,-71,52,-39,8,-2,-38,1,-21,-14,-6,19,-23,0,9,-22,52,36,-13,14,11,4,-16,-100,50,-18,15,56,-19,27,30,34,19,22,37,25,-62,31,-36,-13,32,27,-41,16,-8,-2,52,-29]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.24","t":"Self-report measures are often completed by patients while in the waiting room and evaluated by the clinician during the session. Often self-report measures can serve as a routine agenda item during CBT sessions and highlight important improvements and/or continuing symptoms. Information obtained from these self-report inventories can also provide insight into the way the patient thinks and behaves and factors that might be important areas of need and will inform treatment progress and treatment continuation/discontinuation.","e":[8,18,-182,-81,42,-44,73,-8,36,-1,-17,28,46,47,11,-92,-8,-81,-23,35,-13,-34,-56,1,4,47,27,38,-9,-2,48,4,29,-41,-47,-42,52,13,-15,-20,28,-16,-2,-105,61,3,74,35,34,3,18,-65,17,2,121,-27,-39,44,29,-32,90,14,-32,73,83,-16,-38,37,-49,13,68,14,45,29,-48,12,-19,3,-32,44,28,-41,70,-20,63,9,4,9,-41,65,23,-7,21,33,-88,13,13,-20,-32,-36,-64,-20,-52,-15,12,21,-8,4,14,-19,-51,38,-36,-4,29,22,83,-23,-18,54,16,11,19,46,16,79,-42,1,51,-18,-2,-6,-37,11,13,60,11,1,-1,19,54,-3,-13,76,-3,-31,54,-33,-45,20,-3,-3,1,25,24,-24,-36,47,46,31,73,4,-70,36,-43,-61,-24,37,32,45,-36,-33,-11,11,24,17,63,-2,3,-43,49,-14,6,3,11,-15,20,-46,-14,-45,56,12,-31,-11,-101,-32,-10,12,7,-61,-10,22,-12,22,-46,46,-23,-10,20,-49,66,-23,-13,-11,-20,12,-10,-12,-28,19,15,-24,9,-21,48,16,-12,-17,-29,-18,-33,-79,27,7,-6,39,-13,56,28,20,22,-6,37,8,-92,1,17,-43,21,21,-23,18,7,-21,27,9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.24","t":"B) Problem lists. These are a common and useful strategy for identifying the psychological, social, occupational, and financial difficulties faced by patients. Providers who use problem lists typically elicit a list of five to 10 difficulties from the patient during the first part of session 1. Problems are best identified using open-ended questions (e.g., “What brings you to this clinic?” “What issues would you like to focus on in our work together?”). Problems are best described in terms of symptom frequency (How often does the symptom occur?), intensity (How mild or severe is it?) and functional impact (What influence does the symptom have on daily functioning or general distress?). 24","e":[32,51,-153,-60,66,-9,27,-11,46,-12,-11,-24,42,41,-16,-66,15,-59,-36,18,-27,-6,-40,-6,3,79,-35,-15,-11,27,7,24,35,-90,-55,-44,38,22,20,21,39,-46,22,-96,31,-20,49,47,20,-2,61,-62,9,13,72,50,-4,45,32,-26,114,50,-50,40,68,-31,0,37,-6,17,45,-16,44,38,-74,24,-8,22,18,50,38,-30,78,-51,58,21,2,28,15,92,-19,32,12,32,-120,36,-32,-19,-39,-58,-32,-21,18,-30,32,33,14,48,-13,25,-49,57,-18,-27,-2,-36,57,-37,12,61,-35,-14,63,43,24,1,-25,11,67,1,-4,-27,-26,-19,12,69,4,-20,13,-6,90,12,-12,6,-8,-21,-9,-42,-34,16,-16,29,-22,21,45,-41,-22,12,51,-5,53,-10,-81,67,-19,-58,7,41,45,55,-18,-64,21,-3,81,3,68,-26,42,-17,29,-51,34,23,-4,-25,42,-57,-37,-45,12,23,-27,-5,-32,-48,30,-41,14,-44,1,37,-48,36,-22,82,-32,2,-39,-29,44,-48,12,35,-54,-15,-10,6,-22,31,17,-28,-31,-7,42,16,-53,14,-39,17,-57,-91,61,-5,22,-22,-7,20,0,10,-5,-1,43,21,-73,13,-19,-38,-8,45,8,15,17,14,42,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.25","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 4 Some patients may describe their difficulties or goals in vague or abstract ways, such as, “I want to improve my life,” or I want to be happy again.” Problems and subsequent goals are best described in specific terms to maintain clinical focus. For example, specific problems are listed in the following table. Table 4.1 Problem List Example Problem Frequency Severity Impact Highly distressing; socially Stay at home six Limited social contacts: Social Isolation debilitating; estranged of seven days moderate-to-severe isolation family/friends","e":[15,33,-158,-44,49,10,8,0,24,-13,-26,-1,41,41,-16,3,2,-56,-42,51,-33,-20,13,-8,6,73,24,-31,-65,-9,-9,-2,10,-47,-58,-37,53,80,4,-2,25,-45,21,-82,9,-24,68,-3,6,-17,56,-23,28,-17,118,21,-2,6,26,-31,84,44,-75,56,44,-42,-58,52,-52,-31,54,-33,14,39,-51,20,-13,-9,18,30,20,-11,70,-53,45,12,13,8,2,39,-20,27,-12,14,-136,29,-12,-16,-17,-34,-40,-34,40,-24,10,12,7,33,-16,8,-32,59,-36,-4,16,-29,51,-52,28,57,5,-13,8,80,43,39,-30,1,29,25,-4,-24,-44,11,-18,52,25,-3,-2,25,78,-4,-16,-2,-30,-68,31,-40,-28,11,-32,15,12,31,42,-42,-27,26,44,-18,46,17,-58,50,-10,-17,9,19,19,53,-30,-55,-7,8,70,36,81,-14,13,-29,21,-45,30,25,-8,12,47,-35,-33,-9,-21,56,-32,-31,-60,-83,17,-60,18,-42,-22,32,-34,43,-55,56,-37,2,-20,-17,56,-45,2,39,-43,-39,-8,-6,-39,20,10,3,-23,6,28,17,-34,9,-18,39,-23,-124,52,22,0,8,-34,32,14,53,13,11,42,18,-84,39,-16,7,0,54,4,27,9,8,30,-36]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.25","t":"Pain leading to decreased Experience pain Pain intensity is high, 7 out Pain activity level, inability to each hour of 10, when present work Very intense when present; Highly distressing; influence Feelings of Occur three of sometimes involve suicidal work, social, and intimate Worthlessness seven days thoughts relationships Decreased activity level, Occurs almost Fatigue Not intense but troublesome frequent naps, inability to constantly complete daily tasks","e":[48,34,-153,-53,72,-4,9,-16,36,-31,-45,-5,38,9,26,-28,-13,-37,-29,48,-51,-31,-20,-28,-15,71,-1,-40,-6,43,11,-45,36,-45,-64,-23,58,79,55,28,54,-63,74,-70,-21,-33,54,54,52,-6,39,-50,0,-7,103,3,-35,-21,56,-18,66,26,-21,62,33,-49,-43,40,-7,-21,19,-20,-10,17,-32,45,31,-18,-8,46,42,17,95,-29,64,-15,7,50,34,94,27,29,51,-4,-134,13,2,37,-28,-10,-40,-38,34,-25,31,2,-18,32,20,40,-36,31,-9,-55,27,-32,78,-43,-21,38,-1,8,13,62,4,40,4,-20,37,-30,-18,-14,1,37,27,73,-16,-36,-9,38,63,4,-8,-12,-59,-16,15,-52,-33,12,40,-16,3,-6,13,-74,-60,33,46,9,33,22,-59,30,-4,-54,-20,27,40,25,-18,-61,18,-4,43,35,61,-10,25,-33,18,-11,60,-6,17,-30,25,-66,-45,-8,-27,17,7,-33,-71,-43,46,-22,30,-41,-2,7,-3,2,-26,80,-46,-9,-26,-14,15,-26,-2,19,-23,16,41,0,1,31,51,-26,-11,14,15,-1,-36,-9,-61,17,-18,-51,60,-25,-18,-12,-5,14,-3,35,-18,7,27,-1,-102,-2,-33,-20,-4,38,13,-12,13,46,68,40]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.25","t":"C) Assessing cognitions. Within the CBT model, it is often helpful to examine the patient’s thoughts, especially how the patient perceives them. A commonly used, structured way to examine these factors is to assess (ask questions related to) how the patients perceives themselves. For example, a patient might self-describe as incapable, not useful, or a burden. They may generally perceive others to be critical or hard to please. And their view of the future might be largely pessimistic and involve beliefs that the future will include only more losses and disappointments (see also Thought Records in Modules 11 and 12).","e":[18,-5,-137,-100,88,25,70,3,21,-4,10,19,64,47,17,-45,-14,-50,6,29,-44,5,-22,10,5,62,-61,50,-17,10,29,-3,22,-70,-49,-63,74,45,-22,-2,25,-17,-2,-107,27,20,84,13,50,-14,-19,-58,27,-6,143,28,-9,47,6,-24,75,61,-32,51,51,-42,-42,48,-49,0,42,-11,16,50,-71,-6,-29,-13,-6,21,77,-36,80,-22,46,23,-7,10,1,82,-8,-12,47,36,-105,15,-18,-44,-32,-20,-70,-1,-30,-38,6,43,-40,14,38,-17,-74,12,-42,17,0,-1,50,-4,-7,50,25,36,12,61,6,101,-59,-25,33,-24,10,-13,6,-30,11,68,-38,4,-3,28,53,-15,-8,39,11,-50,19,-35,-48,21,-11,33,4,11,42,-42,-12,25,23,15,43,38,-54,53,-46,-41,20,32,46,13,-37,-53,16,-1,72,-8,56,-8,-9,-11,12,-11,33,13,-11,-30,22,-30,-6,-50,40,16,-53,-15,-65,-57,12,11,27,-38,-10,12,-36,44,-52,40,-22,-8,-39,-42,57,-7,-16,40,-37,23,3,-16,-42,23,24,-48,26,-10,3,10,-61,0,0,39,-14,-76,47,27,10,24,-27,31,19,36,24,42,25,2,-71,-29,10,-38,20,40,-26,36,0,-3,50,-13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.25","t":"D) Assessing behaviors and precipitating situations. Precipitating situations are events, behaviors, thoughts, or emotions that activate, trigger, or compound patient difficulties. The Antecedents, Behavior, Consequences (ABC) Model is a model for examining behavior (symptoms) in a larger context. It postulates that behaviors are largely determined by antecedents (events that precede behavior/thoughts/mood) and consequences (events that follow the behavior/thoughts/mood).","e":[48,26,-177,-70,63,31,80,-27,48,-55,-8,26,93,74,29,-53,-16,-45,-24,-11,-33,-17,2,-20,24,52,-20,-7,-43,20,-27,-8,-18,-76,-56,-74,80,35,16,-42,9,33,13,-45,17,7,44,14,41,-14,54,-19,32,-15,87,58,37,13,4,-35,67,62,-63,50,44,-30,-53,22,5,-39,15,-9,-18,27,-27,-13,-30,6,35,24,42,-11,105,-39,79,15,-45,17,-38,50,4,31,1,-1,-91,5,-40,5,-14,-18,-49,-15,13,-21,18,19,-6,-3,27,-1,-37,82,-30,-16,4,-5,54,7,-15,40,-1,-6,-5,57,-26,44,-41,38,20,-4,9,-12,-8,5,18,51,-23,-20,13,22,79,38,-22,3,-32,-8,16,-12,-29,-8,-10,72,-40,18,14,-15,-83,-24,14,-8,59,0,-11,43,-33,-40,7,35,-3,47,-63,-52,3,-12,42,15,61,-55,30,-41,27,-46,58,26,-7,-29,5,-19,-50,-56,-4,24,-39,-74,-32,-51,7,-27,49,-38,5,9,-42,55,-13,92,-24,36,-39,-13,39,-16,-1,14,-27,-33,-8,15,-18,13,-2,-38,-16,-33,6,27,-37,-15,-33,37,-37,-69,46,10,45,5,6,29,4,3,-14,74,9,16,-34,6,15,-27,6,32,9,6,7,-54,50,-25]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.25","t":"The ABC model (see worksheet at the end of this module) is used in a functional assessment. It follows the premise that behavior (B) is shaped by antecedents (A) and consequences (C). The antecedent occurs before a behavior and may be a trigger for a particular reaction in the patient. Behavior is any activity (even a thought or feeling) that the patient exhibits in response to an antecedent. Consequences are events that occur after the behavior and direct the patient to either continue or discontinue the behavior. 25","e":[42,23,-144,-61,64,16,83,-21,58,-65,-2,33,111,71,42,-47,-15,-28,-26,-1,-39,4,-13,-10,14,57,-14,21,-49,33,-9,11,4,-98,-55,-76,63,79,29,-23,-1,34,-12,-33,15,9,65,16,38,-1,50,-28,23,-4,117,36,43,34,-5,-40,79,76,-84,52,75,-15,-31,53,-27,-24,19,-17,-6,12,-15,12,-18,-6,26,47,29,-12,86,-33,75,-18,-45,22,-21,49,18,50,22,-3,-108,-1,-38,-2,-16,-14,-52,-4,30,-16,32,6,16,-4,25,-2,-14,59,-23,-8,-26,-25,35,-14,-15,39,-22,-33,7,45,-7,20,-35,35,15,0,4,7,-27,-14,36,57,-3,-26,10,6,48,24,15,4,-30,4,44,-18,1,20,-17,50,-28,32,23,-59,-54,-14,17,-3,84,-19,-21,32,-38,-50,-14,23,19,25,-69,-63,15,-9,45,10,38,-49,38,-28,9,-37,19,21,0,-37,8,-17,-77,-35,22,31,-38,-60,-65,-70,-7,-28,62,-46,25,-2,-37,69,-34,56,-18,17,-48,-29,32,7,-22,45,-25,-27,-21,12,-43,7,22,-35,-2,-39,22,23,-26,-14,-54,21,-19,-71,46,-9,40,7,26,29,13,-1,-21,56,44,22,-46,8,19,-44,32,56,-9,24,19,-24,38,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.26","t":"A) Antecedents: Antecedents, or events that occur before a behavior, typically elicit emotional and physiological responses. Antecedents may be affective (an emotion), somatic (a physiological response), behavioral (an act), or cognitive (a thought). They are also subject to contextual (situational) and relational (interpersonal) factors. For example, patients who report depressed mood (emotion) may feel bad when they are alone at home late at night (contextual antecedent) or better when they are around family (relational antecedent). Alternatively, they may feel depressed by thinking, “I will always be alone” (cognitive antecedent). It’s important to remember that antecedents can both increase and decrease a particular behavior.","e":[62,3,-168,-43,48,33,41,-13,6,-45,15,72,74,49,24,-42,-9,14,1,48,-53,-3,5,-9,22,45,-24,-3,-63,11,4,14,12,-43,-43,-59,20,35,38,-31,-2,2,5,-84,-28,-17,35,-2,38,-8,47,-61,0,-16,120,52,51,39,0,-18,89,59,-55,72,79,13,-44,90,0,-16,48,-17,-29,31,-2,17,-27,-9,48,-16,74,-22,91,-6,74,3,-76,14,-14,60,44,22,27,-5,-88,5,-30,33,-38,-31,-54,0,0,8,28,8,-20,-15,16,24,-23,72,-40,-37,-7,10,58,-39,19,43,-46,11,9,52,0,45,-13,-4,-6,-27,10,-16,-33,-35,-11,40,-29,-7,-8,27,49,21,21,-28,-29,-7,27,-60,-33,38,22,16,-28,14,13,-44,-70,-10,13,6,73,21,-23,49,-6,-40,-8,29,20,55,-36,-52,-14,20,47,58,88,-16,27,-38,34,-36,21,27,6,-65,6,-13,-92,-40,-17,-8,-14,-30,-64,-63,-36,-14,44,-45,14,-12,-14,53,-28,91,-5,-15,-25,-16,32,-6,-16,12,-34,-26,-13,2,-25,15,6,2,1,-5,12,8,-14,7,-10,-10,-25,-83,74,-28,30,17,-5,20,26,40,-1,41,55,33,-43,-9,36,-43,9,10,3,15,10,-38,12,-25]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.26","t":"To help your patiens identify antecedents, teach them to pinpoint conditions that affect their behavior. In-Session Example 4.1 “What were you feeling right before you did that?” (Affective) “What happens to you physically before this happens? Do you feel sick?” (Somatic) “How do you normally act right before this happens?” (Behavioral) “What thoughts go through your mind before this happens?” (Cognitive) “Where and when does this usually happen?” (Contextual) “Do you do this with everyone, or just when you are around certain people?” (Relational)","e":[51,-16,-170,-38,66,15,65,-34,17,-37,23,55,53,63,5,-47,-20,-43,-1,48,-57,-12,-47,12,-11,11,-48,10,-47,-1,4,25,6,-60,-35,-94,40,27,18,-36,53,-17,15,-112,-4,-25,53,-26,18,-28,7,-63,3,-8,133,44,57,9,59,-20,119,71,-38,52,27,-10,-59,76,-50,-3,49,-4,19,6,-42,19,6,-5,27,9,35,-2,95,-18,52,31,-52,7,-22,90,31,-6,0,19,-99,1,-55,42,-23,-61,-54,-17,1,-26,-1,17,17,3,35,6,-26,43,-23,13,-28,-1,60,-48,13,44,-43,10,7,70,15,52,-47,-10,-12,-22,5,-40,-23,1,-1,55,-14,-26,-6,18,78,24,-23,-6,-25,-16,18,-44,-18,3,11,24,-2,41,51,-59,-52,-9,41,-12,84,-17,-31,61,-8,-31,19,46,22,51,-52,-55,-15,-1,36,56,59,-30,19,-10,42,-62,31,3,-24,-61,2,-9,-71,-52,-32,11,-19,-21,-63,-64,-12,0,30,-54,-1,-8,-29,50,-37,68,7,-12,-16,-9,48,1,6,34,-58,16,-15,14,-29,36,-7,-15,-17,1,2,1,-31,6,-24,21,-19,-90,45,-11,24,18,-13,6,9,42,-1,39,53,22,-35,17,47,-54,9,28,21,20,22,-12,16,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.26","t":"B) Behaviors: A behavior is anything the patient does, feels, or thinks immediately following the antecedent. Each behavior that your patient displays could potentially include an affective component (feelings or moods), a somatic component (bodily sensations such as rapid heartbeat or stomachache), a behavioral component (what a patient does or doesn’t do), and a cognitive component (thoughts or beliefs).","e":[45,37,-153,-43,44,5,67,-55,58,-73,36,78,64,66,-5,-55,-15,-29,-27,44,-35,30,-5,-24,38,55,-9,9,-32,-7,-27,23,36,-43,-48,-44,15,59,10,16,14,20,-1,-65,22,-7,44,-14,16,7,-3,-87,-14,-8,149,22,79,53,5,-32,88,27,-47,48,82,2,-48,42,-30,0,47,-10,29,16,-18,10,-6,23,45,20,29,-39,79,-23,97,2,-34,15,-17,79,6,7,19,10,-106,-25,-28,14,-16,-54,-64,2,9,4,49,6,0,27,0,-5,-5,57,4,-23,-21,10,84,-17,12,41,7,5,8,40,2,20,-33,9,-15,-1,18,-2,-14,-22,1,41,47,-15,-4,18,84,37,1,34,-23,-30,22,-31,21,13,26,37,-25,9,35,-52,-43,32,39,2,62,8,-64,35,-4,-79,-10,46,9,47,-45,-43,9,19,58,42,64,-39,25,-47,8,-35,12,12,0,-34,2,-22,-75,-60,2,2,-7,-11,-49,-52,-30,-12,65,-60,12,8,-34,38,-35,57,-32,1,-47,-18,48,-30,-18,13,-44,-17,-25,-17,-19,13,44,-35,7,-35,5,17,-15,-1,-9,26,-27,-60,40,-12,33,2,-35,30,9,-13,-18,51,36,10,-39,10,-27,-35,3,39,-1,7,23,-24,66,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.26","t":"C) Consequences: Consequences are categorized as being either positive or negative. Positive consequences increase the chances that a behavior will be repeated through the experience of something pleasant or the removal of something negative (e.g., do not have to do a chore). Negative consequences decrease the occurrence of a behavior, either by the presence of something noxious (e.g., being yelled at) or the absence of something desired (e.g., a child being grounded from watching TV). Patients tend to repeat behaviors that result in something positive or the removal of something negative.","e":[60,50,-125,-29,78,5,50,1,38,-48,-35,35,84,66,40,-23,-12,-43,0,54,-38,15,-61,-31,9,49,26,-39,-42,9,-18,7,-7,-77,-50,8,53,55,52,-43,25,35,20,-50,30,-39,87,42,55,-30,55,-73,-26,-6,106,13,42,-6,-22,-31,56,86,-41,48,52,-5,-47,44,-18,-16,11,10,-25,13,-33,31,2,10,7,43,16,-49,79,-18,76,-23,16,3,-32,80,8,22,34,28,-118,-2,12,19,-14,-14,-20,-50,68,-10,22,33,2,-1,-6,2,-52,50,-10,-11,30,-2,79,-64,-23,78,-7,1,-1,22,-6,9,-28,-16,60,-18,25,-12,-25,27,17,66,39,-10,-3,2,96,32,1,25,-21,-54,9,-20,8,23,19,-2,-30,17,27,-56,-37,49,19,12,78,10,-32,26,-40,-48,-9,-4,-12,52,-45,-22,16,-26,47,-2,25,-45,-15,-57,-28,-32,46,32,24,-40,31,24,-70,-15,27,9,-19,-31,-56,-88,-14,1,43,-52,-1,-6,-40,26,16,62,-6,8,-29,-24,36,-10,1,8,1,-34,-27,-3,-21,-13,-12,-27,-32,-17,45,37,-2,-20,-55,3,-33,-70,28,2,22,21,32,-1,14,-7,-35,23,20,17,-37,-10,14,-61,1,60,23,17,13,25,60,6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.27","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 4 In-Session Example 4.2 “How do you feel immediately after this occurs?” (Affective) “Do you have any bodily sensations after this happens, like trembling?” (Somatic) “How do you react after this behavior occurs? (Behavioral) “What do you think about after this happens?” (Cognitive) “Are you in a different place when this behavior ends?” (Contextual) “Are there any people who make this behavior worse? Make it better?” (Relational)","e":[32,-21,-157,-61,55,21,67,22,14,-35,-43,13,8,59,-13,-36,12,-46,-44,42,-68,-31,-22,12,33,65,-16,11,-24,-47,-15,-14,-2,-51,-67,-68,47,20,-49,-21,38,-47,23,-78,20,-15,78,-19,-9,-3,28,-38,14,-8,133,20,73,13,33,-42,80,33,-46,33,35,-47,-71,62,-47,-36,37,-7,-13,19,-49,21,-4,-20,-1,24,-2,15,95,-18,37,21,-27,11,4,64,31,13,-37,12,-106,11,-22,21,-9,-50,-43,-18,15,-51,7,39,7,4,6,0,-37,31,-4,10,-24,-30,58,-51,13,47,-13,13,-14,55,68,41,-34,9,-45,-5,19,-8,-43,7,21,62,52,-28,13,10,67,10,-39,30,-43,-36,37,-37,-7,-25,-10,31,19,41,52,-51,-39,-12,51,9,59,-11,-17,58,-6,-46,31,25,29,12,-48,-70,14,-17,22,36,47,-73,15,-42,15,-21,21,4,9,-27,15,-5,-45,-33,-18,45,-51,-13,-83,-72,-1,-44,48,-61,41,22,-22,47,-54,71,-28,-2,-39,-24,102,-32,21,41,-58,7,-13,-7,-24,33,22,22,-28,-1,-14,5,-24,-12,-6,31,-30,-102,10,-4,9,24,-28,18,16,25,29,18,42,19,-68,23,9,-15,23,41,-12,18,21,-16,33,-19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.27","t":"When completing a functional assessment, examine both short- and long-term consequences. Short-term consequences tend to be behavioral reinforcers, while long- term consequences tend to be negative outcomes. In the case of addiction, the short- term consequence of using a substance is intoxication, or escape from a negative mood; the long-term consequence may be legal trouble, family problems, or a hangover. Understanding the positive and negative consequences of a behavior for a patient helps design the timing and nature of intervention. For example, in the case above, an intervention would need to follow a noxious antecedent to offset the negative mood it causes. Treating the negative mood would then decrease the need for escape through substance use. A variety of questions may be used to elucidate a short-term consequence:","e":[76,22,-144,-31,9,-4,46,1,32,-52,-19,39,76,22,18,-13,-3,-30,-45,36,-53,16,-50,-36,-10,34,19,-11,-32,3,33,9,-25,-70,-64,-53,38,77,69,-26,-18,26,68,-53,28,-35,72,59,58,-24,42,-39,-23,7,89,31,12,-18,13,-22,73,41,-74,73,75,-21,-7,40,-21,-11,51,11,-4,31,-39,32,13,12,-3,21,39,-18,63,-54,51,-5,16,14,-5,52,12,55,18,27,-130,6,10,18,7,-14,-44,-28,23,-10,28,45,14,12,3,1,-94,79,-4,-25,34,5,31,-36,-19,36,-24,-18,39,35,-12,-6,-61,7,72,1,-27,-4,-62,4,57,59,16,-5,-17,34,74,-24,8,31,-59,-29,61,-44,-16,-9,-19,19,-3,30,37,-27,-48,10,48,-25,65,9,-19,40,-55,-44,1,-11,6,46,-76,-48,25,-14,61,30,40,-56,7,-25,14,-71,0,22,30,-21,47,-5,-105,-7,15,27,-43,-56,-93,-90,30,-3,-7,-58,-10,15,-40,34,2,46,-8,-20,-45,-54,50,2,-8,4,-16,-23,-34,-3,-20,3,29,-1,-2,-50,55,11,-20,2,-29,-12,-18,-76,51,23,1,30,3,-18,-9,21,-36,9,21,13,-36,-8,-1,-46,31,55,6,37,39,7,25,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.27","t":"In-Session Example 4.3 “Does this behavior get you attention in some way?” “What good things happen as a result of this behavior?” “Does this help you in some way?” “Do you feel a certain ‘rush’ from doing this?” “Does this behavior help you avoid something you don’t want to do?” 2. CASE CONCEPTUALIZATION STEP 2: Clinical Hypotheses and Treatment Plan","e":[27,10,-134,-31,74,4,65,-36,24,-40,-23,21,47,73,1,-48,-31,-71,-30,18,-33,-14,-35,-1,21,34,-17,-2,-47,15,1,3,25,-34,-76,-31,64,45,-43,-36,47,-25,26,-81,26,-46,90,-6,38,-43,41,-40,-15,-11,120,38,63,30,29,-27,112,35,-35,27,41,-30,-60,70,-56,-8,26,28,6,-20,-85,27,-8,-3,-6,38,29,-33,74,-70,39,35,-23,-21,-28,48,8,12,6,-8,-94,20,-20,-8,-26,-23,-66,-38,28,-19,48,62,4,29,-4,-2,-43,25,-13,-9,-26,3,70,-25,30,38,-17,-2,-7,44,43,23,-68,-12,-20,-28,4,-30,-29,12,16,67,40,-52,27,16,80,15,-19,40,-26,-39,22,-14,-12,-1,-20,24,26,40,68,-53,-39,-7,51,-18,72,-31,-38,49,-52,-36,44,50,34,36,-29,-56,-4,11,57,10,75,-51,-5,-30,18,-61,-7,-14,1,-48,45,-14,-46,-38,-7,9,-29,-52,-67,-51,18,-19,33,-44,-12,3,-62,35,-36,43,-15,16,-14,-21,66,-10,6,51,-51,19,-18,-1,-42,44,27,-22,-30,-20,14,15,-11,6,-36,27,-61,-113,-1,-20,30,-4,-8,13,25,36,2,57,24,-19,-56,16,-4,-6,-27,48,17,57,45,-14,41,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.27","t":"Establishing focused clinical hypotheses based upon the information obtained in Case Conceptualization Step #1 serves to direct intervention options and possible treatment techniques. These hypotheses may require adaptation as new information becomes available during treatment. Clinical hypotheses can either be used exclusively by the provider or can be shared with patients. Generally, sharing this information improves trust and communication between patient and provider.","e":[62,35,-133,-39,67,8,4,10,10,-53,35,-12,84,61,-38,-28,-14,-57,-9,55,-98,-31,-55,-15,-6,13,15,17,-34,7,8,22,41,-30,-44,-77,41,2,5,-30,27,22,46,-100,3,-12,51,-11,19,-35,46,1,31,-14,112,57,18,55,18,-81,122,78,-70,38,39,-24,-60,65,-3,-58,35,-16,60,1,-50,35,-10,-17,0,37,70,-27,92,-58,18,42,-32,-13,-15,57,-6,11,32,23,-70,16,-38,-6,12,-25,-79,-17,6,-8,10,65,-10,20,15,28,-69,24,-72,-18,0,-48,30,-27,5,2,-21,-7,41,45,-8,31,-58,-29,14,-56,19,-25,-37,10,29,64,30,-46,-1,20,36,12,15,-17,4,-16,17,-32,-9,34,-18,41,27,25,43,-44,-28,-6,42,-1,47,-7,-45,35,-22,-42,30,34,17,19,-25,-59,-7,30,94,29,99,-28,2,5,8,-48,7,29,30,-7,55,-28,-52,-57,-9,9,-33,-21,-69,-21,41,-24,21,-33,-18,14,-67,28,-20,75,5,0,-16,9,36,-18,14,27,-19,8,-50,-1,-49,24,40,9,0,17,-8,10,-69,13,6,0,-17,-89,45,5,34,9,-43,-13,36,53,-7,27,14,-3,-68,-1,27,-25,-38,72,-12,35,39,-28,36,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.27","t":"A focused clinical hypothesis for a person with depression might be as follows: \"Since your retirement, you have experienced many life transitions and numerous losses (e.g., financial, social, functional). Your thoughts, which used to be largely positive and ambitious, are now negative and pessimistic; and you appear to be fearful of the future. In 27","e":[35,27,-163,-63,47,59,38,-37,35,-47,-1,21,90,29,6,-25,-27,-35,-2,71,-68,-41,-92,5,-9,86,15,6,-24,23,36,26,-4,-10,-50,-33,41,65,85,-11,-1,35,9,-92,-11,-6,58,29,72,-44,45,-12,15,-27,64,54,13,43,13,-75,117,31,-54,30,60,-51,-31,56,-25,-66,24,0,2,33,-24,72,-6,-9,-17,-15,49,-22,42,-38,32,-1,-6,4,-5,81,42,-5,26,47,-88,25,-21,9,-4,-21,-46,-23,12,-20,31,13,-41,-14,9,-18,-63,32,-46,-23,42,-27,33,-34,-14,50,-25,9,35,44,-25,49,-15,-5,33,20,27,-21,-55,33,56,55,-22,-5,-16,23,66,-12,-3,-18,-37,-40,27,-17,-56,18,-23,9,3,-11,20,-75,-54,5,31,-25,18,21,-24,58,-23,-45,6,23,8,59,-56,-55,-2,-48,109,22,60,-16,-3,-20,33,-58,35,23,18,-17,33,-10,-40,-59,-7,31,-43,-24,-33,-47,31,-48,18,-41,-17,38,-21,34,-48,46,9,4,-21,-25,23,-19,13,-7,-9,22,-46,10,-43,3,18,3,-12,17,65,2,-59,5,8,16,-32,-121,54,8,20,30,-25,-31,22,14,-18,29,24,-2,-52,22,-6,-3,-7,49,6,38,-9,30,33,-33]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.28","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 4 reaction to your mood and negative thoughts, you have reduced the number of your activities; and you have begun to withdraw from your family.\" The end result of case conceptualization is formation of a treatment plan, an agreed-upon strategy between patient and provider that gives direction to the therapeutic process. A treatment plan should include a presentation of the causes of the patient's current difficulties (e.g., cognitive and behavioral factors creating symptoms or difficulties) and a specific plan. When presenting the plan, actively involve the patient and incorporate his or her feedback. In-Session Example 4.4","e":[51,20,-130,-61,73,4,26,10,20,-26,-12,-33,62,34,-2,-29,5,-49,-41,42,-53,-38,-6,-11,25,30,10,4,-42,9,18,-8,9,-43,-86,-76,54,24,-57,-46,22,-14,23,-72,14,-5,92,8,-31,19,49,-24,17,-28,105,24,-3,34,4,-48,110,73,-77,65,40,-61,-60,53,-13,-34,38,-16,25,4,-10,18,-15,-4,1,30,39,-56,77,-57,43,9,22,-31,-28,53,-30,42,-7,15,-101,33,-30,-7,-29,-47,-51,-33,4,-34,9,65,-22,-6,8,31,-67,21,-40,-6,18,-47,57,-33,57,57,18,-21,35,33,51,27,-43,-22,29,-2,2,-19,-49,18,-12,49,44,-24,2,48,57,-9,-20,29,-44,-23,29,-38,-14,-4,-20,6,19,28,43,-45,-38,9,60,-11,83,2,-61,53,-34,-46,27,34,-7,-6,-22,-32,9,20,93,30,67,-42,16,-45,-8,0,19,49,35,-16,51,-1,-34,-29,13,46,-26,-11,-65,-75,10,-21,44,-39,-15,31,-26,38,-52,51,-8,27,-24,-9,45,-29,18,26,-35,3,-12,-14,-65,-4,6,12,-29,14,20,26,-43,4,-24,7,-18,-99,20,2,18,13,-43,13,38,35,0,33,36,14,-68,51,-2,-3,-24,85,7,33,7,-31,52,9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.28","t":"Example: “In the brief amount of time we have spent together, it appears that we have identified some thoughts and behaviors that are likely contributing to your current difficulties. In particular, your view of yourself and your future are quite negative; and you have stopped doing many things that used to bring you pleasure. My recommendation would be to further explore your thoughts and see if we can find a more balanced view of your current difficulties. I would also like to talk with you more about re-engaging in activities you used to find pleasurable. What do you think about these targets for therapy?\" 3. CASE CONCEPTUALIZATION STEP 3: Identifying Possible Treatment Obstacles","e":[56,26,-121,-50,61,56,51,-31,47,-15,-11,14,35,70,-31,-15,18,-75,-36,61,-49,-22,-30,-15,-26,51,-7,3,-62,25,10,-20,17,-24,-70,-32,70,55,-3,-26,64,3,9,-114,36,-49,88,-23,42,-21,69,-25,24,-37,87,31,12,18,15,-36,73,48,-33,61,46,-59,-60,58,-40,-46,46,6,-3,24,-79,16,5,0,10,-1,33,-37,65,-57,54,20,-4,26,-28,60,-2,35,15,1,-82,-2,-37,22,-45,-10,-59,-30,28,-19,26,64,3,-4,-1,21,-66,19,-25,-11,20,-20,52,-30,23,66,-21,42,-7,52,34,18,-67,-21,38,-15,-2,-36,-8,41,14,40,40,-17,-16,26,94,-9,0,24,-18,-44,1,-52,-49,7,-6,32,46,13,41,-78,-40,42,37,-15,56,19,-35,56,-25,6,25,43,10,19,-30,-67,8,-6,74,30,93,-53,-39,-24,18,-40,29,19,17,-42,54,7,-35,-25,7,29,-37,-46,-79,-65,41,-25,40,-48,-4,28,-42,68,-43,29,-17,3,-24,4,61,-31,1,5,-54,19,8,0,-33,29,-4,-12,-22,-31,48,15,-46,-17,-36,29,-31,-103,38,-4,28,-1,-42,20,5,72,8,36,24,24,-48,19,15,-12,6,69,12,39,26,11,40,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.28","t":"It is not uncommon for patients to simply agree with recommendations from their provider. However, it is important to identify potential obstacles to treatment early on to avoid setbacks or treatment failures. Asking for frequent feedback from the patient helps to reduce over-compliance and serves to include the patient in a collaborative and active treatment approach. As part of this collaborative venture, it is important to ask patients whether they see any potential obstacles to treatment. Barriers might include logistic difficulties (financial, travel), personal beliefs (concerns about stigma, effectiveness of treatment) or interpersonal issues (family not supportive of therapy). 28","e":[29,55,-153,-42,62,20,57,9,41,10,20,3,42,52,-10,-6,24,-73,-20,51,-47,-13,-54,-25,-16,52,30,-24,-51,31,47,-7,29,-63,-48,-52,67,23,8,-9,46,19,16,-84,43,-25,78,15,25,-32,38,-81,-34,10,75,14,-2,49,24,-62,112,29,-54,57,65,-25,-26,50,-6,13,34,8,52,17,-29,35,-3,-6,-11,13,46,-40,63,-51,48,39,5,39,-23,73,0,4,11,15,-101,9,-39,-37,-42,-33,-43,6,0,13,17,11,43,46,14,17,-57,34,-19,-62,18,-16,85,-42,17,33,-33,-15,18,48,8,39,-13,-24,49,-12,-10,-18,-42,6,11,43,2,-25,15,8,64,32,26,13,14,-39,0,-23,-17,-4,19,27,12,37,14,-78,-19,11,34,28,63,23,-54,52,-1,-44,27,41,21,45,-35,-47,42,6,100,30,83,-26,2,-47,24,-65,37,27,-17,11,38,-47,-49,-63,32,19,-21,-25,-47,-16,65,-24,43,-65,-42,39,-32,45,-44,81,-32,-13,-41,-45,55,-57,-22,37,-41,-18,-5,-3,-29,72,37,-36,1,-33,11,-25,-76,-7,-18,11,-8,-103,41,3,22,-13,-30,11,-3,20,4,20,41,12,-68,3,12,-31,-18,29,1,36,1,9,40,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.29","t":"Tips for Using Case Conceptualization in Brief Therapy • Case conceptualization in brief CBT is much the same as with longer forms of treatment, with the following exceptions: » Brief therapy leaves little room for delays in case formulation. » The time constraints of brief therapy must be considered in all treatment/ goal- setting endeavors. Treatment goals should be reasonable, measurable and as simple as possible. » Because of limited time, the focus of treatment in brief CBT also generally limits the depth of cognitive interventions. For example, it is quite frequent to address automatic thoughts and intermediate beliefs as foci of treatment, while addressing core beliefs is often difficult. If core beliefs are addressed, this usually occurs indirectly through more surface-level intervention techniques or at a time when the patient is particularly ready for such work.","e":[68,44,-109,-67,27,9,46,-24,3,-48,17,-26,57,17,-28,-34,-8,-48,-8,51,-46,5,-25,-39,-17,37,7,42,-69,22,49,5,21,-32,-38,-97,90,2,-21,-31,68,2,42,-62,29,-5,75,16,-12,-40,40,-51,35,-58,104,39,-13,42,-1,-26,93,62,-58,92,22,-35,-44,43,-14,-33,40,7,14,47,-42,23,-47,-9,4,43,61,-37,51,-57,37,20,-46,-3,-10,68,-12,12,17,38,-54,35,-20,-7,-14,0,-73,-3,4,9,7,42,-23,5,10,-9,-66,10,-58,0,-28,18,71,-17,43,21,-31,-15,43,23,25,40,-85,-32,44,-65,-14,-37,-43,3,6,47,26,-10,0,34,35,4,12,11,-15,-12,-12,-38,-32,15,-10,13,29,36,56,8,-9,32,44,8,19,10,-42,45,-25,-1,13,19,-5,4,-50,-46,-4,29,90,60,82,-36,-21,-44,-11,-28,-8,48,16,-13,39,-3,-36,-24,15,-2,-66,13,-109,-53,43,0,14,-36,-13,24,-42,53,-23,78,-18,4,-22,-21,74,-15,-38,28,-41,26,-22,1,-63,15,8,2,24,-25,17,29,-44,28,-12,33,-30,-60,14,-4,13,2,-1,-1,4,60,4,47,41,17,-63,-16,-4,-38,-21,63,-28,40,32,-35,57,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.29","t":"Homework Assignment Examples 1. Think about our agreed-upon treatment plan, and consider any adjustments it might need. 2. Make a list of any obstacles to therapy that may arise. SUPPLEMENTAL READINGS Beck, J.S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press; Chapter 3, 4, 5 Cormier, L. S., Nurius, P., & Osborn, C. J. (2017). Interviewing and change strategies for helpers. Boston, MA: Cengage Learning; Chapter 6. Persons, J.B. & Tompkins, M.A. Cognitive-behavioral case formulation. In Ells T. (Ed.). Handbook of psychotherapy and case formulation. New York: Guilford Press, pp. 314-339. 29","e":[62,2,-116,-29,39,-7,37,-7,31,37,-5,-16,64,77,-18,-49,2,-57,9,29,2,-43,-36,13,6,35,-35,2,-71,-7,5,23,-21,-52,-81,-52,108,21,-53,4,25,-5,8,-79,48,-38,106,-3,48,26,18,-34,18,-11,93,29,20,19,41,-35,83,46,-71,56,29,-35,-33,90,-52,2,66,7,39,6,-50,-44,-13,-22,5,34,49,-10,72,-39,55,30,-22,12,-28,77,-23,32,2,30,-45,17,-35,-20,-51,-51,-48,-3,23,-8,15,39,16,-7,-33,19,-77,42,-5,1,12,1,66,-30,54,45,-13,-19,-13,23,21,39,-85,-22,20,-23,-2,-24,-21,31,-6,44,-26,-9,11,-10,75,1,11,43,4,-6,0,-14,-46,14,2,21,46,2,33,-26,-21,0,23,42,60,4,-65,86,-13,-17,18,50,33,33,-34,-60,14,25,67,34,83,-12,20,2,26,-28,22,-1,-1,-39,19,9,-58,-3,-14,17,-22,-22,-86,-86,38,-33,41,-28,-3,35,-42,38,-55,73,-27,-17,-16,-27,45,-11,18,25,-30,14,-15,-12,-46,11,-3,-24,24,-2,32,25,-21,31,2,56,-28,-87,41,1,44,23,-10,39,29,85,1,45,46,8,-68,31,22,-39,-11,55,14,20,19,24,17,-18]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.30","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 4 Example Case Conceptualization Early Experiences 1. Grandmother experiences psychosis. 2. Father has history of dependence. 3. Sister has panic attacks. PAST CURRENT Environmental Stressors Core Beliefs 1. New Job 1. I am vulnerable 2. End of Relationship Situation • Stopped at a red light while driving in a car • Sitting alone by himself Automatic Thoughts • I am going to lose my mind. Behavior Feelings/Emotions • Listens to music • Anxiety • Avoidance (driving with passengers) • Panic • Mental Distraction (staying busy) Physical Symptoms • Depersonalization/Derealization • Tingling sensations • Hyperventilation 30","e":[11,-3,-171,-61,78,34,47,17,17,-31,-21,-19,13,61,-19,-4,1,-21,-41,21,-56,-39,-11,0,6,53,3,5,-29,-17,32,-19,-12,-61,-77,-83,35,50,1,-1,39,-33,44,-80,-9,-21,97,2,3,24,30,-32,41,-4,118,21,18,49,27,-30,84,73,-83,32,28,-45,-67,77,-14,-29,62,-33,-18,30,-12,20,-33,6,30,41,36,-18,81,-32,66,14,-15,2,3,36,16,29,-34,30,-67,25,-29,3,-3,-30,-44,-39,34,-44,16,11,-20,-14,-15,11,-28,56,-28,-22,8,-54,43,-56,30,18,-19,20,-16,59,45,24,-48,-23,-22,-12,8,-18,-34,8,17,39,41,0,1,40,64,11,-11,7,-26,-46,27,-63,-34,-22,13,38,19,63,29,-45,-42,-9,49,2,64,23,-26,68,-22,-49,20,59,32,24,-36,-49,-9,0,49,29,89,-70,19,-31,31,-25,11,24,19,-28,26,-3,-48,-25,-28,43,-43,-23,-75,-115,-6,-42,31,-60,4,10,7,35,-53,54,-28,-7,-17,-15,49,-37,19,25,-35,5,-25,-12,-43,26,28,-6,12,9,3,18,-17,-6,2,22,-27,-96,64,2,-2,30,-41,5,18,23,19,45,15,17,-46,21,-25,-1,2,40,-10,23,13,5,31,-22]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.32","t":"Culture defines individuals’ specific “ways of being” that are shaped by the intersection of their identity and their lived experiences. Culture influences our behaviors and impacts our lifestyle choices, which is why it is an important factor in psychotherapy and therapeutic relationships. Not only should providers become aware of patients’ unique cultures, but they should also consider their own culture to form genuine and effective therapeutic relationships.","e":[18,65,-139,-32,56,48,75,18,46,-23,-21,2,50,16,2,-75,-27,-7,-14,97,-134,-23,1,8,-20,25,10,2,-13,-19,-6,17,-8,3,-54,-40,34,43,39,24,-5,56,2,-51,62,-27,-19,-47,20,29,-1,-75,-10,-26,99,4,16,63,-4,-51,56,70,-114,54,20,-23,-76,31,-49,-62,43,-49,56,13,-30,15,22,3,38,9,43,-16,33,-24,0,27,27,-9,-19,72,7,-36,-12,48,-109,-16,-16,-18,-21,6,-32,-13,2,-16,28,8,-2,44,-46,24,-37,47,-21,-3,-5,-39,34,-56,36,18,-5,-6,-15,59,-27,28,-31,-49,8,8,-1,-48,-9,5,-3,54,29,-44,-8,48,72,12,7,11,-15,-9,26,-43,-11,5,35,53,-28,25,0,-33,-18,33,83,-21,42,37,9,23,-32,-57,-6,28,-21,20,-31,1,0,-8,87,18,88,-26,40,-39,-16,-44,20,-12,-10,-3,50,-36,-57,-36,17,-2,0,-31,-64,-55,-17,-3,33,-37,-63,10,-28,12,-19,61,-22,23,-30,-33,50,-35,-12,54,-28,10,-39,-25,-49,22,33,31,4,11,-14,-16,-39,-8,-7,1,-29,-91,88,41,21,18,-9,-12,9,18,-7,0,17,27,-83,66,-24,-41,-23,15,42,37,26,0,7,-32]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.32","t":"Cultural recognition and appreciation begin with an understanding of an individual’s race, age, and gender; however, culture goes much deeper. Although two individuals may have similar physical identifiers of culture, past experiences and unseen forms of culture can create differences. For example, two Mexican American men may look the same and even be in the same age group. However, they may have grown up with different religions, in different socioeconomic groups, one with a single father and the other with two parents and his grandmother living in the home. Table 5.1 is an inexhaustive list of cultural identifiers that influence an individual’s culture. 32","e":[8,38,-184,-9,26,85,48,8,6,-9,-32,21,66,57,54,-66,-3,-35,22,98,-97,41,-47,2,-4,2,-28,-6,-38,-26,-7,24,5,-3,-8,-66,16,5,33,6,41,32,-14,-55,72,-13,19,-13,66,-10,26,-53,-10,12,52,22,-14,25,34,-43,72,86,-54,42,37,6,-27,68,-39,-43,34,-8,21,69,-48,17,-18,15,21,39,36,-2,48,-11,13,19,-13,14,-53,92,22,-16,25,39,-73,28,-12,17,-41,-20,-22,-18,11,-20,62,34,30,62,-33,10,-75,-13,-46,4,-25,-38,42,-70,36,28,-12,-7,-9,65,-17,8,-23,-21,6,-45,-14,-30,35,-24,-1,49,6,0,0,28,70,13,-5,-31,-2,-24,15,-68,-5,7,56,54,14,24,8,-17,-40,-7,54,21,34,-17,22,84,-26,-64,-5,-7,19,16,-24,-2,-19,2,60,-24,63,-72,12,-48,-24,-60,27,22,6,-66,48,-3,-74,-54,34,15,-14,-27,-49,-43,5,24,-29,-37,-58,-3,-26,33,-40,72,-43,8,-50,-31,40,-11,-27,19,-27,44,-23,-7,-27,18,2,-7,19,-6,2,-5,-51,4,-21,35,-18,-100,114,8,-1,17,-3,21,12,-16,-33,-3,-10,28,-51,23,-4,-17,5,53,16,39,6,14,18,-69]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.33","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 5 Table 5.1. Types of Cultural Identifiers Cultural Definition Select Examples Identifier Human constructed classifications of major White, Black, Asian, Native Hawaiian/ divisions of people based on biology and Race physical characteristics, often skin color, Pacific Islander, American Indian/ Alaska Native facial features, and hair type Classification of major divisions of people African American, Italian American, Ethnicity based on cultural traditions and nationality, Latinx/Hispanic, Native American, often a combination of ancestry and customs Mexican American","e":[3,47,-154,-52,37,38,39,-4,-17,-16,-26,-4,58,33,20,-114,5,-21,20,72,-86,41,-14,5,15,26,28,0,-40,-76,-46,-17,7,12,-31,-60,23,11,32,36,19,32,9,-71,0,11,52,-15,15,44,50,-32,0,-23,82,-4,-20,43,-8,-27,28,90,-98,28,18,-12,-34,97,-43,-44,44,-45,75,53,-50,-19,-24,-8,20,59,15,6,80,0,0,50,-31,20,-19,58,-11,-2,-3,46,-77,25,-30,21,-43,-29,-14,-52,21,-62,40,7,1,29,-56,10,-19,55,-22,30,-16,-64,-5,-50,32,23,-10,-11,-2,47,-29,3,-32,-30,-18,-41,19,-3,3,-18,-12,42,16,-13,0,25,66,5,-30,-16,23,-24,54,-59,17,42,52,42,-12,-7,2,9,-3,10,17,-5,26,8,-11,38,-17,-91,-4,24,28,42,-9,12,-39,6,75,0,68,-58,12,-15,-9,-40,34,33,9,-61,58,-18,-24,-9,-3,22,11,-48,-80,-61,8,-2,-13,-51,-28,-18,-50,44,-39,28,-14,-10,-37,15,56,-3,16,28,-24,10,-52,-21,-10,-41,27,12,10,-9,35,12,-44,-19,-11,15,7,-101,85,-19,39,32,3,34,29,9,-28,3,25,25,-74,28,-42,-27,3,70,-27,-2,7,37,-7,-76]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.33","t":"Human constructed classifications of people Man, Woman, Transgender, Non- based on social constructs related to Gender biological sex, masculinity, and femininity; can binary or Gender Non-Conforming, Genderqueer/Gender fluid differ from gender assigned at birth Heterosexual/Straight, Homosexual: Sexual Describes romantic or sexual attraction Gay & Lesbian, Bisexual, Queer, Orientation towards others Asexual, Pansexual Socio- Classification of social standing measured by Upper Class, Upper-Middle Class, economic level of education, income, and occupation Middle Class, Working Class, Lower Status that results in access to resources Class","e":[3,37,-141,-43,42,80,6,-42,-57,0,-18,13,58,28,-16,-54,-2,1,6,52,-68,38,-9,-1,4,53,3,-44,3,-40,-38,63,20,-32,-45,-66,-16,18,40,3,9,7,-2,-104,16,-8,39,-3,66,-4,49,-12,-7,6,94,-14,-8,29,25,-21,25,116,-76,47,42,0,-25,70,-30,-28,31,-28,38,46,-39,19,-22,13,13,33,71,17,88,23,37,32,-53,-14,-15,82,23,37,35,36,-92,41,-51,-13,-34,-42,-42,-29,15,10,41,24,-10,49,-14,-10,-34,62,-40,-11,-12,-78,36,-47,38,35,28,2,18,83,-49,41,-50,16,-23,-51,-5,-17,-4,-5,-22,116,15,-39,-12,56,75,41,-2,-28,-5,-4,18,-27,-44,58,40,68,10,6,10,-39,0,29,34,9,40,20,-35,37,-41,-74,-16,7,-5,39,-33,-23,-19,28,35,-13,64,-80,28,9,-1,-10,53,6,-29,-75,43,-24,-21,-24,10,21,-2,-50,-65,-73,26,10,-4,-58,-50,-6,-53,23,-39,51,-16,-12,-2,14,52,-17,32,-16,-26,-11,-27,-19,-30,-8,-4,-9,-14,5,54,9,-48,3,10,31,-6,-79,37,-15,10,16,0,39,11,-20,-25,24,-1,-12,-28,-15,12,-13,23,57,-7,6,21,47,13,-23]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.33","t":"Belief in a personal god or gods, associated Christianity, Islam, Judaism, Hinduism, Religion with a system of faith and worship Buddhism, Nonreligiousness Blindness, Deafness, Autism Spectrum A physical or mental condition that limits a Disorders, Dementia, Traumatic Brain Disability person’s movements, senses, or activities, Injury, Physical Impairments, Chronic both visible and invisible Pain, Mental Illness English, Hindi, Arabic, Mandarin, Distinct methods of communication used by Language groups or communities of people Spanish, Zulu, American Sign Language, Braille","e":[25,55,-144,-71,45,31,14,4,30,-45,40,32,40,42,0,-45,-23,-13,-5,97,-74,30,-28,-15,35,36,-6,1,-19,-34,-14,-13,31,-13,-21,-50,15,45,76,3,2,4,-30,-94,19,-21,32,4,57,-10,27,-91,44,-2,74,35,1,38,-6,-21,114,80,-62,-2,54,-1,-49,55,-11,-43,75,12,38,48,-37,-14,-20,7,19,32,54,-14,46,-23,61,50,-40,5,-5,60,5,13,-19,23,-83,23,-26,0,-7,-25,-11,-43,43,5,83,47,-14,12,-60,33,-77,-1,-21,-30,-9,-41,90,-33,15,6,3,30,0,96,-26,34,-17,-22,20,-21,3,-8,11,1,8,67,55,-33,-26,42,62,-11,-7,-37,44,-64,26,-30,-18,-3,70,68,-12,7,42,-39,-38,47,25,0,27,66,-54,72,-13,-32,2,36,23,44,-34,-25,-9,48,65,17,72,-21,-22,-35,0,-34,50,44,-28,-39,57,-16,-66,-14,-12,15,6,-20,-57,-75,0,30,45,-45,-20,20,-51,35,0,59,-28,9,0,-4,53,-38,14,16,-16,-20,-20,-31,-30,15,45,-35,-16,10,44,27,-70,16,25,17,5,-80,72,-3,19,22,-13,2,77,23,-62,23,-10,-24,-31,25,4,-35,-10,30,-21,36,-23,1,33,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.34","t":"DEVELOPMENT OF CULTURAL IDENTITY Many models explain how culture develops over time. These models explain how individuals interpret their identity through interactions with others, and their basis is often minority or majority status. For example, an integrated model of cultural/racial development from Hoffman and Hoffman (2006) is included, which depicts various stages of development and how these stages interact with others’ development (found in Table 5.2). You and your patient may be at different stages of the model, which may impact the conceptualization of your respective cultures, how culture influences the therapeutic interaction, and how culture influences the interpretation of stressors and symptoms. The Hoffman and Hoffman model emphasizes the importance of recognizing minority and majority status when considering culture. Use this model to guide conceptualization of culture and, more importantly, to consider cultural stages as part of the overall therapeutic process. The Hoffman and Hoffman model provides one example, but you may wish to use other cultural models in your practice, such as: • Black American Racial Identity by William Cross (1991) • White Racial Identity Model by Janet Helms (1990) • Stages of Acculturation by John W. Berry (2005) • Filipino American Racial Identity Model by Kevin Nadal (2011)","e":[0,27,-163,-15,50,63,63,-2,19,21,-23,-13,81,42,26,-69,-13,-28,-16,62,-91,15,-24,25,26,58,-25,-6,-34,-27,10,-3,4,-7,-44,-30,37,41,23,16,74,42,-4,-71,28,9,-4,-22,33,-1,64,-10,-24,-25,47,27,-3,36,12,-37,78,108,-102,40,29,-21,-3,48,-31,-40,25,5,46,26,-55,16,2,-33,23,10,40,46,59,-23,24,15,15,18,-30,78,38,1,-7,40,-51,32,-48,14,-56,-38,-46,-53,-2,-69,16,19,9,26,-8,37,-83,29,-35,9,-26,-22,28,-55,32,16,-23,0,2,32,-2,21,-38,-51,-7,-7,-11,-20,-22,-7,4,29,6,8,2,18,82,11,-22,-18,14,12,28,-33,-20,30,25,57,-2,29,-31,-13,-40,15,28,1,55,-19,15,48,-17,-90,-2,-1,9,-3,-8,-17,-3,-12,79,-11,48,-61,30,-30,5,-74,36,25,-6,-56,50,-14,-57,-64,23,41,-28,-48,-53,-54,63,-25,28,-23,-53,20,-24,40,-52,71,-20,-26,-5,-34,45,-5,4,46,-17,-1,-13,-1,-12,-4,-11,7,-26,20,30,-21,-59,-5,-44,21,-26,-73,70,-19,34,18,2,-1,16,-6,-6,16,16,14,-69,35,19,-26,-22,81,11,28,29,-10,6,-58]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.35","t":"Minority Group Majority Group Dissonance Acceptance The minority group realizes that its race or The majority group can diminish comments gender may preclude it from the benefits or actions that indicate racism or sexism is of the majority group. It begins to see that alive. It feels the minority should be more like racism and sexism may be impacting it. it or dismiss the effects of minority status. Stage III. Immersion Resistance Due to the effects of racism and sexism, Members of majority group may feel that members of minority groups begin to racism and sexism do not exist and can feel negative emotions towards the express beliefs about “reverse racism” or majority group. “reverse sexism.”","e":[1,50,-168,-58,77,72,16,39,16,19,-8,51,41,97,18,-28,17,-41,13,85,-75,47,-50,-52,36,65,7,-15,-23,-10,-8,9,22,-13,-56,-10,15,9,32,-6,12,11,27,-84,49,-9,37,19,53,-48,25,-42,1,-8,35,14,-25,9,-5,-23,19,79,-111,44,24,-16,-34,25,20,-54,36,18,14,20,-43,12,-21,8,7,5,35,18,53,-6,64,20,11,-15,-26,119,31,-9,25,7,-72,15,-11,12,-54,-37,-21,-48,10,-23,13,29,5,40,26,0,-64,21,-25,-73,0,-39,52,-54,8,19,4,8,-39,91,3,6,-45,-4,38,-21,-15,-8,-16,15,-6,32,15,39,-5,22,35,37,25,-23,-13,-63,25,-40,-64,40,35,20,22,8,22,-25,-11,17,47,35,45,1,-36,41,-33,-59,-12,-16,2,19,-21,18,-32,6,41,2,49,-87,-21,-16,15,-24,66,20,1,-79,62,28,-44,-37,-6,47,-2,-39,-51,-89,51,14,17,-56,-36,-41,-74,3,-8,46,-33,8,-26,-20,67,-13,18,9,12,9,-12,-1,-13,61,18,2,-48,33,55,-5,-65,-41,-29,29,-22,-109,48,-22,15,2,8,1,37,-18,-18,49,32,25,-54,14,25,-36,-5,52,-2,14,24,2,28,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.35","t":"Stage IV. Emersion Retreat Anger towards the majority group causes When the majority group’s assumptions minorities to associate only with the about minorities are proven false, it may group they belong to, avoiding contact feel guilt and shame about how difficult life with the majority. is for minorities. It may also feel frustration towards other members of its own group who do not agree.","e":[27,25,-197,-22,76,58,31,25,29,23,-32,53,52,81,28,5,35,-16,-26,68,-84,19,-35,-25,60,83,15,-34,-34,10,11,24,25,-38,-75,-19,30,6,13,-9,56,6,0,-57,12,0,27,-17,62,-49,1,-53,-18,-43,10,35,-32,14,35,-8,26,22,-75,66,30,-29,-67,15,-11,-58,30,20,-9,19,-40,22,-2,-28,4,14,61,37,51,-20,66,19,27,3,-34,61,30,-9,27,27,-94,25,0,33,-57,-40,-23,-29,-22,-37,18,18,12,34,25,32,-54,20,-46,-33,38,7,39,-60,16,20,15,-17,-25,48,9,18,-25,-21,19,-5,-47,-57,-35,13,24,-2,-44,6,-17,29,82,39,-4,-47,-15,-57,33,-52,-59,40,10,-4,15,11,35,-17,-46,34,31,14,43,-12,-4,28,-42,-38,-8,26,10,11,-37,-15,-3,-19,38,23,55,-64,38,-42,16,-35,79,1,2,-35,26,9,-47,-45,3,40,-26,-28,-54,-68,24,-24,-25,-26,-1,-27,-60,-7,-16,23,-34,-9,-12,-32,55,9,5,16,-7,-23,32,-36,25,50,-26,20,-28,-12,21,23,-37,4,-34,-32,-29,-89,71,16,22,4,14,13,15,-8,-4,25,20,10,-49,36,25,-20,14,35,-8,-26,47,2,21,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.35","t":"Stage V. Internalization Emergence Minority groups realize that there are Members of the majority start to negative qualities about their own people understand their privilege and how it and that not all members of the majority continues to benefit them. group are the enemy. They begin to see that racism and sexism can be fought against. Stage VI. Integrative Awareness (All) Both majority and minority group members positively identify their own cultural/racial identity and acknowledge other aspects of both their own and others’ identities. 35","e":[6,11,-184,-12,67,53,12,9,8,29,-6,52,35,76,44,-50,18,-53,16,66,-72,34,-12,-26,54,70,1,-29,-18,-16,27,3,28,-27,-29,-11,29,-19,-2,-7,45,16,7,-94,9,16,7,-18,57,-23,36,-23,-6,-26,56,47,-39,0,30,-30,49,55,-92,46,16,-34,-44,61,-30,-38,9,7,2,11,-59,29,-8,-14,26,8,61,7,47,-51,56,11,14,-15,-50,101,57,28,5,18,-81,5,-3,61,-60,-35,-8,-31,10,-66,32,24,17,-2,11,30,-79,2,-66,-26,-7,-5,69,-73,16,15,-28,21,-1,47,20,32,-40,-53,10,-35,-1,-44,-44,-6,-1,22,0,8,-10,33,51,45,-13,-22,10,-49,24,-67,-70,24,21,45,16,-14,1,-30,-11,11,49,10,54,-9,-26,46,-45,-48,14,-5,24,25,-25,5,-28,12,76,-11,54,-78,7,-3,14,-44,49,53,19,-83,55,39,-41,-44,-1,41,-13,-34,-57,-53,59,-17,8,-59,-28,-17,-78,33,-37,59,-30,-22,-33,6,59,-18,4,-1,-20,-3,7,-1,7,36,9,21,-38,3,11,16,-55,-17,-30,29,-7,-109,66,-15,-9,13,19,21,8,-6,-11,18,47,24,-56,20,23,-40,-31,58,-2,10,36,-3,-4,-45]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.36","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 5 CULTURE AND PSYCHOTHERAPY The goal of culturally competent psychotherapy is to ensure that patients’ experiences and culture are considered when providing care. Optimal care is achieved when both the provider and patient are collaborative in the treatment. Appropriate consideration of patients’ backgrounds and experiences results in patients’ feeling heard and understood, creating a safe space for patients to express themselves. Acknowledging your patient’s culture provides an opportunity to fully understand the patient and conveys a level of openness that encourages discussion and exploration of other factors important in the psychotherapy process.","e":[19,35,-159,-33,63,38,65,38,5,4,-26,-1,19,0,1,-34,-23,-25,-43,57,-102,-29,31,-24,20,65,15,32,-52,-52,14,-15,-19,-30,-24,-67,20,25,-31,4,25,25,29,-78,55,1,22,-28,-19,11,3,-75,-13,-8,131,16,-24,30,-16,-42,77,60,-95,44,7,-29,-55,47,-69,-7,17,-52,50,6,-58,24,-24,-24,22,16,46,-24,62,-35,-1,5,12,-32,-20,59,16,-22,-22,35,-89,14,-36,-8,0,-10,-23,-8,42,-15,0,31,14,47,-54,13,-17,52,-40,-2,-2,-52,37,-36,49,43,-25,-16,0,62,10,45,-33,-41,-5,29,22,-37,-37,-7,-35,41,38,-31,24,29,39,5,5,2,-35,-24,27,-37,-22,15,-22,57,20,29,15,-54,-19,-12,66,-17,52,18,-7,30,-12,-44,1,-5,0,3,-35,-11,9,-8,82,8,54,-25,32,-42,-30,-27,40,29,-29,0,40,-34,-36,-10,17,57,-24,-17,-63,-68,-21,-31,29,-41,-53,31,-29,18,-59,75,-40,11,-27,-29,51,-32,23,38,-30,-4,-23,-33,-54,-6,23,30,28,27,-6,8,-56,-6,-2,31,-17,-98,59,28,2,48,-15,27,15,43,6,17,27,53,-73,55,-35,-15,-22,52,19,13,13,1,24,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.36","t":"Traditional CBT and Western models of psychotherapy typically have not considered or accounted for ethnic and cultural values and beliefs of patients. Historically, minority patients have high dropout rates, due to various challenges to care, such as: 1. Psychotherapy can feel “foreign” to non-Western or underrepresented groups because emotional expression and discussing personal experiences may conflict with certain values. For example, some groups view expressing emotions as weak or unstable. Also, some may view discussing themselves as rude or insensitive to others. 2. Inflexible use of manualized treatments can feel impersonal and too formal for patients, limiting the possibility for patients to feel like a collaborative partner in their care. Manualized treatments are developed to be efficacious and are typically not created to be culturally sensitive. 3. When mismatch between the provider and patient’s gender, race, age, etc. are not appropriately acknowledged, it can limit patients’ comfort in expressing themselves.","e":[28,57,-161,-37,67,68,56,25,22,15,-21,11,50,17,6,-49,14,-25,-41,72,-110,7,-7,-14,-10,59,-16,29,-22,-8,42,-11,6,-17,-40,-12,61,15,10,38,75,19,3,-100,29,-10,77,45,20,9,24,-77,8,-27,78,-13,-63,80,-7,-41,62,72,-75,66,31,-42,-34,33,-42,-26,17,-7,46,55,-77,-5,-53,-56,16,31,27,39,9,-33,47,22,34,7,-37,88,16,-56,9,16,-74,17,-37,-33,-59,-46,-38,-13,16,-41,2,20,0,34,-40,5,-34,44,-24,-20,-22,-13,25,-51,11,23,19,15,-5,26,28,89,-34,-37,14,-18,-16,-20,-32,6,-28,48,30,12,-14,11,40,9,25,10,-3,1,15,-25,-48,18,4,35,27,31,8,-49,0,18,42,-26,62,7,-17,21,1,-79,-23,16,16,-9,-25,-27,-5,-7,79,33,54,-50,13,-55,-9,-17,31,8,15,-4,9,-25,-27,-84,11,40,-22,-16,-83,-61,13,-8,24,-32,-33,36,-11,1,-44,51,-58,20,-25,-60,40,-25,1,48,-49,-10,6,-27,-49,36,7,6,3,-16,34,-6,-79,-3,-31,19,0,-79,73,12,-3,9,-5,-8,13,11,14,12,18,38,-74,-19,-4,-21,-1,6,-32,24,19,10,18,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.36","t":"When? (Indications/Contraindications) You should be aware of your patients’ and your own cultural identity. Given the importance of the therapeutic relationship in psychotherapy, it is critical to not only communicate and model nonspecific factors (e.g., warmth, genuineness) but also consider culture and factors of diversity as a process that occurs initially and throughout the therapy process.","e":[50,49,-165,-40,47,39,52,10,31,22,-41,29,31,25,-8,-56,6,-46,-19,53,-85,-7,-12,-6,4,59,0,2,-32,-35,37,29,8,-12,-43,-59,36,54,0,35,50,36,4,-84,36,-4,17,0,19,16,39,-42,-1,-4,94,15,27,58,9,-61,70,77,-98,40,52,-39,-57,37,-44,-30,23,-34,49,52,-30,-2,4,-32,5,27,52,10,80,-44,6,31,25,-21,-5,80,28,-11,-11,45,-75,24,-45,-9,-54,-27,-22,14,-7,-42,19,-10,41,20,-43,-23,-42,65,-27,-34,6,-35,41,-87,29,37,-40,10,6,67,-2,30,-10,-31,-21,-29,-9,-37,-5,23,-16,54,40,-33,-6,16,53,52,-7,-6,-26,-46,14,-54,-36,24,29,51,-32,22,0,-63,-36,-14,72,-27,57,13,2,52,-26,-61,11,55,0,5,-32,10,-7,-31,80,27,59,-46,29,-18,-3,-42,22,-22,-22,-15,32,-10,-74,-10,7,28,-36,-8,-81,-65,-4,-13,13,-12,-66,30,-40,31,-60,77,-36,0,-1,-57,42,-44,-7,25,-40,-28,-25,-45,-58,8,31,36,10,-27,-16,5,-57,8,-5,20,-7,-84,80,10,12,21,1,-2,36,50,-2,23,17,47,-76,32,-7,-53,-25,41,-17,25,16,32,4,-35]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.36","t":"IMPACT OF CULTURE ON MENTAL HEALTH Look to minimize any negative outcomes associated with the intersection of culture and mental health. The Transactional Model of Stress and Coping (Figure 5.1.) describes how patients react or appraise stressful situations or triggering events and, subsequently, how they seek to cope with those stressors, based on their initial appraisal. Patients appraise situations through their own cultural lens, based on their own past experiences of coping and the experiences of others close to them. In addition, stressors and triggering events can be cultural in nature. For example, experiencing discrimination at work or receiving a life-altering medical diagnosis or physical/mental disability impacts both our culture and our mental health. If you are aware and accepting of cultural differences when assessing and treating mental health issues, you will be better informed and in tune with your patients’ needs.","e":[58,54,-176,-23,66,17,54,21,52,-12,-23,19,56,44,57,-62,-21,-10,-33,68,-86,-4,-17,-9,-12,65,3,18,-10,26,10,0,-15,-44,-54,-18,13,57,20,11,25,25,15,-92,38,-1,17,-12,42,1,-11,-82,-18,-8,109,11,-26,57,16,-34,59,60,-71,38,46,-43,-39,48,-12,4,66,-1,34,-12,-64,20,6,-14,9,11,25,-9,53,-56,38,8,6,0,-18,94,37,-18,-10,65,-92,19,-15,-22,-1,-46,-57,-23,24,-45,17,11,-27,18,-39,22,-55,43,-50,-7,4,-27,19,-16,-2,4,-19,11,-20,71,-11,20,-41,-15,44,-11,4,-35,-17,-6,-16,52,-17,-15,10,34,71,-7,-12,22,-22,-24,28,-48,-4,-32,12,68,-15,43,15,-17,-40,5,43,-2,54,-24,7,67,-7,-57,9,40,21,21,-46,-41,-2,-24,76,-3,51,-47,29,-48,-18,-63,49,11,1,-36,64,0,-42,-40,23,29,-19,-15,-66,-74,-6,1,17,-24,-44,44,-37,-17,-33,92,-28,-28,-35,-61,47,4,-23,33,-15,19,-11,-18,-30,-19,14,0,8,-22,43,-4,-43,-12,-20,-12,-14,-63,94,-14,15,23,15,8,10,20,-9,17,31,32,-51,50,-19,-17,-20,37,17,12,7,-2,34,-75]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.37","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 5 Figure 5.1: The Transactional Model of Stress and Coping (Folkman, Lazarus, Gruen, & DeLongis, 1986) Stimuli Perception Filter stressor selection Environment positive Primary Appraisal interpretation of the stressor irrelevant dangerous challenge threat harm/loss Secondary Appraisal analysis of the available resources sufficient resources insufficient resources Stress Problem Focused Coping Emotion Focused overcoming change relation to change situation itself of stress the situation Reappraisal pacing and learning","e":[11,29,-172,-66,71,-19,48,-8,12,18,-51,6,46,28,16,-19,24,-21,-24,10,-55,-63,17,-12,9,58,0,-9,-30,-17,37,-15,8,-59,-68,-57,41,76,-15,-4,-8,-19,24,-68,-12,-16,59,14,4,24,48,-21,-1,4,121,11,3,12,21,-24,90,52,-86,58,51,-51,-28,57,-15,-11,86,-19,7,12,5,-9,-39,-23,18,19,59,18,100,-21,49,-2,-23,1,-18,39,15,49,15,43,-95,48,-24,-15,-1,-69,-21,-12,37,-23,48,21,-35,-9,-27,3,-61,64,-28,-14,0,-65,57,-34,19,41,-23,-8,5,75,48,25,-56,-17,19,-20,27,-11,-42,-1,11,46,-18,-19,-2,46,47,18,-25,22,-28,-51,16,-48,-26,-45,12,62,-34,52,14,-53,-29,-29,55,32,54,-4,-7,44,-16,-35,18,11,41,30,-33,-56,3,-31,61,29,74,-12,20,-50,29,-49,48,33,-3,-37,20,-5,-33,-8,-1,45,-17,-37,-52,-97,14,-24,34,-37,-27,37,-39,16,-67,66,-58,10,-19,-41,53,-20,1,32,-14,-18,-12,-12,-33,-20,0,2,13,22,13,13,-8,10,-20,25,-22,-66,32,5,25,5,-3,59,15,54,23,48,16,34,-43,57,3,-15,25,49,-15,-6,-4,-4,42,-38]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.37","t":"EVALUATION OF PATIENTS’ CULTURE Although providers are experts in mental health and mental health treatment, patients are experts of their own identity and life experiences. To provide treatment, providers should understand and be willing to explore each patient’s lived experiences. Do not assume that culture will always play a role in patients’ psychopathology. Provide your patients with the opportunity to hypothesize how aspects of their culture may play a role. Examples of how to begin these conversations are provided below. Important to note: the patients may be clear as to how culture influences their symptoms, ongoing stressors, or presenting concerns. Therefore, understanding patients’ experiences may be more helpful for the provider than the patient.","e":[21,57,-154,-41,65,33,33,56,42,-15,-9,-7,35,19,12,-62,-8,-39,-30,36,-104,-20,-34,2,-3,34,9,26,-31,5,12,35,19,-27,-46,-34,40,46,5,48,44,32,41,-92,58,-21,27,2,22,-4,-11,-74,10,12,123,35,-27,85,20,-47,83,49,-76,25,26,-29,-53,49,-23,-36,45,-18,35,10,-52,30,-17,-19,16,21,63,-25,46,-45,-2,14,9,-7,-10,86,17,-17,-5,72,-101,21,-40,-31,-5,-20,-54,4,27,-22,38,13,-10,68,-46,-7,-14,44,-39,-16,32,-27,33,-41,14,49,3,30,-19,52,9,42,-24,-30,21,20,-8,-34,-12,-15,-14,61,14,-36,20,7,65,-1,10,-7,-13,-24,16,-39,-29,42,21,68,12,55,24,-36,-26,18,51,10,52,30,-5,74,1,-62,6,28,5,25,-27,1,21,-3,85,2,70,-25,53,-37,-21,-43,32,-17,9,-16,53,-43,-31,-58,20,36,-25,-23,-68,-52,-26,-17,9,-49,-54,24,-11,22,-51,80,-41,-26,-51,-62,47,-24,-1,53,-35,31,-27,-37,-31,18,36,1,25,-27,3,-3,-59,8,-1,-3,-12,-88,87,11,7,9,-18,9,32,30,-27,13,21,33,-67,11,-34,-24,-10,18,20,39,47,33,32,-49]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.37","t":"EVALUATION OF PROVIDER’S CULTURE In addition to cultural considerations of the patient, consider your own cultural experiences. All individuals have unique experiences and backgrounds that may differ from another’s. Evaluating your own cultural experiences and past behaviors will inform ways in which you may interact with patients of different backgrounds. Personal experiences contribute to explicit and implicit biases, which impact how individuals interact with others. 37","e":[12,61,-142,-41,43,84,63,16,44,-14,-10,32,50,60,-3,-71,3,-47,-4,59,-92,-13,-36,15,-5,33,6,11,-72,-16,2,22,19,-17,-58,-48,34,18,-3,20,27,60,29,-70,83,-3,27,15,18,25,-7,-52,-7,2,94,13,-31,72,40,-43,74,39,-71,54,20,-11,-57,60,-42,-32,30,9,20,13,-53,21,0,-16,21,57,44,-9,55,-22,14,-10,4,-3,-29,98,19,-1,5,60,-100,19,-16,-4,-13,-42,-53,-1,49,-7,42,11,6,87,-12,-3,-45,35,-12,4,16,-23,24,-29,-5,43,-6,26,-19,55,-11,35,-36,-36,8,-17,2,-51,-4,-9,-13,22,31,-33,-6,4,65,-10,-25,-23,-10,-39,31,-45,-39,54,37,40,-6,41,26,-31,-43,20,38,5,69,20,33,70,-15,-41,-15,29,28,27,-4,-27,22,-24,81,20,37,-30,24,-33,-3,-67,19,-4,8,-49,31,-16,-51,-58,34,-3,6,-33,-77,-72,-12,8,12,-58,-19,40,-18,42,-52,76,-27,-9,-55,-84,50,-7,-14,53,-39,23,-14,-22,-29,26,20,11,20,-11,2,-5,-56,24,12,6,-20,-107,99,20,22,22,-32,1,9,21,-21,24,3,39,-91,-13,-3,-7,9,31,9,38,34,43,15,-45]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.38","t":"PATIENT AND PROVIDER INTERACTION The interaction of two cultures often leads to cultural differences. Under ideal circumstances, cultural differences create opportunities for individuals to learn about others’ cultures, highlight commonalities among shared cultural experiences, and develop awareness of differing experiences. However, cultural differences can also lead to negative experiences and outcomes, such as discrimination, stereotypes, and injustice. Providers and patients bring their own lived experiences to the therapeutic relationship, but it is imperative to model behaviors that attend to cultural differences. This may be the first time your patient is introduced to the concept of cultural difference and, thus, negative outcomes can be directed towards you. Just as patients can be negatively impacted by not acknowledging culture, you as a provider can be discriminated or stereotyped.","e":[13,70,-145,-19,59,88,28,1,32,-12,-6,7,49,27,39,-41,20,-45,-42,76,-119,5,-17,-15,-2,35,2,17,-65,8,27,19,23,-32,-52,-46,27,12,7,46,59,37,23,-81,67,-34,25,28,20,-4,32,-79,-41,16,103,36,-3,62,14,-54,49,59,-69,56,28,-12,-37,51,-34,-34,15,28,42,26,-44,31,-6,-30,-1,41,36,0,21,-27,12,16,34,-8,-47,92,7,-17,13,53,-120,25,-23,12,-42,-29,-26,-24,49,-16,14,44,17,55,-22,13,-47,29,-51,-25,32,-35,34,-40,-1,30,-9,16,-28,65,9,15,-41,-28,27,-21,11,-49,-32,9,-16,32,49,-30,12,12,67,7,4,-5,-11,-33,15,-43,-44,37,23,37,-5,67,32,-23,-49,27,53,-20,90,-7,-9,41,-3,-66,7,24,18,38,-22,-26,5,-13,85,34,26,-37,-7,-26,-44,-60,18,5,22,-16,22,-11,-64,-75,4,4,-5,-33,-68,-74,-1,9,14,-54,-33,31,-11,6,-25,68,-37,-15,-41,-48,37,-19,-10,40,-38,4,-13,-9,-40,18,34,-17,-12,-28,22,-20,-59,19,-46,-12,-15,-66,81,9,23,25,18,15,-7,11,-20,10,-3,57,-65,11,4,-8,-20,37,0,38,22,8,22,-64]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.38","t":"Both you and your patient may experience discrimination. Discrimination is the mistreatment of individuals based on societal or personal views of an aspect of their culture being inferior. Discrimination can be direct, such as overt racism and sexism, or indirect, such as microaggressions. Microaggressions are intentional or unintentional slights or behaviors directed towards others that indicate social inferiority, hostility, or derogation. For example, a teacher telling parents of an African American student that she is so articulate and well mannered may be an unintentional microaggression. Even though the teacher is trying to compliment the student, the teacher may be making a microaggression because of the underlying societal stereotype that African American students would present otherwise. Both providers and patients should attend to the possibility of microaggressions and discuss any occurrences as much as possible in the moment. Awareness of explicit and implicit biases presented in Table 5.3 can help prevent microaggressions and discrimination from occurring.","e":[89,23,-173,-63,40,107,57,5,9,12,-14,87,76,58,14,-41,-5,-39,-44,57,-31,51,-33,-34,42,40,10,-36,-29,3,-25,31,30,-13,-48,-24,27,12,0,8,27,34,-15,-100,23,24,48,15,27,-37,37,-96,-10,1,74,-12,24,40,24,-2,60,65,-92,39,46,5,-58,0,-26,-50,30,-9,4,25,-24,14,-23,12,27,40,15,-14,32,29,59,-26,-25,16,-43,91,34,32,7,18,-127,-25,-31,-4,-67,-12,-29,-36,59,0,39,25,11,40,12,-22,-29,65,-59,-49,0,1,47,-56,-4,10,6,4,-18,70,6,51,-40,10,28,-45,23,-40,-34,3,-19,9,57,-10,-29,40,57,27,-9,-12,21,-40,3,-6,-17,40,34,50,16,7,23,-14,-33,40,27,-6,77,4,12,48,-45,-34,-19,51,16,9,0,6,29,-1,72,62,53,-65,9,-50,5,-33,63,-13,-5,-91,50,-6,-39,-53,11,-3,-26,-16,-71,-61,12,5,22,-53,-6,8,-18,28,-6,81,-6,-24,-33,-14,37,-29,22,-33,-37,-24,25,-27,-22,14,-1,-11,-6,-1,47,7,-44,-12,-42,17,-8,-98,71,-24,12,21,3,-7,13,5,-4,25,-5,17,-56,11,49,1,6,10,-15,19,10,4,35,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.39","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 5 Table 5.3 Biases Explicit Bias Implicit Bias Definition: Attitudes and beliefs we have Definition: Attitudes and beliefs we have about a person or group on a conscious level. about a person or group on an unconscious Individuals are aware of this bias and express level. Individuals are unaware of this bias and it directly. express it subconsciously. General Examples:","e":[23,22,-142,-70,67,62,31,18,3,38,19,77,52,66,-2,2,-16,-10,19,61,-44,-10,-5,-60,38,40,1,-71,-66,-47,-16,-9,3,-29,-71,-69,46,16,34,-31,-7,27,14,-20,-32,14,42,26,8,13,-11,-40,61,-3,109,-7,6,63,-30,-33,75,2,-76,51,51,22,-70,38,18,-35,32,22,6,18,-26,-26,-34,-10,17,50,28,-34,60,21,83,36,-2,-22,-23,57,8,0,-14,17,-89,-42,-62,-11,-10,19,-63,-19,-4,12,31,25,-22,17,-15,16,-58,77,15,2,-29,-30,49,-46,4,15,57,13,-3,131,2,45,-36,-1,-26,-45,20,-31,5,-9,-32,34,57,-27,-22,78,20,25,4,-32,32,-60,25,-44,-11,14,43,18,-16,16,-4,-60,-28,13,13,-25,57,65,-22,41,-28,-28,38,45,4,46,-34,2,-8,-13,97,42,60,-16,24,-19,8,-16,27,2,-4,-73,36,-31,-35,-23,27,3,-5,12,-69,-65,30,3,58,-59,0,-9,-43,49,-40,48,11,-13,-25,-8,49,0,5,18,34,-8,9,-31,-26,-21,2,-16,-19,52,24,-17,-2,7,2,35,-17,-134,60,33,38,10,-36,45,72,-5,-23,54,-15,45,-58,11,40,5,-11,61,-10,40,-9,22,65,-26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.39","t":"• A boss choosing not to interview an • Assuming a woman working in a hospital is a applicant after seeing the applicant’s nurse instead of a doctor. dreadlocks. The boss feels that dreadlocks • A White individual asking a Latinx individual indicate he will not be a good employee or fit where he was born, because she assumes in with the company’s culture. most Latinx individuals are not U.S. citizens. • A male patient choosing not to work with any female providers because he assumes they are all judgmental, incompetent, and unhelpful. Examples in Psychotherapy:","e":[62,54,-160,-30,36,47,26,-16,-6,6,-47,64,63,5,24,-26,32,-88,-23,7,-63,0,4,-22,39,14,8,7,-29,-1,-27,37,34,-25,-31,-87,32,34,19,21,19,-11,-7,-111,15,27,46,33,30,-46,-16,-76,-1,13,68,-1,77,66,9,-15,65,26,-30,112,26,-26,-14,54,-4,-14,8,13,32,23,-45,14,-51,-13,-5,24,26,8,22,10,58,83,30,-48,-10,70,17,28,31,40,-98,21,-17,-20,-27,-37,-25,-57,-13,-21,34,2,-6,13,5,-36,-6,97,-41,-28,15,-39,49,-73,34,52,-5,-15,-61,65,21,55,-45,-1,9,-41,33,-23,10,19,-18,66,12,-17,30,23,74,10,29,-14,-15,-34,61,-43,-18,27,-3,55,33,28,16,-26,-23,12,28,23,67,-23,-31,57,-22,-75,-23,56,-2,19,1,-43,20,-18,42,-7,75,-52,-7,-57,34,-37,34,10,-10,-34,29,-1,-38,-75,-28,-2,-3,-32,-83,-53,-1,31,0,-37,-28,29,-65,47,-59,23,-31,20,-15,9,48,-6,6,-8,9,-37,9,3,-27,25,-8,-64,3,15,58,-40,-64,-12,-34,9,-14,-108,63,17,-16,2,56,47,-3,25,-33,8,-22,-36,-65,17,8,-43,11,28,-38,1,12,18,30,8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.39","t":"• A female provider choosing to refer a • A White provider being friendlier with White transgender patient to her LGBT colleague, patients than with patients of color. because she assumes she would not be • Appearing concerned or sad when a middle- able to understand the patient’s needs. She aged female patient says she is single and assumes the patient’s presenting concerns does not have any children, assuming that will be tied to being transgender. being single would contribute to a negative • A male provider skipping over the military emotional state. sexual trauma questions during an assessment with a male veteran. He assumes only female veterans experience military sexual trauma.","e":[-11,69,-156,-66,55,104,-1,-33,-9,22,-42,42,80,46,-6,-28,67,-33,-11,9,-116,-27,-50,-13,23,52,1,35,-40,-16,56,32,47,-25,-29,-61,-11,25,3,31,45,1,24,-97,11,-13,27,84,42,-35,20,-38,-31,14,102,-50,11,45,-26,12,34,51,-57,62,44,-43,-31,55,2,-29,23,7,35,37,-15,22,-15,-13,-6,16,53,21,48,2,54,44,45,-16,-34,78,-21,15,37,56,-80,-11,-23,-11,-20,-31,-16,-19,13,-32,20,26,5,47,16,-16,-32,73,-29,-50,15,-32,51,-55,50,41,-4,-12,-44,83,8,42,-65,-11,-27,-1,-11,-26,-4,-13,18,18,28,-7,2,23,32,33,3,-47,-2,-1,32,-40,-32,24,19,50,4,19,68,-30,-12,44,9,-3,68,24,-28,52,-10,-80,2,-16,-28,30,0,-20,22,-22,68,0,54,-73,11,-7,-4,-53,44,-22,-19,-52,19,-19,-85,-46,-15,13,-2,-15,-86,-48,21,30,0,-44,-46,5,-48,47,-38,39,-48,-14,-19,-48,54,-27,-14,-7,11,-37,15,-15,-50,10,5,-18,0,-27,44,-2,-45,3,-29,0,-31,-56,69,2,-12,1,-12,45,-11,-4,15,18,11,22,-83,26,8,-43,11,54,-33,3,-18,4,32,-39]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.39","t":"How? (Instructions/Handouts) You can use many techniques and methods to explicitly integrate culture into psychotherapy in both extended and brief treatment contexts. The following sections provide guidance and techniques to assist you when attending to culture and integrating culture into your practice. ORIENT THE PATIENT TO BRIEF, TECHNICAL TREATMENT. Discuss the patient’s perspective of therapy and any perceived barriers: • What are your thoughts about coming to psychotherapy? What do you want to know about therapy? What do you think about providers? Have you been in therapy before? • How does your family view psychotherapy? Your friends? Your partner? Do they know 39","e":[29,58,-134,-71,27,26,63,11,12,-14,-32,-22,30,16,-19,-74,0,-19,-20,56,-95,-26,-4,-34,-13,31,9,16,-43,-43,19,-4,-8,16,-38,-65,50,12,-33,11,32,31,9,-77,30,-36,51,-41,-2,7,2,-57,-33,-20,105,10,-8,22,49,-35,75,55,-77,55,44,-8,-59,49,-47,-45,47,-10,71,-4,-54,6,-6,-40,30,47,31,-17,46,-63,-29,6,-18,-14,-33,64,-1,-17,5,51,-88,11,-37,-7,-20,-47,-41,10,30,-35,16,12,27,36,-26,18,-52,31,-11,-17,-21,-15,42,-50,54,46,-15,13,8,47,15,26,-66,-60,-6,-5,20,-52,-25,11,-16,43,35,-46,1,28,55,-23,-1,14,-22,-17,-6,-41,-12,-9,14,41,16,59,48,-57,21,-10,82,0,58,39,-12,39,-22,-56,-3,13,14,-5,-13,-5,-13,-5,69,46,77,-41,11,-34,-4,-27,21,-10,-9,-20,37,-33,-40,-22,-1,17,-18,6,-89,-58,-8,-33,28,-30,-19,34,-24,40,-13,90,-33,4,-26,-27,62,-20,12,48,-59,9,-18,-44,-73,13,32,8,12,-12,27,10,-61,22,-12,23,-24,-119,38,18,24,21,-4,10,-17,39,3,11,45,41,-91,25,-8,10,-26,42,5,32,37,30,9,-26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.40","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 5 that you are coming to therapy? If so, what do/would they say? How do they view people who attend therapy? • What are ways therapy may be difficult for you? What were some barriers you faced when making the decision to seek help? How can we work together to prevent any future barriers? • Our time together will be brief; how have you dealt with brief relationships with other people that you’ve been close with in the past?","e":[-21,18,-122,-61,68,37,41,-10,8,-21,-54,-8,-2,3,-30,-49,17,-48,-19,40,-43,-54,1,-13,-8,46,19,0,-69,-3,37,-28,5,-65,-44,-63,61,47,-26,-12,34,-13,4,-99,34,-27,89,10,-1,20,40,-43,-11,17,115,11,19,15,46,-22,89,52,-93,53,24,-35,-36,46,-38,-15,38,-27,32,16,-17,19,-8,-20,24,32,51,-15,82,-48,2,14,-41,21,-3,53,4,14,3,32,-97,23,-53,-16,-34,-61,0,0,51,-37,24,43,-28,2,-16,-5,-60,31,-16,-14,-21,-38,53,-44,59,59,-15,5,-10,77,61,23,-1,-9,-13,-14,38,-29,-58,4,7,37,27,-13,40,34,84,7,-17,23,-25,-41,-16,-21,-35,-15,9,38,6,49,26,-60,-17,15,83,-13,47,30,-9,26,-28,-28,7,24,27,37,-12,-53,21,-6,66,33,80,-31,21,-68,20,-35,22,8,-30,-38,23,-46,-21,-15,-15,38,-30,-51,-28,-89,9,-30,35,-63,-5,47,-30,58,-55,75,-40,18,-19,-60,74,-32,16,23,-29,19,-13,-23,-52,47,21,6,-15,40,6,28,-37,0,-3,51,-17,-106,35,42,23,19,-19,38,3,30,37,14,57,26,-60,24,-8,8,14,46,-9,-9,-3,25,7,13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.40","t":"Exploring patients’ culture can be difficult to achieve in time-limited therapy. It is common for a brief CBT provider to feel tension between sticking to the brief CBT therapy protocol and providing patients with enough time to expand on their experiences and concerns. However, most protocols emphasize the importance of building rapport; and addressing culture can help you build this therapeutic alliance. The exact “balance” between listening/assessing and forming a strong therapeutic relationship with the time necessary to deliver technical/skill-focused interventions will depend on many factors, including the needs of the patient, the duration of treatment, and the provider’s skillfulness in rapidly and effectively forming a strong relationship while maintaining a focus on active, skill-oriented techniques.","e":[19,66,-164,-48,51,15,67,-16,61,-23,-26,-27,23,4,25,-55,-1,-56,-35,66,-73,-14,-5,2,-39,40,10,46,-36,-27,47,-16,5,-10,-55,-65,60,-2,-9,-2,50,14,33,-86,76,-34,35,25,-14,-30,-3,-77,-32,-23,113,24,-32,56,-9,-44,87,41,-75,81,37,-34,-36,39,-30,-24,21,-28,64,34,-52,36,-24,-14,-11,20,46,-12,28,-35,14,0,5,-31,-13,105,13,-37,-4,29,-82,20,-16,-24,-32,-5,-55,-5,8,-17,-9,37,2,11,-20,2,-57,25,-44,-21,-13,-5,16,-38,10,11,-30,-17,-20,35,2,63,-68,-23,32,-2,-25,-39,-27,-10,-24,52,9,-27,-5,31,31,0,28,4,-11,9,-11,-35,-15,23,-3,41,-2,53,31,0,-7,-11,45,13,35,9,-21,7,-16,-36,3,28,11,-11,-52,-37,-1,-7,89,29,67,-8,-3,-60,-10,-36,2,22,-10,2,51,-50,-11,-62,37,7,-38,1,-79,-56,21,-21,23,-31,-38,16,-24,37,-37,79,-46,10,-26,-76,69,-19,-46,47,-61,-16,-12,-6,-56,39,42,-3,12,-52,-5,-34,-58,-2,-29,10,-22,-77,47,59,18,30,22,8,-9,38,-2,19,7,41,-81,30,16,-13,-28,17,19,31,41,-14,18,-25]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.40","t":"ASSESSMENT OF CULTURE WILL HELP GUIDE TREATMENT MODIFICATIONS. Begin assessing culture by asking broad, open-ended questions. Importantly, these questions can also be used to gather information about your own culture and experiences: • What aspects of your culture are important to you? • What are some cultural experiences that have shaped your life? • How has your background, the way you identify yourself, or cultural experiences impacted your symptoms or presenting concerns? • How have your concerns/presenting issues affected aspects of your culture that are important to you? To your family? 40","e":[1,25,-138,-37,35,48,86,27,51,-30,-4,5,54,59,-5,-92,-26,-35,-4,84,-64,-27,-35,8,-10,14,-7,31,-30,-11,-11,-6,1,1,-21,-66,32,39,-6,-9,51,20,15,-63,89,11,28,-32,39,-13,15,-75,-27,4,93,30,-29,42,52,-36,80,68,-103,42,40,-36,-22,43,-49,-12,41,-11,43,9,-82,28,23,7,5,43,27,-13,80,-41,-10,10,-1,5,0,91,17,-4,-10,49,-80,24,-25,-11,-35,-8,-38,-9,6,-26,44,29,31,51,-21,2,-61,25,-23,5,-2,-7,59,-34,16,40,-26,36,-13,48,-11,20,-54,-42,13,16,-9,-51,-15,-20,14,70,-18,-17,-5,-4,82,-2,-2,18,-16,-5,26,-33,-9,-19,8,42,19,6,30,-22,-37,20,59,12,75,12,14,85,-34,-31,-11,27,36,18,-14,-25,30,-9,67,-23,84,-39,29,-28,4,-59,23,-20,-35,-60,64,-21,-47,-44,28,15,-12,-29,-49,-58,2,-3,-13,-34,-30,16,-48,32,-23,67,-12,-11,-48,-43,77,-30,4,62,-30,47,-26,-16,-5,19,23,-22,-5,-7,24,5,-72,17,0,15,-12,-121,100,39,5,22,-12,-5,-1,7,-10,6,69,29,-77,26,10,-3,19,23,7,48,41,19,17,-45]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.41","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 5 Highlight 5.1 Cultural Faux Pas Assuming pronouns/identifiers » Always ask about how individuals identify or how they’d prefer to be addressed. An individual’s race and gender may not match stereotypical classifications. Example: he/she/they; Black/African American/Afro Caribbean; Mexican American/Latino/Hispanic Using illegal immigrant or illegal alien » Use undocumented citizen or undocumented immigrant. Confusing gender and sexual orientation » Gender and sexual orientation are not correlated. Transgender individuals can identify as any sexual orientation, regardless of their gender or natal sex.","e":[-4,55,-161,-34,60,87,27,-2,6,25,-49,9,28,29,-33,-70,8,-70,-3,63,-92,15,-9,-3,40,19,19,17,-43,-56,-7,13,-16,-3,-46,-81,11,22,1,27,19,35,-10,-66,1,14,51,13,15,-20,63,-11,6,10,106,-9,0,37,-1,-12,29,88,-109,53,8,-18,-21,61,-53,-55,59,-28,45,69,-47,-14,-23,9,6,46,16,-5,99,-20,20,34,-5,10,-39,60,-1,-8,12,65,-67,24,-43,7,-17,-51,-39,-28,31,-53,3,3,13,53,-30,-2,-27,79,-12,-54,-11,-55,2,-62,50,39,-15,-26,-16,87,8,35,-39,-21,-32,-34,-11,-10,-22,2,-34,45,51,-15,25,53,43,47,-13,-26,-9,-33,14,-57,-31,25,18,66,19,29,20,-14,-28,14,29,-3,62,-24,-8,61,-36,-105,-27,30,-5,26,-10,4,-5,-16,69,13,36,-79,28,-4,14,-32,33,16,-2,-38,39,15,-23,-18,-2,40,-13,-46,-78,-68,18,-16,-7,-31,-47,2,-52,38,-55,31,-8,-19,-9,-38,83,-7,13,14,-41,-24,-27,-42,-20,5,-9,20,-4,2,39,8,-67,-20,-35,42,12,-108,92,-10,48,12,8,67,23,-11,-1,29,6,38,-44,31,-10,-21,17,56,-39,22,-31,21,23,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.41","t":"Acknowledging the “plight” of living with disability » Referring to the strength or courage of someone living with a disability can come off as offensive and can minimize their identity. Associating race or gender with culture » Two individuals of the same race or gender will not always associate with the same culture. Varying backgrounds can cause unique cultural experiences.","e":[25,48,-155,-50,33,96,9,10,23,-3,-23,-12,64,70,14,-36,-40,-68,-12,76,-115,34,-26,14,17,36,-2,-3,-33,-7,-23,29,32,-20,-29,-40,23,38,11,14,34,0,-8,-69,74,-10,9,9,36,-6,31,-64,-22,-16,94,2,-7,16,-17,-32,56,98,-69,39,62,9,-3,40,-39,-43,49,-19,25,50,-46,20,13,15,-10,37,31,10,55,1,43,28,33,19,-19,94,-28,-1,6,36,-95,7,-13,22,-68,-15,-29,-38,15,-26,33,36,21,54,-4,5,-80,66,-11,-32,-7,-48,35,-90,15,-12,-12,33,-20,82,-16,39,-27,-41,41,-33,-17,-45,3,5,-20,52,11,-19,-16,28,59,9,-23,-42,21,-11,-4,-56,-35,3,45,66,-21,4,33,-11,-44,12,34,-7,34,1,-1,48,-16,-26,-15,26,21,25,-33,-28,25,4,79,-17,23,-43,-2,-51,-8,-55,42,4,-32,-58,62,12,-58,-52,2,17,15,17,-69,-53,29,29,-17,-53,-37,6,-45,-1,-27,41,-32,-3,1,-35,62,-38,-43,28,-15,-17,-4,-34,-25,27,-15,-17,-32,-1,33,0,-79,1,-17,3,9,-124,105,5,9,25,-16,32,16,-6,-31,3,18,13,-40,84,6,-42,-34,46,-16,16,10,0,42,-9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.41","t":"YOUR APPROACH DURING TREATMENT SHOULD SHIFT, BASED ON YOUR PATIENT’S PRESENTATION. Providers use language during treatment based on their training, their theoretical orientation, and their own cultural experiences. However, often technical language, jargon, and various descriptors can make patients feel uncomfortable. Use your patients’ language and cues to shift your approach and be more aligned with them. Some examples include referring to the treatment process as talk therapy or counseling instead of psychotherapy, describing the patient’s issues or concerns (e.g., “I am no longer able to do what I used to do”) compared to symptoms used for diagnoses, using the term client rather than patient (taking into consideration the clinical context of your work), or referencing stressors instead of situations or triggers.","e":[37,15,-131,-64,57,18,-1,-1,15,1,-12,12,51,52,6,-67,9,-66,-57,53,-49,-20,6,-51,-3,14,-24,25,-43,-8,31,19,19,-10,-61,-70,18,33,-29,-2,46,-5,17,-92,37,-29,51,14,8,3,9,-74,-52,-5,122,23,4,71,30,-59,90,58,-82,51,42,-25,-42,36,-26,-35,61,18,55,39,-43,-7,-23,-40,-6,38,6,-44,66,-36,48,56,11,12,-32,68,-23,-21,-7,44,-133,11,-43,-19,-21,-56,-80,-2,19,-32,8,38,15,8,-23,-2,-12,49,-2,-39,-15,-37,39,-48,28,-2,26,-34,-29,28,46,43,-57,-46,17,-22,-9,-18,-27,27,-17,64,34,-32,36,9,64,11,30,-18,-16,-21,-6,-32,5,13,11,40,30,64,60,-23,-25,20,47,5,95,-3,-33,35,-3,-47,-11,52,-4,-10,-31,-8,12,5,79,51,67,-39,10,-20,14,-48,14,7,-15,9,29,-61,-23,-43,-30,20,-32,4,-74,-91,6,-17,15,-38,-24,27,-66,18,-51,55,-20,1,-48,-42,78,-15,12,7,-57,23,7,-11,-38,47,12,-8,12,15,32,-5,-59,41,0,4,-6,-88,28,-8,33,9,10,47,12,28,0,33,25,19,-70,16,20,-13,-18,45,-16,2,6,-16,32,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.42","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 5 CONSIDER V-CODES WHEN MAKING DIAGNOSES. The Diagnostic &I Statistical Manual, Fifth Edition includes diagnoses appropriate for patients when traditional diagnoses of psychopathology do not fit. Awareness of cultural influences may lead to consideration of these diagnoses, and they often decrease stigma related to receiving a more clinical diagnosis. These diagnoses are called “other conditions that may be a focus of clinical attention” and are referred to as “V Codes” in the ICD-9-CM and “Z Codes” in the ICD-10-CM. Some of the diagnoses include:","e":[53,1,-167,-55,55,10,52,3,15,-25,-12,3,65,13,-31,-60,-22,-36,-27,-3,-71,-35,-25,-17,42,41,16,28,-44,-7,27,-17,22,-56,-36,-63,39,45,-8,15,-14,8,20,-65,-4,14,52,-11,34,8,68,-54,22,-2,119,-17,-21,12,24,-8,78,66,-76,0,52,-43,-87,23,-16,-15,39,-30,46,20,-56,14,-10,-50,16,24,37,-38,54,-20,19,9,-4,7,-17,46,15,-10,-18,75,-101,17,-5,28,-22,-38,-20,-26,20,-50,14,25,28,-25,-13,-29,-41,47,-10,-23,16,-71,60,-68,-17,46,-17,-13,7,76,38,38,-32,-33,5,-61,32,5,-33,-5,-22,35,31,-14,-9,27,64,14,-22,-7,7,-28,2,-18,-11,-15,2,59,0,15,-3,-59,-22,23,45,-5,43,38,-31,40,-15,-62,19,51,6,4,-52,-21,19,-11,52,7,47,-69,47,-19,-18,-43,32,34,-36,-19,17,-53,-36,-27,-18,45,-1,-39,-76,-70,-22,-18,24,-17,-33,40,-38,11,-46,45,-29,8,-14,-41,73,-58,34,29,1,-5,-43,-28,-63,14,3,29,25,-12,14,14,-45,14,12,-17,8,-135,38,0,2,44,-28,50,44,31,14,20,49,32,-35,24,-5,-10,-17,58,-3,17,-5,12,42,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.42","t":"Tips 1. Engage in life-long learning and professional growth. This brief chapter scratches only the surface of cultural awareness in psychotherapy. Ongoing training throughout your career will ensure that you are continuing to grow and develop your awareness of culture. 2. “Cultural competency” is an evolving process. Due to the variable nature of human behavior and the complexity of culture, individuals will never reach full cultural competency and awareness. Your goal should be to practice being culturally competent, not assume that you have cultural competency. 3. Be curious. While exploring your own and your patients’ culture, be appropriately curious about culture. When struggling with what is appropriate or inappropriate, consider your patient’s perspective. What questions would you be OK with answering or being asked?","e":[32,26,-150,-7,63,41,86,38,42,10,-31,1,18,21,14,-78,7,-79,-31,54,-91,-16,29,-4,-14,41,-20,28,-21,-65,19,0,-24,-7,-3,-66,35,-2,19,29,50,13,20,-83,55,-17,22,-30,3,-5,13,-66,-7,18,93,26,-26,42,-3,-98,90,57,-91,60,-3,-40,-69,72,-64,-3,28,-37,38,38,-46,17,-27,-44,22,39,9,5,58,-49,-11,3,-7,-27,-21,103,20,-11,-20,48,-64,34,-27,27,-16,-20,-10,1,7,-18,-6,32,28,34,-48,15,-33,50,-34,-12,-53,-5,20,-60,42,16,-20,-8,14,56,10,60,-18,-60,-8,24,-3,-23,-18,25,-47,67,37,-27,28,19,51,-23,31,6,-34,-33,15,-53,-15,32,-2,47,12,7,35,-35,1,-11,77,-8,49,3,-12,31,-11,-70,2,23,14,-1,-41,1,-4,-16,68,-1,64,-60,13,-28,3,-47,17,17,-4,-8,34,-41,-52,-15,14,41,-32,-7,-70,-82,-18,-28,5,-35,-40,36,-18,46,-36,67,-34,-4,-11,-33,65,-34,4,34,-30,12,-20,-20,-55,13,41,16,20,19,-14,2,-69,-1,3,31,4,-114,70,11,16,33,-39,33,7,33,-15,12,35,57,-59,30,-9,-8,-31,18,22,34,54,23,-7,-47]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.43","t":"SUPPLEMENTAL READINGS & REFERENCES American Psychiatric Association. (2013). Cultural Formulation Interview (CFI). Washington, D. C.: American Psychiatric Association. American Psychological Association. (1990, August). Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Population. Retrieved from American Psychological Association: https://www.apa.org/pi/oema/resources/policy/ provider-guidelines Folkman, S., Lazarus, R. S., Gruen, R. J., & DeLongis, A. (1986). Appraisal, coping, health status, and psychological symptoms. Journal of Personality and Social Psychology, 50(3), 571–579. https://doi.org/10.1037/0022-3514.50.3.571 Hoffman, J. L., & Hoffman, J. L. (2006). Sculpting race: An innovative approach to teaching racial identity development. Retrieved from Summary Stages of Racial Identity Development: https://www.racialequitytools.org/resourcefiles/Compilation_of_Racial_ Identity_Models_7_15_11.pdf","e":[33,41,-164,-56,35,10,38,-7,19,3,33,-41,44,76,9,-46,-9,-58,-38,38,-100,-19,6,15,53,49,-22,9,-74,-36,17,38,34,-5,-46,-90,45,36,-7,10,70,64,6,-78,14,3,30,-18,21,-23,16,8,10,-15,82,-19,-18,74,2,-43,54,58,-101,51,48,-25,-2,76,-45,-19,39,-4,78,34,-57,12,-41,-24,14,40,40,44,62,-39,43,9,16,23,6,56,-17,31,-17,22,-30,35,-44,-3,-46,-47,-77,-12,11,-22,25,17,-20,26,-20,4,-43,60,-22,5,-7,-27,36,-39,47,38,-32,-31,38,25,-3,15,-46,-41,-16,-17,20,-16,-46,-36,-30,27,-23,10,7,19,56,18,4,-24,7,-26,4,-40,-20,18,10,60,29,12,-18,-21,-30,7,31,2,76,-25,-14,66,19,-59,-21,18,31,26,-21,-16,22,-9,65,-11,46,-66,57,-16,24,-53,44,37,4,-61,19,-3,-64,-34,-16,40,-36,10,-69,-37,42,-42,7,-32,-7,39,-35,17,-12,76,-18,-14,-7,-23,54,26,20,35,7,22,-2,-24,-26,13,38,-8,13,4,17,9,-52,0,-31,32,-17,-106,56,-12,6,20,-4,18,25,1,-1,3,22,55,-57,24,10,-16,-2,54,11,22,-8,16,26,-53]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.44","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 6 Module 6: Using Technology for Distance-Based Therapy OBJECTIVES • To understand how technology is used in psychotherapy and its effectiveness • To identify special treatment considerations and barriers regarding the provision of psychotherapy through technology-based approaches • To identify strategies to enhance patient engagement and intervention effectiveness when using telemental health services What Is Telemental Health, and Why Is It Important?","e":[-29,13,-168,-61,54,-2,18,0,25,-23,-16,9,53,-6,-37,-17,9,-29,-32,26,-41,-65,-14,-49,11,16,27,20,-32,-23,28,-37,13,-36,-68,-48,17,33,-59,11,-11,-53,-4,-76,62,-5,65,2,19,-11,-4,-48,-5,-25,131,-31,-43,14,28,-43,99,93,-70,55,52,-37,-44,43,-44,-11,68,-40,27,1,-13,-15,-17,-60,11,61,15,-35,87,-52,24,21,-7,17,-12,82,19,41,-3,32,-108,19,-16,11,31,-42,-31,1,47,-51,29,31,-6,2,-12,13,16,46,-19,-26,23,-29,57,-25,38,6,0,-17,1,66,46,41,-33,-24,-12,30,19,12,-60,-13,14,40,16,-32,39,23,28,-12,-21,16,-36,-34,10,-23,-6,-21,-5,39,41,25,47,-82,-16,-25,98,21,50,11,-37,37,-26,-44,8,10,21,40,-43,-17,10,-9,46,48,54,-41,36,-42,12,-51,17,45,-42,3,15,-54,-40,-9,2,77,-52,-30,-84,-67,15,11,59,-56,-26,49,-21,63,-54,43,-33,8,-30,-51,57,-26,23,-4,-17,-23,-44,-28,-60,34,27,-11,0,4,-4,-26,-38,19,-11,47,-1,-102,19,25,35,32,-26,34,23,57,63,11,1,45,-64,30,-34,-35,-12,37,2,-6,1,5,13,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.44","t":"Conducting therapy with technology-based modalities has rapidly increased for mental health care. Specifically, using technology-based approaches as a means for providing psychological services has served to reduce mental health disparities and overcome distance-based barriers. Telemental health is the practice of using technology to provide mental health services and may include telephone, two-way video conferencing, mobile phone applications, web-based text messaging, email-based interventions, web-based chat messaging, or asynchronous telepsychiatry (formerly store-and-forward services). These remote telecommunication modalities present opportunities to enhance mental health care through services offered clinic to clinic (e.g., provider located in one clinic while the patient is physically present at a different clinic location) as well as from a provider directly into patients’ homes or other secure locations.","e":[1,22,-162,-45,51,-33,-31,-1,66,2,1,-3,60,34,-21,-25,-19,-35,-76,12,-48,-34,-27,-49,-2,24,33,28,4,-5,44,-51,17,-12,-53,-16,12,17,-31,34,38,-33,-21,-82,82,-2,33,-14,47,-48,-27,-68,-5,-33,118,-70,-34,55,17,-51,125,88,-55,25,77,-8,-42,38,11,10,66,1,36,-18,-16,-21,-15,-68,-11,42,30,-58,42,-75,41,26,13,23,-5,103,21,30,6,48,-107,3,-18,10,16,-66,-48,5,48,-35,11,70,-7,-15,-55,30,8,21,-25,-43,30,-27,44,-18,42,-35,14,-7,-5,38,8,36,-48,-1,29,17,6,1,-29,-12,-9,57,-19,-38,32,17,56,-32,-22,-1,-7,-15,-6,-8,6,-38,-4,43,55,17,53,-51,-16,13,65,39,24,-3,-30,40,-7,-43,-1,36,19,29,-42,11,-20,1,61,36,45,-90,34,-51,25,-51,9,36,-36,-15,29,-42,-37,-57,-5,48,-61,7,-84,-8,25,30,77,-55,-22,45,-32,36,-37,64,-15,-26,-29,-49,52,-22,1,-30,-16,-12,-57,-43,-59,42,17,-36,14,-22,14,-38,-59,20,3,29,22,-53,38,-9,26,30,-37,43,13,57,36,41,-4,31,-40,-1,-13,-28,-12,32,36,-20,-14,-34,14,-29]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.44","t":"Telemental health services may be used effectively across an array of settings including, but not limited to, hospitals, short- and long-term care facilities, school systems, institutional correctional facilities, rural health centers, and community mental health clinics. Telemental health modalities are associated with clinical effectiveness, treatment adherence, patient and provider satisfaction, psychotherapeutic alliance outcomes, and cost effectiveness commensurate with services provided face-to-face. Telemental health services are useful in providing evidence-based psychotherapies to individuals, groups, and families. When? (Indications/Contraindications)","e":[-20,32,-171,-42,32,-42,-34,-5,66,16,9,4,55,40,-31,-35,-19,13,-15,12,-46,-16,-31,-50,11,46,39,19,-12,-30,43,-27,66,-45,-69,-53,15,14,-21,10,33,11,-14,-86,56,-5,45,12,50,-37,-13,-62,-33,5,111,-58,-4,28,6,-55,135,63,-78,32,101,32,-35,50,33,11,61,-18,25,-10,-12,-9,-11,-29,-6,54,26,-42,60,-66,33,28,35,-6,-22,96,33,20,13,59,-130,0,-18,28,5,-57,-38,-1,16,-14,26,50,24,11,-50,-7,-3,47,-12,-41,16,-30,70,-38,27,-9,25,-7,-2,53,-23,16,-68,-2,12,-1,1,5,-18,16,4,53,18,-26,7,23,61,-9,7,9,-6,-40,21,-37,0,24,0,31,28,19,-2,-45,-38,-7,62,54,3,-1,-20,34,-31,-41,-2,53,21,55,-31,-12,-4,-7,71,34,47,-57,39,-45,26,-42,7,0,-17,-2,37,-40,-63,-52,25,52,-32,-7,-90,-19,7,21,52,-64,-20,26,-39,58,-22,68,-28,-22,-37,-34,61,-16,-4,4,-6,-27,-43,-31,-68,42,1,-29,27,-42,20,-27,-79,25,5,36,15,-65,43,2,10,0,-1,3,40,32,16,41,6,27,-40,-7,-21,-54,-6,42,32,18,-5,2,13,-36]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.44","t":"Technological advances and the subsequent integration into healthcare services have made remote delivery of mental health care accessible to underserved and disadvantaged populations. Telemental health services help minimize barriers that prevent patients’ access to care when they need it (see Figure 6.1). When traditional face-to-face therapies are unavailable or inaccessible, alternative treatment modalities may be appropriate for individuals that frequently travel for work, those who serve during military deployments, and people who work irregular schedules. 44","e":[-16,47,-178,-52,49,26,-15,15,72,-10,-4,17,51,12,5,7,-6,-39,-52,25,-46,-16,-16,-29,-7,31,44,19,-27,12,52,-40,30,-47,-21,-20,36,32,1,22,44,-14,-30,-100,72,-14,53,15,57,-43,11,-56,-40,-14,104,-72,-25,39,23,-58,124,72,-45,20,90,4,-39,57,29,-10,30,-12,22,5,-33,-6,-17,-43,-42,29,30,-25,56,-96,62,38,39,22,-1,105,-4,27,8,42,-103,-3,-35,4,-9,-49,-40,-17,29,-45,37,41,20,20,-11,19,-23,38,-39,-28,36,-45,50,-36,36,-5,0,13,-23,40,-8,37,-49,-5,42,8,1,12,-14,5,-11,38,-26,-26,9,29,71,1,-25,-15,-15,-25,-26,-20,-10,-18,27,59,45,50,47,-78,-8,13,42,14,40,-4,-60,28,-1,-38,2,35,19,43,-32,-3,-24,7,67,54,40,-79,32,-53,32,-59,15,18,-13,-31,15,-19,-36,-74,26,42,-45,-21,-80,-24,18,26,65,-71,-11,44,-24,28,-20,83,-21,-17,-4,-63,57,-25,19,-28,-14,-11,-20,-54,-64,50,16,-36,11,-18,40,-19,-86,-11,-16,46,18,-82,36,-2,5,16,0,31,31,15,43,19,-1,27,-25,11,-17,-17,-7,31,37,8,-29,-16,3,-32]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.45","t":"CONSIDERATIONS Potential risks of using technological modalities when providing remote mental health treatment must be considered. Risks involve the need for crises management procedures as well as clinical issues, including the potential for negative impact on patient functioning. For example, patients with anxiety may have fears associated with avoidance that are potentially maintained by using telehealth services and thereby reducing exposure to feared stimuli (e.g., going out of the house). Additional precautions may be warranted to effectively observe and assess mobility (e.g., ask the patient to walk across the room in front of the camera) and hygiene (e.g., inquire about the last time a patient showered or brushed their teeth).","e":[44,23,-168,-39,55,25,-5,11,71,-17,-14,9,50,42,-10,-31,25,-32,-58,-8,-45,-37,-19,-13,-33,31,46,7,-2,13,59,-23,-16,-68,-47,-45,44,48,-17,14,48,-15,-5,-81,56,24,81,0,62,-23,48,-76,-2,-17,105,-56,0,43,5,-63,116,67,-51,2,50,1,-64,35,17,15,56,1,25,34,-37,6,-11,-21,-21,54,2,-22,74,-61,63,36,33,-2,-17,77,1,6,29,41,-100,27,-12,-17,-12,-30,-23,18,29,-27,-12,16,-2,28,-6,28,-22,55,-23,-30,67,-29,48,-28,26,5,-16,17,-9,16,-10,41,-48,3,68,6,-4,0,-48,-10,9,54,-7,-16,7,23,83,19,-22,-19,-6,-12,6,-10,2,-30,-8,42,-4,49,81,-29,-56,16,51,26,51,-12,-23,50,-15,-59,22,45,12,34,-29,-29,31,-6,47,25,70,-84,29,-41,23,-48,17,12,0,-26,36,-7,-46,-48,36,13,-58,-40,-89,-55,20,35,55,-48,-14,39,-25,38,-27,53,-9,-23,-35,-82,53,-39,-8,-15,-13,-39,-4,-37,-63,20,-17,-27,9,-33,16,3,-67,2,-13,30,2,-71,59,11,-2,29,-6,8,26,30,51,24,-4,33,-17,-12,-38,-22,-13,28,9,-2,1,-13,6,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.45","t":"Patients may be offered various telemental health modalities, but it is the provider’s responsibility to ensure alignment with the patient’s presenting concerns as well as to be knowledgeable about data to support the intervention using the selected delivery method. Some smartphone applications, for example, provide treatment programs that are not empirically supported. Despite concerns about the appropriateness of technology- based modalities, telemental health services have been used successfully across an array of populations. 45","e":[-25,50,-152,-27,56,-6,-39,-25,86,6,8,-25,90,35,-30,-29,4,-20,-27,42,-42,-27,-69,-45,-15,12,50,-4,-18,-9,69,-5,56,-28,-60,-61,19,6,-13,38,17,-18,-20,-66,65,6,40,21,43,-41,-25,-65,-34,-34,109,-43,-27,42,9,-58,126,67,-66,46,65,7,-36,39,22,11,61,4,44,-5,-8,-31,-19,-22,-17,38,46,-44,77,-54,33,12,22,8,-17,110,45,19,28,33,-140,-13,-36,7,2,-70,-36,22,28,-6,41,63,35,34,-27,-7,9,22,-15,-30,25,-9,67,-46,37,14,11,-20,3,38,-14,16,-45,-7,13,5,-5,-14,-12,-13,-10,49,-4,-28,19,19,62,3,2,-10,0,-25,14,-15,-2,17,0,11,38,22,27,-60,-28,2,53,46,30,-11,-49,28,-20,-43,-18,15,26,44,-27,7,-15,0,87,43,22,-41,49,-39,30,-54,-10,10,-25,-35,23,-34,-52,-48,17,44,-24,0,-74,-6,29,40,52,-72,-14,25,-34,30,-38,59,-13,-2,-41,-58,49,-29,-17,8,-37,-23,-28,-25,-59,53,-1,-34,7,-58,20,-51,-61,16,-15,24,33,-70,51,8,28,9,-35,5,39,26,12,38,29,41,-38,1,-2,-57,3,45,13,-18,5,-21,-5,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.46","t":"• Age Group: Research has been conducted on telemental health with all age groups. Providers should determine whether patients can effectively use a desired telemental health modality through direct conversations with patients about acceptability and feasibility. Occasionally, patients from various age groups (e.g., older adults) may require some education on how to use different modalities. Typically, younger patients are more likely to desire technology-based treatment. However, patients of all age groups can be instructed on how to use technology for treatment. • High Risk Populations: Clinical concerns arise when providing telemental health to patients who endorse current suicidal ideation or substance use. For patients with past suicidal ideation, consider the level of suicide risk, the length of time since the last reported episode of suicidal ideation, and the number of past episodes when deciding the appropriateness of telemental health. High risk patients in crisis often require focused and highly intensive treatment approaches that may make weekly therapy inappropriate. However, telehealth modalities may be an important element of a broader treatment approach that includes a mixture of face-to-face and virtual appointments. Ultimately, the decision to use telemental health with high-risk patients should be based upon clinical expertise; and a clear emergency plan should always be identified (i.e., emergency contact, involving family and friends). • Patients with Severe Mental Illness: Telemental health can be conducted with patients who have been diagnosed with severe mental illnesses. However, patients who are not adherent to psychotropic medication or other treatment recommendations may not be appropriate for telemental health treatment. Distance may pose an ethical risk in ensuring the safety of your patient. As with high-risk suicide patients, the use of telemental health procedures for those with serious mental illness may be most effective as part of a interdisciplinary treatment plan. • Rural or Out-of-State Population: Telemental health is an optimal option for rural populations that do not have access to treatment. However, different states have regulations on providing treatment across state lines, which should be considered. • Exposure-Based Treatment: Telemental health services can increase effectiveness of treatment of anxiety- and trauma-related disorders. Patients can use technology in their environment, allowing you to guide them through relevant exposure exercises. • Treatment-Avoidant Populations: Telemental health options engage patients that may not otherwise use therapy. However, these care options can reinforce avoidance and limit patient progress in treatment. Use your clinical judgment to determine if a patient high in avoidance or low in motivation is appropriate for telemental health throughout the course of treatment.","e":[-9,51,-171,-35,34,19,-38,15,69,0,-25,-7,60,27,-24,-50,15,-31,-40,16,-78,-49,-56,-30,-11,33,20,31,-15,9,72,-30,34,-6,-87,-51,32,30,18,10,45,-13,-1,-103,22,-8,67,11,67,-39,-15,-82,-36,-24,75,-76,-53,48,9,-76,94,55,-68,5,86,5,-72,69,35,6,60,-5,27,2,-8,20,-27,-42,9,56,36,-12,61,-83,26,13,27,-3,-3,105,21,22,15,52,-88,10,-14,10,9,-40,-50,-10,21,-12,2,40,33,-8,-43,3,-24,15,-36,-40,46,5,57,-30,55,-11,1,-10,7,48,-11,30,-54,1,27,1,-23,-8,-21,14,11,45,-2,-25,4,4,87,3,17,1,-1,-22,-1,-4,-12,-14,-2,22,45,38,22,-61,-43,-8,66,51,6,11,-43,56,-19,-34,-8,28,17,32,-34,2,21,-11,67,20,53,-61,34,-26,33,-70,33,15,-5,-21,28,-26,-25,-44,26,43,-51,-20,-75,-23,50,23,31,-62,-46,42,-44,38,-49,75,-31,-17,-31,-60,48,-32,-7,-10,-25,-10,-60,-27,-54,40,4,-47,31,-30,13,-39,-71,28,8,21,27,-66,53,-10,-18,15,-23,7,44,35,8,37,22,36,-43,-1,-36,-39,-16,42,7,-8,4,-5,-9,-35]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.47","t":"ESSENTIAL PSYCHOTHERAPY SKILLS | MODULE 6 PRIVACY Consider the environment of your patient to ensure appropriate levels of privacy during treatment. Telemental health services are an option for patients that have access to reliable, private technology software, especially if transportation is an issue. Stay-at- home parents or caretakers may have issues in connecting that are contingent upon their caregiver duties or responsibilities. Additionally, ensure that your facility or office has designated areas to conduct telephone or video sessions. It is important to ensure secure network connections and video conferencing software to meet privacy standards and HIPAA requirements.","e":[-19,41,-173,-38,54,-8,0,7,62,14,-17,11,38,21,-39,-16,8,-27,-18,-6,-65,-36,-12,-8,41,47,43,27,-11,-24,37,9,21,-37,-71,-86,17,55,-74,11,19,-19,-15,-73,42,21,39,-6,35,-22,16,-23,-16,-10,118,-45,-17,15,21,-41,118,81,-91,62,40,-13,-52,43,5,-15,50,-13,40,7,6,-8,-14,-35,9,51,37,-7,95,-40,38,-4,5,-21,-5,90,16,16,-2,42,-69,48,-11,34,12,-38,-45,-30,19,-33,0,23,-10,20,-37,2,14,51,-31,-19,24,-40,69,-70,49,21,-27,-9,16,50,41,45,-50,6,-13,2,0,-12,-38,23,0,11,19,-15,11,16,29,40,-27,2,-3,-40,25,-41,-27,-17,-14,20,34,30,13,-79,-30,11,70,54,66,0,-34,58,-32,-41,0,28,16,14,-39,-9,-8,-6,68,17,28,-67,54,-34,33,-35,9,33,-21,-15,16,-66,-46,-21,14,55,-55,-11,-68,-72,18,-17,44,-62,-44,37,-30,51,-38,55,-27,-28,-36,-69,61,-26,30,3,-9,-21,-49,-24,-84,28,17,-3,21,-4,-13,-18,-52,16,-17,54,3,-111,25,32,31,43,-34,29,33,22,38,44,-8,27,-53,56,-43,-24,-4,39,-8,-11,-2,-24,7,-35]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.47","t":"How? (Instructions/Handouts) Providing telemental health services using technology can be a complicated process, and you should consider it on a case-by-case basis. As with any new procedure, you are encouraged to explore and be knowledgeable in the modalities and delivery. You must be vigilant and prepared (proactive) when using telehealth procedures. Various factors can be considered when using telemental health:","e":[5,45,-163,-21,46,-15,-20,-4,69,-21,6,-22,70,61,-17,-29,31,-46,-18,10,-28,-48,-69,-18,-13,7,4,27,-9,-42,50,-19,62,-40,-42,-78,24,-8,-40,23,35,-22,-10,-95,64,-2,46,18,38,-35,-31,-58,-65,-49,107,-22,-14,30,31,-62,122,89,-72,35,66,-12,-55,62,25,41,51,-9,55,-30,4,-12,-29,-5,-12,55,59,-32,87,-39,8,-10,-4,-25,-7,130,26,3,13,56,-99,-12,-13,27,-4,-73,-1,-15,-1,-16,-6,31,30,20,-15,-18,13,34,-29,-14,24,15,95,-10,24,17,-18,-12,-3,38,-3,46,-70,-34,32,6,17,19,-15,-2,23,52,-2,-35,32,2,65,20,5,-27,7,-13,-25,-38,2,-8,-4,0,17,18,55,-50,-24,3,51,59,37,-22,-47,34,-31,-38,-17,51,9,27,-25,5,19,2,65,35,44,-58,19,-57,21,-60,1,32,-35,-36,23,-22,-62,-43,41,48,-37,-14,-69,-10,14,26,44,-44,-29,46,-46,52,-22,64,-23,-15,-34,-30,57,-14,-7,-18,-12,-12,-34,-23,-78,35,-3,-46,30,-23,2,-51,-49,29,-1,-14,39,-93,34,5,21,-14,-21,16,48,31,21,46,45,23,-52,-27,5,-53,-9,47,39,-25,9,-16,-10,-34]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.47","t":"ASSESSING PATIENT SAFETY Although no condition-specific populations are currently considered inappropriate for telemental health services, individual patient safety should always be considered before providing services through any telemental health modality. Current best practices include: 1. Assessing patient’s current and past suicidal ideation 2. Obtaining emergency contact information for the patient as well as others that may be at the same location of the patient during each session 3. Obtaining the patient’s physical location and address for the duration of the session 4. Obtaining contact information for the patient’s local emergency services and law enforcement agencies (see American Psychiatric Association, American Telemedicine Association, and American Psychological Association in Resources) 5. Routine safety planning, which includes continuous monitoring of environmental changes such as patient’s appearance and sobriety level, as well as access to lethal means 6. Establishment of crisis protocols, with consideration as to how these protocols may require deviations considering domestic violence situations and/or with patients located at settings other than those originally anticipated (e.g., patients may change locations to the home of a relative, friend, or other setting)","e":[23,15,-175,-43,63,5,-16,2,50,-3,-6,-7,37,13,-31,-49,34,-65,-39,-4,-55,-31,-57,-26,48,37,31,38,-50,7,33,3,21,-49,-52,-91,21,47,-1,6,49,-6,8,-96,44,1,68,-10,57,-20,-3,-37,-42,-11,94,-29,-19,37,13,-64,88,71,-53,-15,43,22,-68,66,8,33,26,8,20,29,-53,30,-9,-27,-4,46,49,-6,89,-90,44,23,-1,-8,-14,74,21,39,41,56,-108,33,-32,23,-14,-73,-23,-31,-2,-34,-4,30,17,20,-1,-5,-19,35,-41,-28,68,1,86,-8,9,38,-7,-10,10,38,-6,27,-36,27,33,1,-33,-15,-19,7,-27,55,5,-9,15,0,63,15,-15,-17,27,-45,3,-9,-27,5,6,45,27,21,31,-52,-43,31,56,32,56,-8,-66,61,-17,-41,-6,16,30,18,-41,-45,35,-19,52,7,50,-73,12,-42,26,-66,48,22,-11,-51,11,-31,-33,-51,37,62,-33,-33,-67,-41,59,2,42,-54,-31,44,-59,57,-47,63,-39,-31,-14,-48,33,-27,-8,1,-30,2,-17,-17,-48,37,6,-25,15,-22,22,-9,-82,22,-1,6,-29,-52,30,-12,-9,45,-34,24,35,-7,23,43,21,34,-47,-8,-27,-28,7,24,-3,-13,20,7,14,-43]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.47","t":"DETERMINING APPROPRIATENESS OF THE PATIENT’S CASE Prospective telehealth providers are strongly encouraged to engage in self-assessment related to the provision of psychotherapeutic services across an array of telehealth modalities. It is important to review issues spanning state and regulatory licensure, technology, ethics, professional relationships, and specific training requirements (STEPS) before providing telehealth services (See Table 6.1). 47","e":[-3,34,-150,-37,50,12,14,3,69,25,-6,0,35,66,-51,-56,22,-66,-9,8,-59,-77,-47,-8,20,13,48,41,-10,-15,52,31,33,-44,-57,-85,45,20,-39,12,23,-15,-5,-83,50,-6,50,41,56,-8,-8,-38,1,-29,102,-17,-25,61,-11,-56,105,61,-77,35,75,-33,-31,39,7,3,42,-25,29,30,-23,0,-20,-35,-15,33,51,-13,101,-18,2,3,8,6,2,101,10,46,16,42,-77,-3,-15,-7,-5,-56,-21,13,-5,-20,-5,29,-21,11,13,-4,-18,40,-32,-22,29,-10,73,-8,14,78,-11,1,6,60,-12,58,-53,-15,12,3,19,-13,-29,-13,-21,49,-3,-30,11,11,56,14,20,-15,-4,-32,5,-38,8,26,13,25,21,10,45,-54,-24,34,59,12,43,-1,-49,76,-30,-36,-20,17,37,17,-24,-29,36,-2,44,16,70,-29,26,-1,37,-56,20,17,-16,-53,-6,-30,-33,-7,24,49,-71,-28,-75,-60,1,23,45,-54,10,33,-38,71,-66,32,-41,0,-9,-59,47,-44,-17,5,5,-10,-44,-15,-66,22,11,-19,25,-15,-8,-21,-71,21,-5,13,11,-93,50,16,4,35,-21,30,17,3,37,50,44,70,-61,-15,-4,-55,-9,55,11,-6,-8,25,15,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.48","t":"Technology Issues † Basic properties and operations of various telecommunication systems (e.g., internet & DSL) † Strengths and limitations of various equipment (e.g., plug-and-play devices, set-top devices, and roll-about videoconferencing systems) † Minimally acceptable video (15-18 frames per second) and audio quality standards † Ways to respond to equipment and telecommunication failures † Patient understanding of the uses, installation requirements, benefits, and drawbacks of telecommunication technologies involved","e":[38,67,-163,-9,55,-8,36,-17,23,-32,12,9,9,49,-25,-63,-27,-49,3,56,12,-39,-47,-80,22,55,29,-11,-60,-15,39,-48,6,-59,-44,-84,14,-18,-4,24,45,-67,10,-24,67,-14,25,24,41,-27,14,-33,-17,-10,88,-31,-70,52,40,-22,54,84,-62,19,59,-8,-7,12,30,-15,22,-34,30,3,-42,-27,-50,-42,-45,62,19,-22,76,-1,37,5,-6,37,9,116,25,53,56,-12,-73,27,-3,21,15,-18,4,11,22,-10,28,95,18,33,-25,-3,-56,53,-2,-8,11,-40,83,-6,4,36,-16,7,9,42,24,4,-32,-12,7,-12,-22,-9,-35,-30,-9,89,0,-55,18,23,66,10,-32,-26,-3,1,-1,-8,-1,-18,13,38,-8,19,59,-41,18,6,33,2,22,2,-67,56,-43,-34,-12,40,46,38,-37,-26,14,35,19,2,80,-57,-11,-54,-5,-23,-16,14,-25,-24,37,-81,-62,6,-19,22,-41,-43,-60,-53,61,34,76,-56,18,23,-33,30,-23,43,-51,31,-24,-49,44,-47,-15,35,-12,-30,-9,-42,-38,34,31,-8,12,-12,21,-53,-56,17,-12,48,-9,-102,8,11,-13,19,-11,-19,44,35,-3,44,-6,20,-74,-32,10,-41,-3,34,12,-21,39,25,5,-29]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.48","t":"Ethical Issues † Ways to communicate professional credentials and training to prospective telehealth patients † Methods of obtaining informed consent in telehealth † Confidentiality issues that must be addressed when providing telehealth † Strategies to ensure confidentiality and privacy when providing telehealth","e":[12,24,-117,0,98,37,-31,9,69,40,-5,-8,45,47,-12,-8,16,-96,-3,-11,-62,-35,-60,1,35,13,39,5,-9,-41,9,16,73,-28,-46,-59,24,17,-16,13,81,-26,-22,-69,29,-33,10,36,51,-39,22,-36,-14,-2,76,-14,-6,49,1,-60,116,80,-93,27,81,-44,-33,57,30,27,37,-28,48,-6,7,-7,2,-39,-27,62,14,23,66,4,5,27,-4,-33,-3,88,8,33,0,21,-81,16,-19,35,20,-49,3,-27,16,0,7,41,1,26,-4,20,-43,13,-15,7,41,-8,49,-35,21,56,-15,-16,25,56,-3,81,-50,-24,-10,19,8,-1,-28,-16,-28,28,2,-23,14,0,57,26,5,-47,-2,-28,-4,-22,16,-6,26,18,12,35,49,-56,-23,-23,16,29,23,5,-44,73,-24,-21,0,34,29,75,-53,-27,39,14,61,29,49,-56,-3,-40,9,-47,40,24,2,-46,25,-74,-26,-22,5,59,-47,-41,-62,-84,27,2,48,-12,-10,33,-41,73,-8,39,-21,-39,12,-54,30,-52,-15,-5,-27,-8,-27,0,-62,25,-24,-29,-16,-2,18,-42,-81,24,-11,-4,5,-108,18,7,16,-7,-19,38,12,7,10,20,17,50,-63,-9,8,-35,-10,44,37,-20,23,50,4,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.48","t":"Professional Relationship Issues † Practice parameters for telehealth (e.g., length of sessions, protocols for managing poor technical reception, waiting time before considering a patient a “no-show,” record keeping, etc.) † Discussion of reimbursement issues with telehealth patients and/or third-party insurers † Record-keeping requirements for providing telehealth services † Reporting obligations (e.g., duty to warn) in providing telehealth services † How to manage situations that involve potential for self-harm and/or injury to others † The types of information that should be included in a telehealth practice disclaimer † Emergency coverage that will be provided for distant telehealth patients † Information about the social or community network in which telehealth patient(s) reside","e":[26,23,-167,-39,48,-6,-5,-1,66,18,-19,-5,22,40,-6,-55,11,-47,-45,-17,-65,-53,-61,-28,-31,40,60,19,-26,-27,32,6,43,-42,-69,-74,16,7,-8,23,58,-44,-12,-58,32,-38,28,75,60,0,27,-54,-21,-10,65,-30,-36,62,29,-66,125,73,-80,44,84,-32,-27,42,20,-1,45,0,-5,-10,-20,-4,-44,-12,-2,49,26,30,75,-13,31,30,6,-20,-14,96,-5,19,-4,0,-95,9,-33,13,-24,-38,-10,-13,36,-4,4,17,5,44,-23,-2,-19,33,-16,2,39,-30,80,-41,26,47,-20,-14,36,87,-19,36,-16,5,24,9,-13,-9,-50,9,-22,61,19,-31,-20,25,90,15,32,-53,19,-17,1,-31,-11,21,10,20,-22,40,36,-48,-30,-8,62,14,38,-12,-59,77,-33,-19,-12,47,36,41,-42,-21,18,-11,47,29,79,-29,10,-35,27,-59,42,21,-27,-41,26,-61,-35,-21,17,47,-51,-26,-57,-54,5,23,54,-23,-1,35,-18,69,-12,30,-43,-19,-7,-52,28,-55,-6,4,-10,-3,-41,-18,-68,29,-9,-49,4,-36,9,-27,-42,33,-18,21,-15,-95,29,0,4,16,-19,13,25,32,14,19,9,55,-63,-2,-27,-39,-14,53,14,-11,19,31,26,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.48","t":"Specific Training † Patient’s knowledge and skill in using telecommunications equipment † Professional telehealth training workshops, symposia, or caucuses † The latest legislative, research, and clinical developments as informed by literature † Telehealth research and practice literature related to the patients served † Conceptual, methodological, and ethical issues in conducting telehealth assessments 48","e":[-6,8,-143,-28,79,7,9,44,61,6,-7,-15,31,20,-8,-78,27,-63,-28,8,-63,-37,-70,-36,23,7,12,7,-20,-58,1,-15,63,-6,-93,-51,21,10,10,23,38,-16,-19,-62,43,-31,29,18,38,-13,-8,-49,4,16,71,-20,17,24,24,-66,101,110,-130,24,71,-18,-17,66,-7,20,66,-25,32,5,-46,6,-9,-15,-40,40,18,24,68,16,16,29,-24,8,9,98,27,40,28,19,-88,9,-27,-7,16,-49,0,-16,22,-39,18,47,23,0,-17,2,-40,37,-27,10,2,-29,25,-34,-2,32,10,-23,18,47,-8,47,-51,13,-27,4,11,-34,-58,-21,-15,76,-9,-29,10,15,56,-6,3,-44,21,-16,5,-14,22,15,12,35,-6,4,44,-55,-6,8,36,33,18,22,-48,47,-34,-20,-13,28,62,34,-50,-49,29,7,59,33,83,-37,-10,-20,20,-38,14,20,-25,-59,-6,-65,-62,-12,3,53,-39,-46,-72,-78,43,13,41,-23,14,41,-43,62,-10,37,-48,-52,-19,-9,11,-25,3,-10,-9,-18,-31,-9,-35,27,17,-27,-31,-10,-2,-53,-73,43,11,35,-25,-86,12,-3,13,-3,-4,32,36,25,23,32,27,29,-77,-4,8,-33,-9,27,18,29,31,50,4,-33]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.49","t":"DETERMINING PATIENT COMFORT The decision to integrate innovative telehealth modalities into your practice must be carefully considered and discussed with patients. You must consider patient comfort and familiarity with technology as a patient’s willingness to engage. Your patient’s opinion of telehealth modalities impacts outcomes of implementation and efficacy of service delivery. Additionally, it is important to consider only technologies that are accessible, practical, and feasible for the patient because a patient’s familiarity with technology may impact their view of a clinical professional (e.g., some patients may prefer in-person or technology-assisted clinical interactions). The primary and secondary language of the provider and patient may impact service delivery such that a telephone- based or in-person interpreter may be necessary. Finally, providing care through any technology-based delivery system will not be effective if you do not ensure availability of time and resources before offering contact, communication and care. You must be able to provide and maintain quality, consistent care for services to be effective.","e":[-18,56,-161,-60,37,17,-22,-1,74,26,-14,-10,44,45,-19,-23,19,-68,-15,41,-75,-24,-61,-47,-8,41,44,47,-19,-12,68,-21,46,-33,-83,-59,35,26,-22,26,19,-16,12,-75,83,-1,26,-11,61,-36,4,-58,-29,-32,99,-26,-22,51,-7,-78,86,60,-68,49,59,-12,-41,37,21,3,35,-2,28,8,-39,-10,-31,-16,-20,61,44,-8,83,-43,36,-10,6,-18,9,112,7,13,23,33,-102,-4,-1,-14,9,-78,-19,3,-1,-3,-2,37,-6,26,-15,3,-32,19,4,-42,36,0,50,-26,17,18,4,12,13,32,-12,44,-35,-16,37,14,12,-8,-21,-10,-16,39,6,-29,18,42,67,-5,4,-41,-14,-39,-17,-8,-3,32,13,30,24,48,33,-58,-33,6,55,13,43,5,-40,43,14,-20,-10,2,29,27,-16,-21,30,1,47,-10,59,-50,23,-30,15,-32,20,-4,-34,-7,17,-56,-48,-22,28,40,-50,-47,-83,-46,49,22,57,-69,-14,57,-26,21,-52,69,-19,-13,-38,-55,35,-32,-26,2,-16,3,-10,-11,-59,40,43,-26,12,-5,-27,-50,-82,11,-20,23,12,-83,55,50,39,10,6,1,46,40,33,20,22,8,-64,-11,3,-56,-21,34,7,-15,13,10,16,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.49","t":"TIPS FOR CONDUCTING A TELEMENTAL HEALTH SESSION • Conduct a practice telesession before your first session with the patient. This will decrease the likelihood of equipment failure and allow you and the patient to become comfortable with the modality before the treatment session. Some facilities offer services that will conduct practice calls with patients before sessions with providers. • Look directly into the camera if you are conducting a video session, instead of at the patient’s image onscreen, to ensure good eye contact. • Pay attention to your surrounding background area, and remove anything that may be distracting on camera. • Wear plain clothing without busy patterns (e.g., plaid, geometric shapes) or bright colors. • Obtain patient’s emergency contact information at the beginning of every telemental health session and keep this information readily available through the session duration. • Verify patient’s physical address/location at the beginning of each appointment and note any changes that occur during the session. You should also take note of local emergency service information in the locality of the patient. PLEASE NOTE: If you call 911, you will be connected to emergency services where you are located. This can cause an unnecessary and potentially dangerous delay.","e":[-18,29,-181,-52,38,-46,-29,-10,71,-10,-3,3,40,60,-15,-34,19,-77,-51,-25,-44,-42,-46,-10,-10,12,20,63,-36,-45,50,-30,26,-9,-45,-53,-1,27,-37,17,79,-58,-18,-98,47,-16,65,0,7,-19,-22,-16,-66,-39,93,-54,-13,35,69,-68,137,41,-60,28,10,-19,-66,75,28,56,45,25,38,-13,-17,33,-12,-22,-15,23,2,6,83,-80,38,14,-9,-22,-17,79,50,9,28,62,-99,26,-17,89,14,-70,-3,-14,-5,-63,-27,44,21,0,-33,-30,4,16,-33,-32,15,16,78,-22,39,-17,-25,-36,3,23,22,35,-35,-15,25,5,-30,-12,-29,24,-17,34,12,-24,24,-2,35,4,-5,-44,12,-17,13,-48,8,14,-13,-11,31,47,81,-56,-19,1,55,42,33,-22,-45,40,-10,-51,4,60,34,0,-13,-22,1,-18,37,47,33,-67,17,-34,27,-46,-22,29,-24,-12,21,-24,-35,-53,6,66,-48,-28,-65,-25,56,9,22,-45,-27,14,-41,57,-27,63,-22,-34,-45,-28,39,-22,11,-17,-24,25,-28,-31,-56,59,0,-26,3,-34,-3,-16,-37,29,-20,-15,-10,-55,13,-24,14,-3,-21,29,4,36,11,38,46,-5,-75,9,-7,-39,-14,20,29,-6,40,-46,-6,-34]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.49","t":"OVERCOMING BARRIERS Providers who are unfamiliar with technology are often reluctant to provide psychotherapeutic interventions through technology-based modalities, due to fear of hampering the therapeutic alliance (e.g., communicating warmth, understanding, sensitivity, and empathy). Although specific challenges to providing telemental health services do exist (see Table 6.2), both providers and mental health patients have observed the therapeutic alliance over distance-based technologies to be comparable with that of face-to-face clinical interactions. 49","e":[3,80,-164,-40,81,31,-1,5,64,12,-30,2,43,34,10,10,6,-42,-38,35,-74,-41,-25,-56,-14,11,37,-5,-17,-11,66,-16,21,-28,-40,-35,43,19,-14,45,32,-21,-6,-77,48,-29,46,-4,28,-42,26,-60,-23,-33,94,-51,-42,62,-3,-58,112,67,-51,29,89,-3,-45,47,16,-8,58,6,37,44,-18,-8,-33,-49,-11,59,41,-34,40,-47,46,35,-1,11,-17,122,4,16,15,24,-96,22,-31,-10,-31,-44,-32,38,39,-11,0,27,2,4,-30,47,-24,46,-36,-47,21,-50,46,-49,35,-9,-2,6,-23,45,5,50,-29,-28,39,-9,22,-31,-46,8,-7,57,-12,-36,29,19,48,11,7,-44,-3,-58,-21,-20,-3,-28,24,53,18,48,24,-58,14,7,53,34,37,5,0,-10,6,-24,32,12,20,39,-40,-23,-16,14,53,55,46,-44,12,-39,31,-65,32,14,-14,-27,19,-28,-41,-43,-7,28,-59,-34,-84,-36,19,15,74,-52,-25,40,-28,40,-39,77,-28,-1,-22,-79,61,-35,-22,-6,-18,-31,-5,-34,-59,53,10,-38,7,-32,-5,-26,-82,9,-13,34,6,-80,34,24,28,2,-5,19,-2,41,32,39,-5,63,-32,5,-19,-22,-23,39,21,10,-2,0,17,-2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.50","t":"Privacy/Confidentiality † Complete written informed consent for treatment, review service that will be provided and limits of confidentiality when using electronic communications (e.g., wireless telephones, cellular devices); verify that the person engaging in the clinical interaction is the patient. † Make explicit to patients that all services are considered as taking place at the provider’s place of work, regardless of the location of the remote site. Crisis Situations † Exclude patients who are actively suicidal at intake; have knowledge of local resources available to patients within their community.","e":[36,30,-143,-28,94,37,-15,4,59,10,17,-5,32,-9,-12,-48,-10,-83,-25,32,-69,-26,-49,7,18,16,58,-5,-46,-25,30,7,48,-16,-59,-65,25,32,-28,3,63,-5,-16,-83,37,-30,24,1,54,-60,29,-19,-31,-13,112,-20,-1,32,5,-63,118,67,-69,22,71,-17,-58,62,-6,-3,34,-3,47,24,-9,-20,-8,-20,-21,36,48,-9,81,-44,51,34,-12,-24,-1,73,21,18,56,48,-74,14,3,16,-9,-47,-21,-33,-2,-7,23,41,-3,19,-34,-11,-7,29,-54,7,39,-34,72,-37,28,32,12,-1,-13,16,-13,56,-25,19,6,-7,-8,-11,-28,28,11,56,0,-46,22,4,28,45,-37,-6,18,-42,17,-23,-20,24,16,44,25,25,25,-44,-17,8,42,41,59,33,-72,75,-33,-30,-16,18,28,29,-58,-25,13,16,94,29,56,-55,43,-41,24,-39,11,32,-2,-11,32,-68,-14,-29,5,23,-39,-17,-68,-57,36,12,67,-48,-28,42,-48,47,-14,80,-12,-34,-11,-18,53,-57,23,2,-6,-15,-16,-32,-61,24,22,-14,-3,-25,8,-13,-106,31,-25,36,-39,-77,24,15,0,19,-22,28,15,9,-14,31,-5,26,-67,11,-23,-25,-8,29,11,17,38,5,21,-37]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.50","t":"SUPPLEMENTAL READINGS American Psychological Association. (2013, July 31). Guidelines for the practice of telepsychology. http://www.apa.org/practice/guidelines/telepsychology American Psychiatric Association. (2020). Telepsychiatry Toolkit. Retrieved July 02, 2020, from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit National Consortium of Telehealth Resource Centers. (2020). National Consortium of Telehealth Resource Centers. Retrieved July 02, 2020, from https://www. telehealthresourcecenter.org/ Shore, J. H., Yellowlees, P., Caudill, R., Johnston, B., Turvey, C., Mishkind, M., ... & Hilty, D. (2018). Best practices in videoconferencing-based telemental health April 2018. Telemedicine and e-Health, 24(11), 827-832. Turvey C., Coleman M., Dennison O. ATA practice guidelines for video-based online mental health services. (2013). Telemed J E Health, 19(9), 722-730. doi:10.1089/tmj.2013.9989","e":[7,7,-157,-35,26,-43,-34,-3,68,8,18,-39,69,49,-24,-49,8,-71,-47,-17,-80,-65,-41,-35,3,29,-4,24,-43,-6,44,-27,30,-15,-63,-46,34,15,-24,21,73,-16,-8,-57,37,-50,48,20,57,-30,-22,-6,3,-40,91,-50,-32,59,9,-67,109,55,-64,21,58,-14,-48,61,1,24,49,-32,24,1,-35,-8,-13,-70,-10,49,49,-7,51,-52,19,-12,-28,20,10,85,3,57,10,43,-22,5,-20,13,-34,-51,-64,5,43,-32,21,50,2,-17,-49,18,5,48,-3,-8,38,-39,59,-17,33,47,-22,-37,-6,48,-14,38,-18,-30,-11,1,-6,0,-46,36,-16,39,-17,-33,38,12,62,15,-10,-45,-1,-17,-11,-28,17,-4,30,38,31,22,6,-84,-36,12,82,28,29,-6,-26,98,6,-32,-5,19,35,15,-71,-29,27,-18,38,37,68,-56,55,-27,37,-25,38,37,-10,-54,-28,-33,-15,-20,-6,65,-110,-13,-76,-27,69,-29,52,-44,0,25,-33,55,-62,83,-27,3,-15,-52,44,17,18,7,-3,12,-44,-31,-49,65,-1,-17,27,-33,6,-23,-29,-1,13,21,-9,-100,20,-16,-4,23,-29,38,18,33,71,28,20,44,-38,1,-19,-27,7,30,53,8,9,50,34,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.52","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 7 Module 7: Orienting the Patient to Brief CBT OBJECTIVES • To learn how to convey information about the structure and content of CBT » To introduce the cognitive behavioral model » To introduce the collaborative nature of the therapeutic relationship What is Orienting a Patient to Therapy, and Why Is This Process Important? Orienting the patient to therapy involves: • A discussion of the theory underlying brief CBT • A description of how the presenting problems can be conceptualized and treated with this approach • Education about the structure, format, and expectations of therapy","e":[-2,27,-133,-63,57,-3,48,-42,38,-14,-8,15,80,-3,6,-43,-9,-35,-23,5,-37,-14,-11,-6,6,40,16,12,-61,4,57,-42,10,-49,-65,-61,62,50,-68,4,34,-18,6,-87,37,5,104,30,3,-14,-12,-52,27,-37,125,61,-2,27,20,-12,87,46,-56,75,4,-55,-32,46,-37,0,52,8,41,21,-45,23,-15,-22,10,32,45,-27,54,-29,57,-5,-16,-11,-6,59,0,26,25,29,-123,28,-47,1,-6,-38,-65,-27,33,-2,21,38,12,8,25,-34,-54,40,-30,-7,-22,2,59,-15,18,40,-7,-10,38,50,47,39,-49,-21,-7,-28,6,-22,-35,-37,20,29,-2,-1,30,32,23,0,5,16,-19,-10,17,-10,-25,16,-21,24,22,18,39,-65,0,-56,38,7,26,32,-64,38,-38,-53,18,11,32,27,-29,-42,20,-2,76,68,29,5,-6,-43,15,-29,39,60,-27,-14,16,-23,-26,-12,-1,35,-57,-27,-68,-53,22,-22,47,-23,-14,2,-21,50,-53,40,-20,16,-27,-44,45,-8,-12,-10,-58,-1,-13,15,-60,14,21,-8,-21,-10,-2,-1,-33,-15,-41,31,-39,-71,25,37,38,25,6,33,-2,49,22,40,72,-10,-78,17,32,-43,-4,39,-3,16,14,1,29,9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.52","t":"Orientation for brief CBT involves a discussion of the focused and time-limited nature of the therapy, plus the provider’s rationale for selecting brief CBT to treat a particular problem. As noted in Module 1, this rationale includes the strong research basis of brief CBT and the fact that it is an empirically supported treatment.","e":[31,42,-140,-88,44,9,62,-48,48,-29,22,7,82,-18,-19,-47,-17,-62,2,35,-35,1,-44,-19,-10,57,29,11,-52,3,58,-5,26,-5,-43,-74,58,10,-21,6,31,9,27,-80,41,-2,86,51,-1,-32,-12,-45,28,-65,107,11,-6,63,7,-6,85,64,-46,69,62,-47,-21,49,-33,-16,51,22,27,28,-48,23,2,-30,-16,38,23,-31,32,-29,54,-10,-15,7,6,51,8,29,23,33,-119,16,-26,-24,-21,-8,-70,-21,28,17,19,30,6,30,10,-25,-55,50,-41,-11,-33,-6,67,-31,34,40,-11,-5,15,52,16,47,-61,-32,20,-53,-10,-48,-23,-37,-1,42,11,-1,7,28,18,-17,12,12,2,1,29,-16,-1,40,-33,9,18,28,48,-52,-7,-10,37,20,22,24,-54,22,-44,-34,5,4,15,7,-39,-44,15,14,102,80,57,-15,2,-50,14,-20,16,60,-4,-32,36,-25,-44,-22,13,2,-69,-16,-90,-49,49,1,20,-4,-5,24,-8,58,-34,52,-15,11,-17,-44,86,-7,-29,-1,-46,-5,-22,22,-83,31,28,0,-12,-27,22,0,-54,-7,-23,26,-21,-77,20,34,16,8,45,19,-5,32,2,57,51,-15,-58,-12,34,-37,9,32,-10,6,25,6,24,-4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.52","t":"Many patients have little, if any, exposure to psychotherapy other than examples in the popular media. Although media may be a good avenue for disseminating innovative treatment strategies and therapies, there is an abundance of misinformation that patients may be exposed to. Conveying the legitimate science of CBT in ways that your patients can understand may help build motivation for change during the therapeutic process as well as debunk previously misinformed perspectives. Providing patients with an understanding of the therapeutic process allows them to be more active and aware of their role in the progression of therapy. Knowledge of the process of brief CBT enhances the collaborative nature of therapy.","e":[32,64,-152,-41,70,-14,27,11,44,-12,0,9,64,3,-11,-60,-39,-69,-32,47,-83,-44,-5,-14,-33,20,-50,4,-5,-13,63,-25,-8,-25,-28,-59,66,27,-21,15,40,-7,-8,-78,23,-18,57,0,-6,-46,39,-70,20,-1,134,-6,-15,25,4,-75,88,76,-58,48,68,-9,-57,58,-14,13,49,14,33,45,-40,-23,-47,-36,-54,31,62,-30,34,-47,52,12,19,-10,2,62,35,-13,30,45,-93,7,-34,-22,-37,4,-52,-8,7,-15,-4,37,6,-10,-1,19,-54,23,-40,-24,-8,-24,59,-40,5,45,-2,11,-3,26,9,44,-35,-47,14,-30,-47,-47,-19,3,18,77,25,-5,22,30,55,21,6,14,-17,-7,-6,-25,-32,9,-3,28,24,23,47,-52,-5,-22,64,28,58,8,-54,20,-40,-21,12,28,15,17,-69,-26,-19,17,78,19,66,-33,-2,-34,3,-20,16,9,13,15,33,-39,-44,-35,2,30,-40,5,-104,-27,29,15,36,-44,-26,36,-31,38,-41,68,-39,-2,-36,-62,55,-28,19,17,-42,3,6,-31,-63,33,38,1,-10,-27,-3,2,-54,-6,-16,37,-28,-72,39,32,2,13,-11,6,28,75,2,15,25,29,-74,13,18,-66,-12,29,6,45,45,-7,25,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.52","t":"When? (Indications/Contraindications) Discussing the rationale for CBT and describing the process of therapy should occur in the first session. However, it is useful to revisit the model throughout treatment to expand upon the rationale for CBT skills. The explanation of the model can be tailored to the patient's presenting problem, and examples to explain each component can be drawn from those generated in discussing problems specific to your patients (e.g., \"I can't seem to get out of bed, and then I feel worthless\"). For patients who think in concrete terms, it might be necessary to provide many examples and initially focus on behaviors rather than cognitions. 52","e":[41,31,-145,-43,60,30,53,2,40,-9,-33,40,50,45,3,-68,-16,-57,-18,14,-28,-4,-25,-25,5,64,-44,37,-13,-2,63,-5,38,-57,-63,-82,51,20,-36,-36,65,-14,28,-98,11,-28,114,36,-11,-23,54,-43,0,-38,129,59,24,41,21,-56,104,60,-43,44,61,-18,-53,69,-29,-1,52,-13,21,24,-43,-2,-24,-14,-26,48,41,0,81,-63,45,30,4,-8,-8,67,14,-2,-4,14,-91,-1,-63,-32,-51,-32,-52,-27,-11,-30,10,54,19,-28,-6,-31,-66,38,-33,-13,-23,2,83,-41,12,48,-34,5,6,40,20,62,-53,-16,34,-37,-18,4,1,10,33,55,19,-30,2,17,63,11,-1,0,-1,-44,29,-31,-40,18,0,28,4,25,58,-60,-19,4,49,-17,72,0,-69,47,-34,-23,2,26,22,9,-45,-38,-17,-10,74,57,72,-12,-5,-42,14,-39,17,19,-4,-36,15,0,-46,-53,8,22,-72,-16,-82,-54,50,-8,23,-7,-11,27,-52,31,-61,61,-33,1,-27,-21,48,-16,-16,24,-52,-13,6,-12,-36,29,17,-10,-8,-13,9,21,-28,12,-14,23,-30,-78,26,-5,28,21,12,-4,30,47,7,48,32,29,-83,-5,22,-62,2,51,-7,9,29,6,34,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.53","t":"INTRODUCING THE COGNITIVE BEHAVIORAL MODEL The cognitive behavioral model is a theoretical paradigm for explaining associations among thoughts, feelings, and behaviors. Most individuals believe that situations give rise to their emotions, as it may be easier to understand how intense emotional experiences occur in specific situations. However, the cognitive behavioral model suggests that thoughts we have about situations influence our behaviors and impact our emotions (Figure 7.1). This perspective does not negate the impact of external/internal stimuli (i.e., situations) on emotions, rather it facilitates a shift in perspective to facilitate the therapeutic process. For instance, individuals who are depressed or anxious tend to display patterns of unhelpful or “inaccurate” thinking. In the cognitive elements of CBT, the provider trains patients in specific skills that help them learn to improve their mood and change behavior by modifying the way they think about situations.","e":[-1,33,-140,-64,96,42,80,-13,39,-23,-3,11,96,60,16,-30,-19,-20,-17,37,-53,-20,-14,-17,8,97,-33,14,-11,15,27,-33,-12,-47,-76,-59,51,49,6,21,46,26,0,-76,4,-7,68,-5,36,14,18,-32,54,-27,118,39,34,69,-1,-69,92,57,-52,39,21,-7,-44,50,-29,-21,41,5,-8,29,-44,13,-16,-26,8,3,81,-12,63,-50,64,16,-7,19,-31,66,0,8,14,15,-91,17,-50,-34,-34,-20,-59,-26,18,-24,-15,41,-40,7,5,32,-89,37,-14,7,-7,-3,53,-20,14,53,17,20,0,36,-4,61,-63,-24,-1,-26,0,-24,-13,-21,26,36,-15,-8,11,58,48,11,-3,-1,-9,-25,15,-19,-34,-25,-9,48,-17,8,2,-48,-44,0,36,-7,64,14,-18,30,-42,-59,42,4,36,23,-61,-52,-1,1,81,29,65,-22,7,-43,1,-31,44,14,-13,-37,18,2,-38,-62,10,15,-48,-38,-75,-68,26,-30,60,-36,7,18,-33,22,-41,58,-1,-2,-25,-22,45,-19,1,25,-17,12,8,-7,-10,14,-2,-12,-19,21,1,-5,-28,-1,-31,38,-38,-64,49,8,49,39,-23,19,-3,31,12,60,38,36,-94,-8,-14,-44,6,39,3,15,4,-32,80,-9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.54","t":"INITIAL SESSION To prepare for the initial session, thoroughly review all intake information and use modules in this manual. You need the intake information to initially conceptualize and formulate a therapeutic plan. Using the patient’s presenting problems, symptoms, current level of functioning, culture, and history helps in developing the therapeutic plan. From the intake information, it is imperative that you assess the patient’s suicidality. This can be done by asking about the patient’s suicidal ideation, intent, or plan and determining his or her level of hopelessness, as well as the reasons for hopelessness. If the patient’s suicidality seems high, then crisis intervention is above all other therapeutic considerations. In the case of an acutely suicidal patient, seek supervision or consultation and follow approved clinic procedures for managing a suicidal patient (e.g., contact on-call psychiatrist for evaluation).","e":[10,17,-152,-62,58,9,1,17,16,-1,-38,-1,68,23,-17,-26,53,-73,-46,23,-45,-59,-50,-1,36,45,-7,14,-42,36,41,-24,10,-23,-60,-57,50,75,-12,-44,9,-48,55,-99,-5,-9,99,1,18,-34,38,-28,-54,-28,83,40,-2,41,25,-80,100,51,-41,4,44,-13,-46,47,5,3,57,2,22,15,-54,33,2,-6,12,48,26,-17,116,-84,45,23,10,4,-6,48,16,58,19,39,-107,16,-38,31,-22,-42,-37,-36,-11,-46,17,61,9,8,-9,-13,-44,37,-33,-23,35,-20,79,-3,33,23,-36,-3,13,59,18,29,-21,7,36,5,-21,-30,-48,-6,31,43,5,-45,-14,-6,24,3,-22,19,-14,-29,20,-11,-28,11,4,36,24,19,37,-58,-31,-10,43,3,80,2,-84,62,-11,-29,8,40,38,-3,5,-46,17,-18,76,25,86,-23,43,-42,17,-51,34,11,-6,-36,35,-21,-16,-31,20,51,-19,-45,-40,-29,68,-20,21,-31,-14,26,-66,11,-68,87,-20,-4,-18,-21,68,-34,3,7,-37,18,11,-18,-37,21,27,-5,0,-33,9,18,-65,2,-9,-13,-53,-53,24,-3,5,18,-19,21,6,35,-17,40,37,30,-100,19,6,-33,-12,18,-5,-6,18,-10,28,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.54","t":"Patient Expectations for Treatment You should inquire about what the patient knows about how therapy is conducted. Orienting your patient to therapy includes describing the cognitive-behavioral model and answering any questions he/she might have about the progression of therapy. Using the patient’s examples to help explain the cognitive-behavioral model will assist him/her in being able to see how the model can work and how it has worked for other patients with similar problems. Patients may confuse psychotherapy (i.e., typically uses Socratic dialogue, motivational enhancement strategies, and collaborative planning to foster patients’ motivation for change to positively impact psychopathology) with counseling (i.e., advice is given and the focus may not be reducing the contribution of cognitive-behavioral components on patients’ problems). Further, patients often think therapy is a place where they will come and be lectured and told what to do, or a place to vent without a focus on behavior change. It is essential in brief CBT that the patient understands that therapy is a partnership between the provider and the patient, in which they work together so that the patient can better understand feelings and solve problems.","e":[7,36,-128,-38,83,0,51,-8,43,14,-1,13,46,33,10,-32,4,-49,-35,47,-60,-35,-34,-20,17,33,-14,25,-38,19,51,26,9,-22,-78,-68,81,40,-28,7,61,-30,17,-113,19,-29,97,-20,11,-1,15,-40,16,-4,107,37,29,55,4,-42,96,40,-49,49,46,-11,-41,49,-52,-15,77,31,55,34,-33,-10,-28,-22,3,11,68,-19,44,-62,44,24,12,27,-17,80,-23,12,29,20,-110,28,-66,-30,-39,-35,-59,12,28,-11,-13,55,17,28,-18,-4,-54,22,-28,-14,-9,-20,57,-2,62,37,24,-1,11,45,27,49,-69,-29,23,0,12,-34,-46,15,-5,34,25,-18,28,14,75,0,23,19,6,-56,-6,-13,-30,37,-12,36,15,53,18,-61,-20,0,20,14,61,11,-37,42,-22,-51,44,11,11,31,-33,-43,1,3,76,44,83,-24,-8,-10,25,-30,35,6,-8,-21,22,-15,-39,-34,-1,26,-60,-15,-63,-49,37,-25,50,-27,-19,38,-34,53,-52,88,-18,-9,-26,-56,35,-45,5,39,-38,4,-7,-4,-49,31,38,-55,-27,-3,12,1,-38,15,-8,32,-13,-100,25,20,40,20,-45,11,25,51,15,54,41,29,-75,1,2,-34,-11,52,9,39,26,-9,56,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.54","t":"Negotiating the amount of time the patient will need to be in therapy is also important. For brief CBT, patients typically attend weekly individual sessions for four to eight weeks. However, the amount of time in therapy and the number of days a week can be reassessed periodically and adjusted to meet the needs of the patient (see Module 8 – Goal Setting). Discussing Symptoms and Diagnostic Issues with the Patient Most patients want to know how they have been diagnosed. Explain the disorder in terms of cognitive and behavioral symptoms to clarify how CBT will directly address their problems. Giving patients descriptions of common symptoms of their disorder can also be helpful.","e":[6,29,-163,-65,14,-31,50,-17,66,-24,-23,27,30,-1,-2,-61,-29,-52,-58,35,-40,16,-15,-23,-47,66,-21,64,-3,25,46,-2,26,-39,-51,-73,71,24,-7,-23,68,-22,24,-96,32,-41,96,31,-24,-26,-19,-59,-24,-16,102,38,-58,29,2,-26,118,18,-71,79,40,-17,-36,54,-30,-15,33,-31,40,32,-15,-19,-35,1,-9,32,57,0,47,-66,77,1,-18,21,17,97,-9,12,-2,39,-58,-11,-29,-13,-29,-6,-46,-9,-12,-24,-1,38,-21,-11,3,-16,-100,24,-22,7,-14,4,23,-50,24,28,-15,-18,2,59,32,44,-41,-9,33,1,-34,-12,-32,7,10,37,38,17,-21,22,45,-15,8,25,3,-18,9,-44,-29,27,24,14,20,26,63,-52,-22,4,62,-1,25,-4,-65,33,-51,-20,4,46,15,0,-32,-67,-10,6,51,32,61,-19,-3,-35,28,-38,4,27,6,1,16,-75,-13,-42,34,10,-54,-6,-65,-45,59,-16,-6,-55,-20,14,-21,52,-9,57,-6,-28,-34,-43,40,-8,-42,24,-40,-3,-17,-16,-37,46,63,-9,-7,-44,21,9,-44,7,2,24,-18,-51,28,-2,-6,37,-14,-12,12,49,31,45,42,36,-100,-24,-1,-27,-13,21,-12,9,33,13,41,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.54","t":"In-Session Example 7.1 Example: There are cognitive and behavioral aspects of feeling depressed. Cognitive characteristics of depression include having negative thoughts about yourself, such as “I am no good,” or “Things are not going to get better.” Behavioral characteristics are ways your body tells you you’re depressed, such as changes in your appetite or sleep patterns. 54","e":[33,-4,-125,-54,64,49,53,-46,13,-48,-13,41,41,75,23,-41,-7,-41,39,91,-47,15,-83,-30,13,110,-18,-1,-19,41,-21,-17,8,-31,-52,-9,48,67,60,47,32,-2,20,-57,-29,-20,72,24,33,-19,37,-84,-8,-59,92,3,20,32,19,-54,86,36,-33,58,77,-22,-45,50,-50,-27,64,14,-23,20,-47,-2,-10,-6,23,13,46,-29,62,-46,75,37,-16,3,13,70,-9,-2,6,51,-83,14,-23,10,-16,-30,-19,-27,-26,-20,41,45,-21,-18,-22,11,-58,44,9,-24,1,-26,51,-27,-30,54,-28,5,21,54,26,30,29,-7,17,-10,-5,-26,-41,30,9,39,-37,-10,-27,21,87,-1,-21,12,-28,-46,31,-27,-31,22,-12,-9,32,-22,15,-64,-31,9,27,-13,57,41,-49,52,8,-44,-8,57,48,45,-29,-25,-39,-22,69,39,79,-23,27,-22,19,-28,29,24,22,-53,42,-31,-60,-39,17,4,-38,-27,-80,-66,23,-25,41,-39,26,9,39,19,-33,50,-3,15,-19,3,24,-24,17,-16,-17,31,-32,-21,-12,-12,20,-20,-18,13,49,28,-20,13,-18,-7,-6,-104,83,12,29,46,-41,-11,27,27,3,20,45,33,-71,-21,-57,-11,2,25,7,28,2,26,68,3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.55","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 7 Feedback The collaborative piece of CBT involves asking a patient for feedback on the session (e.g., “What did you think about our session today? Did we leave out anything you think is important to discuss?”) and on how the patient feels about the cognitive- behavioral model (e.g., “Do you feel you have at least a basic understanding of the model, or should we be sure to review it in detail again next week?”) at the end of the first and subsequent sessions.","e":[10,-22,-155,-57,82,10,59,-39,15,-21,-4,-3,37,69,20,-35,-3,-68,-9,26,-54,-16,-33,4,50,43,5,44,-46,-12,49,-38,22,-57,-83,-47,47,16,-96,-5,55,15,13,-88,49,15,100,8,3,-3,10,-34,12,-5,101,16,10,15,14,-51,83,26,-42,90,18,-43,-35,61,-36,7,19,9,58,46,-49,19,-31,-23,2,12,50,-48,64,-15,46,-18,-27,-5,-50,81,11,-6,3,20,-87,36,-22,-17,-31,-49,-69,-25,-3,-26,9,38,-26,6,9,-5,-59,-10,-45,-2,8,-11,51,-21,-9,39,-40,-34,11,24,27,65,-32,-1,-5,-29,-10,7,-29,-34,8,32,-14,27,13,19,13,13,-16,18,26,-29,31,-7,-36,-8,26,5,29,12,-2,-53,-17,-16,25,16,29,21,-43,42,-27,-36,22,21,77,28,-54,-57,16,-32,57,35,31,-30,-18,-46,31,-4,40,67,27,-2,5,-21,-36,-60,11,37,-36,-52,-57,-38,24,-36,55,-30,-32,22,-11,52,-52,55,-39,6,-35,-59,69,-31,-13,22,-27,33,-7,-2,-47,34,6,-10,-20,-8,-8,-32,-25,-18,-42,17,-24,-97,13,-9,17,27,-14,40,-16,50,43,24,51,-30,-102,22,5,-27,27,23,-8,11,7,-31,46,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.55","t":"Encouraging patients to offer feedback strengthens the rapport and trust within the therapeutic relationship and indicates to patients that they are active members of the therapeutic process. It shows that the provider cares about what patients think and feel and values their input. This is also a time to resolve misunderstandings about the cognitive model or things that occurred in the session (e.g., “Was there anything that bothered you about the session, or anything that you’d like to change?”). Getting feedback from the patient shows how important it is to work as a team and helps you work on sharpening your abilities in therapy. It also allows you to attend to and repair any real or perceived therapeutic fissures or needed treatment modifications in a timely way.","e":[20,21,-150,-78,90,1,67,17,64,-4,-1,25,44,33,6,-5,27,-81,-32,34,-66,-43,-63,-8,-1,37,5,17,-63,28,45,-6,25,-13,-55,-42,69,24,-21,-32,24,25,-5,-53,23,-43,36,-12,5,-14,0,-56,-40,22,111,-1,9,55,47,-72,91,45,-63,61,59,-7,-35,28,2,25,18,18,29,35,-42,33,-22,-10,-10,-12,77,-49,35,-37,47,27,-8,9,-54,93,22,16,13,22,-127,28,-30,-31,-56,-31,-45,1,35,-11,45,58,4,27,3,14,-42,-1,-58,-23,6,-21,64,-42,-1,45,-3,11,-37,32,8,74,-11,-21,20,5,-17,-22,-64,-8,10,70,22,-41,36,10,29,27,5,11,-1,-33,19,16,-24,13,22,13,13,34,22,-69,-20,-4,17,35,61,32,-57,31,-28,-27,29,-4,23,16,-43,-13,25,-31,87,21,73,-17,11,-41,16,-61,37,8,2,-14,44,-52,-50,-64,23,38,-34,-10,-60,-25,42,-22,67,-14,-38,21,-36,33,-37,61,-40,-6,-45,-53,36,-50,21,19,-28,8,-12,-3,-17,45,41,-7,-13,-23,-24,-20,-62,2,-33,17,-46,-78,20,10,32,0,-33,31,-4,54,11,16,18,33,-91,8,3,-36,-13,3,21,40,20,-24,37,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.55","t":"Highlight 7.1 Important Introductory Elements • Introduce Processes of Psychotherapy. » Transparent » Collaborative » Time-limited • Introduce Cognitive-Behavioral Model. » Research basis » Association between behaviors, thoughts, feelings, and situations » Use of examples from patient’s past week to clarify associations • Educate the patient about his/her disorder. » Description of patient’s problems in cognitive and behavioral terms. • Instill hope and empowerment. » Request for feedback » Creation of a warm, collaborative therapeutic environment 55","e":[44,3,-148,-68,71,-3,71,-10,45,-4,-3,-4,61,57,-12,-66,1,-55,-31,44,-74,-39,-17,-53,6,79,-37,-31,-57,-33,24,-12,13,-16,-35,-56,62,53,-28,7,28,14,15,-88,15,-1,60,-30,4,30,30,-6,5,-22,85,14,-1,29,42,-54,100,68,-83,65,47,-26,-39,69,-42,9,28,13,53,36,-26,-7,0,-34,23,24,47,-8,57,-41,33,8,-14,10,-37,50,-2,19,8,46,-79,13,-43,-10,-53,-49,-33,-15,27,-37,11,16,1,17,-28,35,-62,60,-35,-24,-13,-43,91,-22,42,44,-6,2,16,49,-7,30,-39,-28,-6,-41,-1,-20,-32,0,7,51,12,-12,2,30,33,40,-31,14,-2,-17,24,-23,-8,7,25,49,-6,35,-12,-83,-17,-42,16,-15,60,31,-43,31,-34,-68,26,16,55,25,-27,-50,-6,22,40,22,67,-43,18,-7,48,-57,36,25,9,-34,7,-43,-72,-7,-8,20,-48,-36,-60,-72,6,-61,63,-41,-20,25,-36,60,-48,94,-35,26,-32,-27,43,-43,3,-1,-34,7,-26,-12,-47,36,22,-5,-35,-10,-4,-2,-60,25,-37,28,-40,-74,10,-1,37,6,-19,23,-14,72,-1,33,62,22,-75,26,-5,-32,6,19,-8,18,35,14,11,-24]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.56","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 7 HOMEWORK ASSIGNMENT EXAMPLES 1. Keep a running list of questions you may have about the therapeutic process, and bring it with you to the next session. 2. Use the cognitive-behavioral model diagram for at least three situations you experience this week. 3. Create a short list of the things you liked about the previous session and a short list of the things you wish we could have changed about the previous session and/or concerns you might have.","e":[25,-18,-145,-56,61,-24,37,-44,8,-20,-20,-7,68,61,-9,-28,8,-68,3,4,-29,-21,-19,11,6,48,-3,39,-47,-7,13,-30,-19,-61,-68,-42,67,43,-71,-5,47,-26,-2,-77,68,-7,122,-2,21,3,28,-34,23,-21,100,41,13,6,29,-40,84,40,-61,57,-12,-35,-38,82,-54,10,53,5,61,28,-61,-11,-32,-15,14,34,31,3,86,-36,69,15,-21,-13,-15,76,-14,12,6,33,-63,39,-26,14,-33,-54,-60,-28,7,-33,-10,41,-2,-9,-5,-3,-81,24,-20,4,9,24,42,-31,26,49,-43,-18,5,24,35,49,-53,-10,5,-48,12,-28,-29,3,13,46,-20,10,18,1,37,-13,-24,34,-16,1,-5,-26,-51,-5,-6,3,31,-8,40,-26,-12,-29,36,10,30,-11,-43,58,-25,-28,12,50,52,39,-54,-68,3,-10,38,27,26,-16,0,-18,25,8,36,49,-8,-23,12,-14,-31,-17,-8,31,-36,-39,-93,-67,18,-41,22,-35,-24,12,-11,41,-56,53,-44,-5,-16,-50,80,-2,-12,13,-53,16,-18,-6,-56,1,-5,-18,5,-17,14,22,-14,-11,-30,43,-29,-78,35,-7,37,41,-8,47,11,68,32,38,75,-8,-98,24,16,-37,9,52,-2,7,7,-2,17,-12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.57","t":"Goal setting is the process of collaboratively identifying specific therapeutic outcomes for treatment. Goals must be observable, measurable and achievable and relate to cognitive or behavioral changes relevant to the patient’s presenting problem. Goals are tied to specific skills to be addressed in treatment. Goals increase the continuity of sessions; allow directed, focused treatment; and enable the patient and provider to assess the progress of therapy and identify change in an objective manner. When? (Indications/Contraindications)","e":[34,52,-128,-7,29,11,33,-14,16,21,30,32,112,19,48,-26,-13,-45,-17,57,-8,-35,-10,-18,-13,55,34,3,-30,5,10,45,12,-8,-40,-78,71,38,-6,-14,-29,-18,-19,-101,23,3,42,-3,52,-13,-1,-53,-48,-32,116,52,-13,36,19,-55,118,54,-62,59,43,-51,-23,9,-38,-1,46,16,19,16,-43,-16,-40,15,-27,12,48,-44,26,-25,52,38,18,25,-38,74,-25,38,3,-22,-110,8,-19,6,13,5,-68,-9,-16,-24,37,27,16,23,1,-1,-32,45,-25,-4,-24,23,96,5,18,41,50,-31,34,61,-2,6,-70,-35,31,55,15,-50,-32,11,-1,60,-1,-35,-2,17,52,-8,-4,-13,-37,-34,62,-18,-15,14,20,17,9,-1,23,-57,-52,45,34,-24,75,49,-62,22,-42,-20,-6,0,-3,41,-23,-37,-21,18,96,36,72,28,5,-31,14,-51,39,38,-50,2,49,-61,-45,-21,15,6,-18,-10,-32,-27,8,-14,45,-21,-64,31,-94,30,-21,79,27,2,-15,4,2,-16,14,-22,-10,-3,9,8,-26,12,16,-16,-4,29,45,-7,-62,-4,22,55,9,-45,22,18,8,22,7,10,46,67,-29,-11,25,2,-66,31,0,-38,-50,36,12,20,9,0,8,-50]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.57","t":"In addition to identifying the problem and building rapport, goal setting is one of the first therapeutic activities to be completed in brief CBT. Although goals can be changed/ modified at any point during therapy, to maximize applicability and benefit to the patient, a preliminary set of goals should be established and agreed upon by the end of the first or second session. How? (Instructions/Handouts) Goal setting begins with the identification of broad goals. These are global and refer to areas of functioning (e.g., family, work, social relationships, financial concerns, health). Broad goals are closely tied to your case conceptualization and the patient’s presenting problem.","e":[37,29,-143,-16,19,15,43,-9,14,-13,-6,22,101,15,15,-21,-10,-72,-16,46,-28,-24,1,-21,-30,59,14,23,-26,13,30,32,18,-23,-33,-61,84,44,-36,-30,7,-12,-4,-113,30,-45,88,16,30,-25,4,-34,-22,-64,114,50,-32,35,21,-57,107,50,-61,75,28,-44,-35,17,-45,-4,50,-6,38,36,-30,-15,-46,2,-20,25,28,-28,30,-34,53,24,12,19,-34,82,-13,25,1,4,-82,8,-11,-3,18,-7,-69,-15,-4,-2,16,26,16,-11,10,1,-49,33,-27,-5,-46,47,77,-12,24,59,13,-38,36,52,4,37,-84,-26,55,30,-4,-32,-34,2,2,49,5,-15,-10,24,22,-1,18,-9,-25,-12,36,-40,-26,19,5,14,45,9,36,-45,-21,29,63,-16,41,8,-58,28,-16,-13,-8,1,11,39,-27,-62,-28,4,94,45,70,29,2,-42,20,-52,27,58,-22,15,18,-54,-25,-39,21,17,-67,-4,-60,-27,31,-13,25,-19,-44,58,-63,37,-33,80,12,-9,-30,-28,41,-9,-32,-4,-40,-7,-7,12,-40,40,4,-13,3,-14,37,10,-38,-25,16,53,9,-46,31,29,24,20,12,5,16,62,-21,8,51,19,-88,25,7,-35,-33,28,0,9,23,12,14,-44]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.57","t":"Once broad goals are identified collaboratively, you and the patient should prioritize goals. This process involves determining the most central issues that cause concern and arranging them from most important to least important. Starting with the problem that has the best chance of being solved and is central to the patient’s presenting concerns can help increase the patient’s commitment to therapy. If one skill is prerequisite to a subsequent goal, you can prioritize that goal in treatment (e.g., relaxation before exposure, awareness of thoughts before thought challenging).","e":[51,24,-142,-15,43,13,47,-20,32,-2,-9,22,71,38,16,-2,13,-80,-17,39,-21,-34,-1,-31,-19,54,19,-27,-57,28,40,11,17,-64,-23,-79,63,47,-22,-14,12,3,24,-129,44,-26,53,0,45,-18,26,-23,-31,-49,75,56,-17,31,33,-38,133,65,-59,49,24,-49,-45,35,-36,0,24,-22,40,39,-34,33,-17,6,-14,-2,50,-28,62,-37,24,33,10,3,-29,105,13,26,12,38,-113,27,-29,-8,-18,-31,-65,-8,-12,-34,5,35,30,34,-5,15,-36,14,-33,8,1,14,86,-26,7,25,-15,-42,36,64,-17,41,-54,-14,49,54,-21,-32,-2,22,-25,76,-29,9,-3,6,24,18,10,-10,-30,-30,31,-18,-45,29,-6,4,32,19,46,-38,-46,-7,31,-28,44,21,-41,41,2,-29,34,-2,12,57,-32,-62,3,-3,107,52,76,-9,26,-41,5,-46,17,51,-52,-6,31,6,-44,-28,10,46,-37,-13,-56,-29,35,-37,1,-36,-57,16,-61,51,-58,86,-18,-9,-34,-53,35,-3,-18,27,-36,-34,-19,-5,-50,67,-9,-32,-14,-4,21,-3,-47,-13,-13,31,11,-41,49,35,25,16,-24,26,21,74,-19,21,40,8,-46,26,22,-24,-41,36,-3,-6,6,-16,18,-57]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.57","t":"Use a graded approach to goals, in which you take small steps in service of the larger goal each week through session content or homework assignments. Identifying and sequencing action steps involve breaking each goal into smaller steps to help the patient know what to do at every stage of accomplishing the goal without feeling overwhelmed by a huge task. It is important to note that all patient concerns may not be attended to in a brief treatment format. 57","e":[36,51,-166,-19,21,-8,59,-21,34,-16,-14,-16,77,60,-15,-35,11,-100,-42,45,4,4,5,-27,11,38,-1,-28,-49,24,-1,14,26,-41,-17,-58,73,11,25,-45,4,-8,5,-98,53,-47,67,-24,58,-12,13,-48,-35,-22,76,62,-1,24,54,-24,115,60,-36,36,39,-34,-34,24,-12,-5,28,-14,73,9,-71,15,-21,6,5,31,23,-35,114,-19,64,9,-11,32,-29,90,-46,4,31,25,-130,23,-11,46,-34,-53,-64,-5,3,-52,12,33,17,30,31,13,-18,38,-39,-5,0,60,87,-9,-6,15,-3,-64,6,43,-4,35,-57,-11,41,-7,12,-45,-46,19,-6,50,-41,0,10,-18,6,4,-11,3,-7,-20,6,-38,-22,2,16,7,16,22,62,-39,-22,35,36,-10,66,-29,-42,49,-37,-30,37,1,25,-1,-40,-38,9,4,59,47,76,-35,-3,-47,35,-18,35,49,-15,-21,53,-33,-16,-26,-8,12,-13,-35,-36,-30,39,-37,-21,-30,-29,2,-76,22,-4,74,6,-3,-15,-2,52,1,-28,-3,-26,-21,-11,-11,-60,46,22,-19,13,-37,71,31,-47,-12,-13,23,-25,-69,21,-14,39,-8,-4,7,9,75,-11,39,54,0,-51,43,14,8,-44,41,32,14,7,5,35,3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.58","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 8 Once goals have been identified and prioritized, they are operationalized, which involves defining the goal and all the steps that it will take to achieve it in concrete, observable/measurable cognitive or behavioral terms.","e":[-2,-7,-145,-9,85,5,50,-29,38,-37,-39,2,74,31,32,-53,-9,-68,4,34,1,-7,19,-18,41,46,23,-1,-55,-2,30,-31,3,-75,-53,-69,57,17,-53,-43,5,-3,12,-97,38,17,90,33,22,-9,13,-28,29,-19,121,63,7,7,-11,-32,131,73,-50,66,-3,-35,-51,41,-44,-12,45,-23,27,44,-46,9,-53,-11,-11,39,45,-18,79,-15,41,-17,-3,-11,-30,68,-20,8,11,18,-90,34,-15,-1,12,-30,-68,-38,6,-37,15,47,1,-23,-1,-8,-56,24,-51,20,-29,8,61,-21,-12,53,-9,-47,44,35,22,51,-45,-7,1,-10,28,-15,-7,-19,-24,41,-15,0,24,45,5,-2,-9,-2,-7,-35,24,-2,-29,-6,-5,16,11,5,42,-16,-6,-26,50,-8,35,1,-55,35,-36,-50,15,7,50,49,-35,-47,-1,-2,73,47,41,11,3,-38,-8,-9,40,92,-22,-33,20,15,-18,-15,-22,45,-33,-24,-53,-37,5,-33,31,-69,4,5,-36,32,-47,52,-11,35,-27,-13,77,-18,-25,1,-25,-18,-21,-5,-46,6,0,4,-9,2,11,21,-25,-32,-22,52,4,-63,37,19,-1,53,11,43,34,73,23,42,61,15,-62,16,1,2,-28,42,-1,4,3,3,25,-19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.58","t":"Another important process of brief CBT is ongoing measurement-based care (MBC) used to assess the progression of the patient’s symptoms throughout therapy. Use disorder- specific, validated self-report tools allowing patients to identify the degree specific symptoms contribute to their distress. This process informs baseline distress and end-of- treatment progress and identifies areas still requiring attention during therapy. You can administer self-report tools to patients during the first and last sessions and as frequently as each therapy session. Some gold-standard instruments are as follows: • Depression: Patient Health Questionnaire (PHQ-9, 9 items; PHQ-2, 2 items; Kroenke, Spitzer, & Williams, 2003) • Anxiety: Generalized Anxiety Disorder-7 (GAD-7, 7 items; GAD-2, 2 items; Spitzer, Kroenke, Williams, & Lowe, 2006) • Suicide: Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2010) • PTSD: PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, Keane, Palmieri, Marx, & Schnurr, 2013) • Alcohol Use: Alcohol Use Disorders Identification Test - Consumption (AUDIT-C; Bush, Kivlahan, McDonnell, Fihn, & Bradley, 1998) • Drug Use: Drug Abuse Screening Test (DAST-10; Skinner, 1982)","e":[50,-22,-176,-64,36,-30,51,-26,45,-26,32,19,79,8,-10,-65,-38,-49,-32,44,-61,-28,-26,-24,12,70,-8,36,2,27,60,-16,27,-46,-66,-38,83,48,-17,2,54,-28,17,-83,31,26,92,40,15,-5,48,-58,66,-31,112,0,-27,41,13,-44,78,22,-64,49,62,-34,-24,29,-55,24,66,-7,62,84,-48,14,-48,-35,-1,49,44,9,81,-43,75,-13,-23,16,-13,44,25,0,-17,58,-82,47,0,-39,-14,-31,-28,-30,-6,18,22,33,6,-1,3,4,-69,49,-41,-13,-8,-4,63,-22,-24,35,9,-14,16,25,-14,59,-32,26,36,-17,-20,-27,-27,5,9,67,16,8,-18,21,24,-8,-26,22,-18,15,37,-19,-48,1,8,20,-1,16,42,-32,-37,3,56,46,20,-8,-65,46,-19,-69,6,52,32,23,-48,-68,1,-5,46,45,61,-8,47,-54,55,-28,58,37,-4,-5,15,-56,-15,-42,33,33,-93,3,-88,-55,31,-8,16,-76,-13,49,-30,31,-38,79,-11,-4,3,-44,65,-5,-2,-9,-47,-7,-34,-24,-6,28,18,-5,9,-30,49,41,-27,-16,14,8,-27,-83,60,17,8,22,-10,36,8,59,9,28,31,4,-83,18,-3,-37,20,35,-16,1,35,7,29,-2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.58","t":"In-Session Example 8.1 Example Goal: Learn two cognitive and two behavioral strategies for coping with stress. 9 Operational Cognitive Goal • Learn and use thought testing and problem solving to manage anxious thoughts/situations. 9 Operational Behavioral Goal • Plan and complete one pleasant or social activity per week.","e":[-9,3,-173,-14,51,-36,42,-60,41,-12,-29,-2,45,58,40,-38,2,-63,-42,1,-5,-25,18,4,10,102,-10,-17,-34,29,16,-10,-4,-38,-41,-42,53,41,5,-39,13,-55,30,-86,34,-43,72,6,64,-22,35,-37,-9,-36,125,48,7,35,17,-25,128,8,-45,31,23,-35,-39,78,-61,29,78,-9,29,6,-76,-16,-25,-24,-3,46,44,-15,60,-29,95,15,-5,-3,-14,76,-1,39,2,35,-78,37,-6,-2,12,-3,-39,-22,9,-50,22,28,-17,9,-27,25,-54,71,-15,-2,-14,10,57,-11,23,32,-10,-36,13,53,38,41,-60,-18,11,5,7,-41,-43,9,12,15,-41,-27,36,28,37,-10,-60,10,-13,-67,24,-49,-38,-4,-31,18,8,41,59,-25,-48,-9,49,15,74,-21,-72,56,-31,-43,36,43,38,10,-30,-76,-28,19,68,19,65,14,-4,-18,37,-45,40,33,-16,-33,50,-8,-61,-14,-8,29,-32,-23,-79,-77,37,-2,31,-16,6,-5,-17,4,-33,46,-8,-23,3,-36,58,-8,-35,7,-3,0,6,-11,-34,0,21,-29,-23,-33,39,12,-5,19,-10,30,-20,-66,29,-7,5,39,-3,43,29,75,24,43,42,3,-55,40,-40,-11,-27,37,18,18,6,-17,32,-44]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.58","t":"ASSESSING FACILITATORS, BARRIERS, IMPORTANCE, AND CONFIDENCE Once a goal or multiple goals have been established, it is critical to assess the patient’s situation and attitudes about the goals. For example, ask whether there are aspects of the patient’s life that may facilitate or inhibit the goal. A strong family and social-support system may help a patient to reach a goal, but a functional limitation may create an obstacle. Explore facilitators and barriers and discuss strategies to maximize the chance of goal attainment. 58","e":[28,49,-164,5,56,29,45,-9,21,-3,-23,-11,51,63,53,-9,10,-87,-25,49,-38,-29,-40,2,36,64,21,-17,-80,22,13,5,21,-71,-20,-66,46,54,-8,-24,-13,0,-11,-84,41,-12,39,-24,70,-33,10,-31,-17,13,85,44,-16,36,28,-23,83,58,-70,18,36,-24,-11,52,-26,-7,27,5,50,27,-39,41,-32,13,-16,9,74,-31,90,-13,36,21,-12,20,-39,71,-4,32,37,18,-114,33,-36,-13,-19,-27,-54,-2,9,-17,41,13,26,55,18,21,-63,28,-60,-25,-5,-4,74,-13,13,27,9,7,26,72,-14,59,-50,-19,31,15,20,-40,-16,-34,-12,47,-22,9,4,6,34,16,24,-27,-7,-58,13,-6,-43,-11,2,53,28,30,8,-70,-33,38,32,-1,76,-2,-35,46,-5,-14,25,-14,9,52,-3,-45,0,-3,85,11,56,-22,11,-32,14,-54,42,44,-40,-49,38,-30,-62,-26,34,39,-1,-21,-49,-9,56,-17,29,-46,-46,13,-46,46,-25,75,-3,-9,-50,-19,49,-24,-30,27,-8,-5,3,6,-7,36,27,-20,-14,-12,23,13,-85,-25,-8,59,-11,-88,45,29,15,-9,-16,29,24,22,0,28,39,25,-51,2,11,-27,-10,33,6,38,13,5,9,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.59","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 8 Assessments of importance and confidence are also important. Ask the patients to rate the importance of the goal on a scale of 0 to 100 (where 0 is not important and 100 is very important). Discuss ratings lower than 60 or so, and refine goals to increase meaning. Similarly, ask patients to rate their confidence in obtaining the goal. Here, confidence ratings could be a little lower but would, hopefully, increase as treatment progresses.","e":[1,30,-162,-35,79,31,36,-1,12,-11,-29,11,56,15,18,-6,5,-88,12,27,-40,-41,-28,-10,39,62,-10,24,-69,8,40,-19,5,-61,-62,-54,55,54,-34,-27,35,-15,15,-48,53,40,76,18,43,-6,12,-37,43,-7,118,66,-28,0,21,-18,86,37,-61,62,17,-34,-29,33,-61,17,15,-23,29,62,-92,5,-37,-6,-12,43,37,-12,88,-7,31,-18,21,16,-4,68,-9,13,10,46,-75,44,-7,-28,-7,-19,-70,-8,-11,-31,-10,45,15,11,4,-15,-64,5,-42,-32,-6,18,75,-33,-21,42,12,-24,52,51,21,59,-36,21,14,-23,0,-30,-43,-47,-3,61,7,13,12,35,-5,34,5,1,-5,-57,21,4,-27,-13,9,-13,35,19,4,-38,-6,8,39,25,60,1,-31,36,-29,-44,32,3,43,55,-9,-45,26,-37,42,0,35,-7,22,-57,27,6,33,51,-28,-22,44,-25,-31,-35,13,36,-50,-23,-69,-15,53,-30,15,-37,-27,6,-29,17,-61,61,-18,5,-57,-64,56,-24,-42,25,-30,-6,-8,-5,-32,40,26,-6,23,-23,14,13,-40,-14,-21,48,-8,-93,33,41,-11,20,7,21,39,72,34,48,72,9,-76,14,-2,-37,7,40,-13,20,19,5,26,1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.59","t":"TROUBLESHOOTING GOAL SETTING Some clues that goals may need modification are worsening symptoms, no change in symptoms, patient failure to complete homework (see Module 10: Homework), and patient/collateral report that the patient is not benefitting from treatment. In these cases, it is important to revisit initial goals with the patient and elicit feedback about the progress of therapy (e.g., “What do you find helpful?”). Often, too-ambitious goals need to be modified. In these cases, it is important to frame the revision in terms of taking small steps towards lasting change, normalize the difficulty of making changes when depressed or anxious, and join the patient (e.g., “I think I may have gotten a little ahead of myself; let’s modify these a little, so that they can be the most help for you”; “I may have missed the mark on this one; what do you think about adding/changing/removing a goal?”). Goal revision should not imply to patients that they have failed in therapy. It is an opportunity to model functional change in response to changing situations.","e":[46,20,-154,-15,29,7,20,5,45,-9,-4,10,69,30,-4,1,44,-63,-25,53,25,-60,-21,-27,-11,52,19,-8,-39,33,50,8,-17,-64,-56,-36,85,63,6,10,34,-4,3,-96,29,-33,95,1,55,-21,48,-33,-30,-18,80,49,-4,24,41,-78,103,29,-49,69,8,-31,-15,7,-34,-18,56,33,7,47,-66,20,-44,6,-27,1,32,-21,63,-42,73,19,21,53,-27,72,-23,13,16,-8,-97,15,-11,28,-44,-13,-55,-22,-17,-28,8,44,38,8,10,-3,-58,33,-20,-25,-1,2,64,-20,-1,68,-23,-33,25,46,10,23,-53,-32,69,25,-22,-25,-51,33,11,54,3,-12,-3,-5,60,6,55,-1,-15,-51,24,-17,-50,-3,-2,-6,35,19,27,-43,-32,27,42,-15,66,-18,-71,62,11,-13,11,48,-7,63,-30,-44,41,-11,59,34,98,-25,-34,-57,30,-33,42,24,-16,5,33,-19,-53,-28,26,55,-32,-27,-28,-29,41,-19,25,-12,-41,35,-34,17,-31,46,-6,-7,-27,-1,43,-20,2,2,-10,-5,6,7,-40,30,-3,-17,4,-4,52,20,-29,-20,-11,26,5,-86,41,10,28,-9,-12,-1,54,85,-15,12,44,23,-59,34,-5,-15,-23,47,25,48,6,25,36,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.59","t":"If a patient is worsening, discuss any changes in context (e.g., relationship, work, sleep, medication compliance, physical health) the patient is experiencing. Create a new goal pertinent to what the patient believes is worsening and what might help. At this point, you should also consult a supervisor/colleague or other professional (e.g., patient’s treating physician). If patients are not improving, elicit their feedback about changes they are experiencing and their perceptions about why these changes have occurred. If a patient seems to have trouble understanding the assignments, focus on more concrete and behavioral skills. Highlight 8.1","e":[46,-6,-146,-51,82,30,-7,-30,46,-18,12,66,54,36,1,-14,21,-65,-31,9,8,-22,-39,-9,-8,44,-12,22,-46,49,47,37,-1,-28,-34,-60,84,56,23,-2,51,-12,52,-114,42,-50,36,4,23,-11,-7,-60,-26,7,88,34,-2,35,22,-81,99,37,-34,58,28,-23,-39,67,-15,1,37,25,-1,27,-80,18,8,-48,18,33,56,-29,89,-40,55,11,13,19,-20,101,13,6,36,27,-127,-10,-18,-7,-46,-62,-66,-17,6,-34,2,50,20,28,-14,-3,-40,15,-12,-40,42,-13,56,-14,5,61,-10,15,-5,41,44,52,-52,13,71,-3,-19,-24,-24,21,-26,84,3,5,-1,-10,59,23,30,28,-29,-34,49,-21,-31,10,14,38,24,-2,55,-36,-32,24,38,-4,74,-11,-68,66,-3,-41,19,47,5,38,-39,-37,23,2,77,59,58,-31,-28,-31,-1,-20,21,25,22,13,0,-42,-40,-48,0,9,-32,-25,-47,-47,14,-40,36,-36,-25,5,-18,36,-41,39,-42,-41,-27,3,34,-11,11,-7,-55,4,0,27,-45,47,0,-31,-4,-3,24,-24,-65,11,-34,26,-11,-61,35,4,15,-11,-23,23,34,80,-4,57,30,8,-42,37,16,-30,-15,71,30,36,33,14,40,-43]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.59","t":"Tips for Goal Setting • Provide Rationale for Setting Goals. » This helps painets understand the direction of treatment and how they will be involved in the process. ƒ Example: “If you can identify what you want to change about your situation, we can then take steps to correct the problem.” 59","e":[38,38,-135,3,84,-13,-2,-24,38,-6,25,25,108,35,18,-35,16,-54,29,57,8,-76,-22,-29,-20,48,9,12,-28,3,22,21,6,-52,-40,-67,86,16,-4,-31,2,-45,4,-113,17,-41,60,-9,47,-3,16,-62,-52,-46,91,33,20,37,63,-40,104,73,-43,62,24,-41,-36,49,-23,28,61,20,27,11,-56,-1,-28,21,-10,35,39,-19,58,-48,26,13,28,31,-16,77,-28,30,41,36,-79,10,-16,42,-25,-23,-36,2,-8,-22,20,36,44,26,23,-2,-38,25,-5,2,-31,39,93,-21,21,67,9,1,19,54,24,21,-67,-47,54,31,20,-42,-36,13,26,83,1,-28,42,4,69,0,13,-44,-37,-41,29,-17,-29,7,2,7,45,14,70,-59,-49,46,47,-43,53,2,-65,33,-17,-14,17,29,-12,31,-23,-42,-5,29,108,29,67,22,-16,-64,44,-61,50,45,-31,-16,26,-35,-84,-3,-13,12,-25,-17,-39,-48,25,-37,-1,1,-27,12,-76,21,-30,59,21,2,3,-6,32,-6,-5,-15,-54,10,29,4,-41,25,-15,-6,-6,18,33,1,-22,5,23,29,1,-73,30,15,7,-9,8,13,47,68,-2,8,60,14,-50,50,10,-45,-29,60,43,5,3,49,-2,-65]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.60","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 8 • Elicit Desired Outcomes. » This involves assisting the patient in defining goals and specifying reasons for coming to treatment. ƒ Example: “List a few things you would like to get out of therapy.” • Be Specific About What the Goal Is. » Determine each goal, what the goal is attempting to target, and what the patient’s role is in reference to the goal. » Guide patients toward goals that require change from then (vs. others). ƒ Example: ”You said that you want your wife to listen to you. Since we can’t really make someone do what we want, what could you do to help you feel heard or cope with a situation when you don’t feel heard?”","e":[-15,5,-133,-60,88,12,33,-2,33,-28,-26,21,71,18,29,-7,16,-64,-12,32,-24,-26,-14,-3,25,30,17,44,-80,5,11,-13,32,-53,-68,-55,69,43,-73,-16,25,-25,-2,-92,45,-11,108,25,-1,-37,8,-54,26,-8,145,40,4,18,-2,-36,96,46,-60,74,32,-50,-36,22,-49,-14,61,4,24,24,-47,-9,-67,-16,1,37,37,-53,53,-39,15,-8,-2,-6,-12,38,-31,15,9,32,-103,23,-15,-27,21,-39,-64,-23,23,-33,7,36,8,12,5,-9,-49,26,-37,-27,-24,2,55,-9,-11,68,2,-10,12,26,43,44,-60,-15,9,4,27,-32,-37,-4,4,39,27,-1,39,32,44,-2,-20,9,-29,-35,28,15,-45,-1,-3,5,43,41,46,-32,4,-2,35,6,58,-8,-72,50,-32,-29,8,16,48,59,-24,-69,-17,8,63,42,53,-1,-2,-50,1,-13,57,58,-16,-3,10,-15,-6,-28,-9,20,-54,-15,-63,-42,8,-44,18,-48,-22,27,-33,40,-60,52,-8,19,-17,-32,78,-25,-22,20,-72,-4,-2,-10,-50,30,29,-3,-8,16,6,28,-30,-28,-31,42,-18,-86,30,17,17,26,18,39,20,77,24,34,43,2,-85,37,10,-26,-8,44,3,24,19,-12,38,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.60","t":"• State Goals in a Positive Light. » This clarifies what patients want to do instead of highlighting what they don’t want to do. ƒ Example: “List some things that you want, instead of things that you don’t want. For example, instead of ‘I don’t want to be depressed anymore,’ you could list, ‘I want to enjoy my favorite hobbies again.’”","e":[1,38,-140,-15,42,15,-10,-38,42,-23,7,50,89,49,18,1,9,-76,2,47,-14,-38,-47,-42,28,60,8,-16,-64,51,-31,23,10,-42,-34,-47,60,61,21,-33,40,-3,16,-98,48,-37,87,11,34,-64,29,-36,-21,-27,105,12,36,-6,5,-15,76,38,-13,71,77,-37,-50,7,-53,8,50,43,19,12,-74,25,-44,-11,2,19,42,-40,70,-64,60,37,20,16,-6,46,-18,-11,46,42,-125,12,-12,13,0,-43,-51,-33,10,-38,41,-1,5,24,-27,-23,-16,52,-33,-7,-10,6,67,-31,4,69,18,7,38,83,31,17,-54,-4,51,-7,4,-47,-32,53,-31,57,15,-18,25,-16,73,17,-16,8,-21,-65,26,-5,-32,22,-10,-9,54,-13,22,-72,4,26,22,-30,82,6,-43,45,-4,-56,14,49,-7,40,-30,-36,2,-3,95,-6,26,10,-12,-64,22,-33,55,44,-23,-17,29,-2,-60,-4,0,25,-41,-20,-57,-19,11,-38,37,-13,-41,3,-68,37,-74,36,4,4,3,-20,43,-16,-27,1,-45,-8,-2,-9,-42,26,8,-2,-20,-4,52,18,-24,8,-40,40,-12,-100,32,14,19,10,-5,50,19,55,-9,21,27,11,-74,47,-10,-16,-2,42,5,27,7,27,56,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.60","t":"• Weigh Advantages and Disadvantages of a Goal. » This aids in understanding the costs and benefits of the patient’s achieving the goal. » It may be used to motivate an ambivalent patient or identify salient goals for a passive patient or a patient seeking to please the provider. ƒ Example: “What would be the benefits if you accomplished this goal? What might be some of the costs to you?”","e":[22,67,-150,-25,51,19,-1,-15,35,10,-27,12,95,49,54,-13,8,-80,24,47,-30,-18,-20,-9,13,40,-1,-22,-73,24,-27,-3,41,-36,-40,-21,92,52,-7,-28,-9,-47,32,-69,64,-3,40,6,47,-13,-8,-60,-16,3,124,-16,-9,4,15,-7,111,64,-55,34,88,-30,-5,11,-41,30,59,-6,31,-4,-62,15,-24,12,-15,20,38,-57,83,9,70,17,19,-8,-43,64,-38,18,45,22,-152,0,-22,-5,7,-6,-43,-1,20,-2,47,35,37,15,6,-20,-38,28,-26,-10,-18,-27,63,-16,-24,39,10,17,1,82,-31,70,-50,-32,41,4,34,-34,-33,-5,7,60,-5,-14,-3,13,62,8,-16,-43,-23,-62,28,-8,-42,38,-33,18,18,54,26,-79,-21,28,27,-11,72,29,-43,26,-11,-15,30,14,23,50,7,-38,-6,-10,88,8,50,4,6,-52,-10,-44,44,37,-25,-55,48,-24,-67,-4,-5,7,-10,-22,-78,-50,39,42,28,-35,-47,20,-55,23,-12,26,18,-8,-25,4,39,-26,-6,11,-14,8,-7,23,-17,28,19,-11,-2,15,50,-4,-27,-2,-29,7,-14,-67,59,33,37,-6,28,46,8,45,23,-3,22,-9,-57,37,15,-39,3,55,25,53,13,16,30,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.60","t":"• Define Behaviors Related to Goal. » This instructs the patient what actions to perform in relation to the goals that have been set. ƒ Example: “What would it look like if you were less depressed? If I saw you and you were feeling happy, what would I see? What do other people do when they are happy? What things do you think have changed in your life since you have been depressed? What did you used to do that you enjoyed that you don’t do anymore?” 60","e":[35,5,-143,-2,55,-1,65,-60,41,-67,-14,59,83,57,26,-17,-24,-55,-39,80,-5,-2,-34,-19,11,60,21,-30,-46,10,-42,21,10,-36,-46,-14,65,75,40,-8,1,41,-40,-105,31,-51,52,-18,64,-25,21,-36,-15,-42,137,37,47,6,6,-39,92,35,-42,22,51,-37,-42,26,-63,-2,63,25,3,22,-51,23,-11,7,30,3,17,-32,38,-19,77,27,-5,18,-28,57,6,3,30,-4,-121,7,-19,-1,7,-32,-41,-40,31,-5,62,48,23,14,-5,2,-27,60,-5,-11,-17,12,65,-19,12,53,30,0,9,60,-3,6,-39,-4,18,42,6,-35,-21,37,-22,47,-5,-10,-10,19,74,-8,-14,10,-34,-34,27,-24,-13,-17,-29,6,12,-10,53,-37,-56,32,39,-28,52,9,-54,36,-20,-30,40,24,17,63,-36,-47,-11,-1,83,29,54,-7,-14,-50,8,-41,61,11,-13,-28,36,-55,-82,-33,-23,21,5,-20,-63,-39,5,-20,45,-47,-20,11,-49,47,-18,32,2,4,-8,7,22,-30,9,-8,-42,-6,-4,18,-22,1,0,-28,-14,-5,56,14,-19,6,-8,48,-25,-71,18,6,34,-2,-33,31,37,57,-14,28,38,10,-43,59,-21,-6,-15,52,24,44,24,4,64,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.61","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 8 • Define a Level of Change. » This determines how much a patient should do a particular behavior. » To increase the patient’s chance of success, set achievable goals. In other words, it is usually not reasonable to try to do something every day; and setting a goal like this will result in failure if the patient misses just one day. Alternatively, discuss the goal with the patient; and start small. If patients succeed, they are more likely to remain actively engaged. ƒ Example: How often do you think it is reasonable to do something pleasant? Once a week?","e":[-4,29,-173,-35,59,23,50,-24,44,-26,-23,18,64,29,29,-15,1,-79,-21,34,-28,-3,1,-14,21,28,7,30,-52,13,8,-22,36,-51,-39,-40,66,46,-12,-34,23,-14,17,-82,39,-10,110,14,13,-40,3,-69,20,-6,133,67,-4,19,-27,-37,117,27,-45,76,14,-18,-37,41,-49,-24,35,-18,27,28,-38,0,-56,-13,-9,35,30,-31,82,-27,48,-31,12,13,-26,64,-32,-6,14,29,-92,-13,-5,4,-2,-20,-81,-39,20,-4,-24,61,1,2,11,-16,-38,21,-45,-41,-10,28,66,-2,19,40,-15,-30,25,56,17,54,-39,-4,35,-3,26,-15,-41,-13,5,55,33,-9,15,15,14,-3,15,5,-15,-28,22,-20,-18,8,4,16,28,10,26,-25,-14,16,41,-3,40,-29,-76,33,-43,-12,-5,46,21,57,-11,-72,8,3,39,19,38,-17,-13,-67,2,-15,43,56,-3,-1,20,-55,-28,-38,-12,2,-20,-4,-65,-38,29,-21,20,-64,-36,34,-41,37,-45,53,-1,37,-32,-21,86,-20,-46,17,-21,-28,5,2,-43,24,38,-2,-7,-7,21,5,-14,-33,-20,46,-4,-77,-4,10,4,31,11,39,44,56,32,28,38,7,-86,41,-5,-35,-31,51,19,-2,16,7,33,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.61","t":"• Regularly Evaluate Symptoms. » Track how effective the goals are in decreasing mental health symptoms and increasing functioning and quality of life. » For example, assess the following areas during the intake process, during the actual intervention strategy, and a month to a year after termination of therapy: ƒ Patient’s level of satisfaction with your assistance and the results of therapy ƒ Amount of growth the patient experienced from the beginning of therapy to the end ƒ Benefits obtained by the change made by the patient and which treatment was effective in helping to accomplish the goal","e":[57,-5,-151,-33,49,-41,48,25,53,-33,-10,20,57,21,23,-29,-4,-82,-42,44,-39,-29,-38,-24,-1,77,5,27,-11,40,20,-8,18,-41,-42,-43,83,66,22,-46,33,-14,31,-86,35,-33,56,18,27,-48,19,-27,-35,5,117,51,-29,10,27,-64,107,29,-62,25,74,-38,-30,45,-48,-7,39,-9,24,15,-26,11,-12,4,-1,37,21,-25,62,-77,57,48,0,22,-28,101,-5,59,3,60,-106,-8,-6,-15,14,-26,-64,2,18,-35,51,41,10,1,2,1,-58,34,-24,-6,33,11,70,-22,11,52,2,5,2,29,8,-1,-26,6,33,42,0,-13,-35,13,-9,68,29,-25,21,-9,54,-40,2,19,-41,-46,27,-29,-32,7,-9,53,48,28,37,-69,-58,9,45,-4,57,-3,-28,74,-20,-52,8,16,31,40,-30,-33,16,10,88,34,75,0,17,-38,39,-45,59,12,-7,-24,68,-51,-67,-19,41,60,-54,-26,-71,-56,29,-48,11,-73,-19,23,-60,13,-48,53,-8,-18,-52,-37,42,-4,-12,7,-50,43,-25,-24,-1,31,31,-13,-14,-1,15,14,-65,4,-4,11,-23,-58,39,-14,-1,-4,-21,5,36,42,4,33,23,28,-65,26,12,-47,-14,30,15,43,23,36,40,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.61","t":"EXAMPLE HOMEWORK ASSIGNMENTS 1. Make a short list of broad goals. What areas of your life do you wish to improve (e.g., work, family, social, recreational, financial, health, etc.)? Think about which goal would be most important. 2. List three issues, in order of importance, that you want to discuss in the next session. 3. Weigh the pros and cons of each goal that we have agreed upon in treatment. SUPPLEMENTAL READINGS Beck, J.S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press; Chapters 3, 4. Cormier, L. S., Nurius, P., & Osborn, C. J. (2017). Interviewing and change strategies for helpers. Boston, MA: Cengage Learning; Chapters 3, 4, 5, and 7. 61","e":[46,-12,-123,-21,27,-4,23,-31,25,38,4,-16,83,90,-2,-28,-9,-61,2,40,5,-43,-25,16,9,49,-29,-14,-62,16,-8,20,-33,-43,-71,-46,108,50,-31,-13,19,-17,15,-76,78,-46,86,-22,66,2,10,-41,5,3,82,34,9,12,55,-28,103,45,-85,66,25,-22,-25,79,-66,20,45,-9,64,16,-68,-17,-9,-8,15,28,37,-23,69,-50,35,32,-8,5,-19,77,-23,38,2,29,-68,23,-14,-12,-23,-43,-65,-21,24,-21,44,27,17,8,-34,22,-71,30,-15,-1,12,19,75,-30,43,65,-20,-31,12,37,26,49,-78,-23,17,7,-14,-33,-27,37,-15,58,-50,-7,11,-7,67,-6,-5,27,-20,-23,3,-26,-57,9,-1,11,37,-7,45,-30,-23,-13,30,19,51,3,-72,91,-3,-8,27,38,32,58,-43,-64,15,7,69,8,73,0,18,-7,33,-28,24,0,-4,-7,31,5,-57,0,-11,16,-14,-20,-89,-71,39,-52,32,-26,-33,11,-45,49,-51,72,-15,-27,-29,-35,46,4,1,18,-44,7,-32,-7,-47,14,-10,-41,26,-9,32,20,-30,17,4,61,-24,-86,51,11,37,15,-3,42,34,104,2,33,59,-25,-74,31,19,-34,-27,37,17,28,17,34,13,-38]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.62","t":"Agenda setting is a collaborative process through which you and the patient decide how session time will be spent. You and the patient offer items you would like to discuss and then decide the order of items and the amount of time you will spend on each. Each item should serve a treatment goal (see Module 8: Goal Setting and Module 4: Cognitive Behavioral Case Conceptualization and Treatment Planning). Agenda setting ensures that session time is well spent and that both provider and patient have input into session content. When? (Indications/Contraindications)","e":[39,68,-146,-50,13,10,33,-41,33,39,21,15,66,54,39,-40,-31,-19,-43,7,-3,-15,-67,-7,-1,45,17,-19,-25,-1,30,11,21,11,-32,-104,61,24,-28,17,-5,-19,7,-108,-1,-3,68,2,3,-49,5,-37,-63,-48,102,24,-8,109,36,-30,139,35,-27,100,39,-20,-17,31,-32,4,44,13,42,-16,-29,10,-11,-17,-24,24,32,-40,73,-17,30,32,39,-12,-25,71,-8,3,-16,-10,-79,44,-22,7,-38,7,-69,10,-4,10,10,18,3,15,-3,-10,-19,17,-38,10,4,-5,112,5,48,13,21,-65,37,39,11,39,-53,-43,20,11,-14,-36,-12,11,16,40,-7,-54,10,18,39,7,-28,-28,-16,-10,55,-22,-10,30,-6,38,-7,14,24,-47,-28,1,29,26,102,23,-66,32,-46,-10,25,54,6,-12,-14,-31,-9,-5,63,44,84,-21,15,-13,-5,-24,-26,21,-33,-15,38,-60,-34,-41,-8,5,-10,-18,-48,-28,37,-2,37,-24,-48,1,-63,11,-29,80,26,3,-1,-25,45,1,1,-7,-22,3,6,13,-2,23,27,-47,-14,-10,49,-14,-33,-7,-33,33,-38,-77,2,11,36,10,-19,25,28,38,-41,17,34,-12,-70,30,24,-54,-55,42,18,-12,18,11,21,-51]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.62","t":"An agenda should be set within the first 10 minutes of every session. Without setting an agenda, it is very easy for vocal patients to “run away” with the session by recounting the events of the past week or describing the history of a problem. It is also easy for more passive patients to never indicate which items are most important to them. Collaboratively setting an agenda ensures that both your and the patient’s needs are met. Setting a time limit for each item increases the chance all items can be covered.","e":[46,40,-175,-42,27,5,16,-13,24,15,-27,39,39,87,39,-33,-15,-47,-58,29,7,-17,-65,-39,1,46,23,-25,-36,15,49,-6,38,-23,8,-113,27,8,-7,2,22,-16,29,-99,15,-21,84,21,3,-77,-3,-42,-74,-21,52,20,-16,79,51,-27,152,-10,-43,90,36,4,-19,32,-3,24,24,10,38,-20,-26,43,0,-13,-7,17,30,-26,90,-49,50,8,16,12,16,101,12,-9,-6,14,-62,32,-30,46,-51,25,-46,1,-7,-12,28,-1,-3,19,-15,-42,-15,29,-41,25,14,-4,114,-25,55,8,-22,-57,28,41,-1,35,-33,-20,53,4,-30,14,-37,30,15,59,-2,-27,9,-1,20,29,-10,-54,-19,-25,30,-24,-16,64,-18,7,11,42,23,-48,5,-11,13,1,87,8,-71,26,-35,-26,25,48,3,-3,-22,-19,6,12,40,32,71,-24,-1,-27,25,-48,-34,7,-34,-16,22,-56,-50,-54,14,13,-16,9,-47,-16,73,-21,18,-18,-24,-10,-45,26,-32,70,26,-11,-6,-46,65,22,-25,-7,-15,-12,-10,18,-8,36,20,-37,-5,-57,25,-22,-34,-7,-44,16,-22,-89,7,16,32,5,-15,26,15,39,-25,2,44,13,-85,-12,26,-64,-38,50,10,-15,21,0,24,-38]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.62","t":"Encourage patients to think between sessions about what they would like to discuss in session. If patients do not offer an agenda item, you can introduce an item and check with patients to see if they feel it would be valuable to discuss. How? (Instructions/Handouts)","e":[7,41,-144,-76,66,36,8,-29,50,-21,8,34,37,66,26,-20,1,-87,-27,29,-20,-15,-78,-21,6,26,6,-3,-45,39,36,-13,46,-2,-22,-79,39,26,-44,-10,22,15,-7,-89,54,-12,75,5,13,-67,23,-40,-36,2,93,31,22,67,78,-17,129,34,-10,58,58,-12,-45,48,-12,18,62,31,85,2,-37,60,-18,-13,-14,3,36,-26,86,-34,21,42,18,-2,-12,84,20,-26,34,35,-120,30,-27,-2,-53,-25,-59,-3,30,-17,32,27,3,56,4,-12,-15,19,-68,12,17,-32,92,-29,43,21,-15,-31,46,45,44,50,3,-28,24,-22,-7,-10,-42,-1,16,49,10,-53,38,-8,21,23,-35,-25,6,-60,46,-42,-38,34,3,21,21,43,39,-67,-10,-19,34,11,61,1,-60,20,-22,-41,47,38,35,-2,3,-38,16,-12,86,34,57,-12,7,-74,-2,-45,-3,9,-24,-40,25,-38,-40,-35,-17,41,-10,-27,-58,-30,63,-12,49,-10,-27,-1,-48,22,-53,55,-6,-22,-12,-51,81,-24,-33,12,-44,25,-1,2,-29,61,37,-18,-8,-41,32,-21,-26,7,-53,17,-49,-108,-11,8,45,-15,-14,32,5,33,-11,30,39,12,-62,-12,2,-32,-29,25,14,3,18,11,23,-3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.62","t":"It is your responsibility to model how to set agendas for the patient. In the first few sessions, you will be setting the agenda because often the patient is unsure of what is being asked or what to discuss in therapy. You can help patients become more comfortable with setting their own agenda by asking questions like, “What is the main reason you came to therapy?” or “What is causing you the most trouble right now?” or “What are your most pressing issues today?” or “What are your thoughts about the focus of today’s session?” It is also important to assist the patient in prioritizing issues on the agenda to give an acceptable amount of attention to each. After listing and prioritizing items, allot an approximate time to each item for discussion. In accordance with the collaborative process of psychotherapy, sometimes lower-priority patient or provider agenda items may need to be addressed at a later session (i.e., if it is not feasible to allocate adequate time for addressing said items during the current session).","e":[32,39,-134,-53,52,16,37,-22,48,15,-29,0,56,59,12,-36,16,-60,-42,15,-28,-55,-64,-26,0,41,14,-29,-20,27,43,3,6,-20,-16,-95,54,47,-23,7,34,-33,10,-143,11,-36,70,15,-12,-53,26,-42,-30,-28,85,15,11,88,36,-42,138,46,-46,79,42,-35,-40,18,-22,5,36,12,56,10,-41,18,-1,-22,5,7,43,-31,74,-60,17,41,18,32,7,95,28,13,-5,20,-89,43,-36,-7,-33,-11,-47,10,10,-23,19,12,-8,26,-27,-9,-21,20,-41,13,15,-16,93,-35,46,31,-8,-31,15,42,27,52,-37,-27,30,27,-29,-5,-26,24,7,50,-1,-26,22,8,46,8,-24,-12,-9,-28,39,-26,-33,36,-17,16,-2,24,50,-59,-12,-10,40,-6,69,16,-41,40,-19,-18,33,23,29,12,-21,-42,11,-15,84,62,83,-15,32,-29,14,-51,-6,-7,-27,-18,14,-53,-39,-41,-8,43,-13,-12,-62,-37,41,-38,12,-24,-36,0,-51,37,-48,86,6,-2,-9,-64,67,-30,4,9,-45,0,-3,-9,-25,57,6,-27,-22,-13,15,-9,-37,-3,-52,22,-38,-89,35,29,56,17,-45,29,9,55,-12,14,69,21,-73,16,26,-37,-44,38,-1,-2,12,2,25,-49]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.63","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 9 Pay close attention to time management of issues on the agenda, and steer the patient away from superficial issues. As time passes, the responsibility of setting an agenda for the session should shift to patients. This will eventually help them to set agendas, prioritize problems, and suggest interventions for issues encountered after completing therapy. This level of increasing patient responsibility also translates into their overall functioning by increasing autonomy of functioning as they work toward ending treatment. Highlight 9.1 Typical Session Outline","e":[15,10,-161,-67,52,15,55,-38,62,-5,-27,-4,52,36,31,-37,28,-36,-28,8,3,-9,-26,-7,22,47,14,20,-37,3,56,-20,-15,-62,-33,-77,64,38,-61,-2,31,-41,11,-98,30,2,89,27,-4,-22,41,-66,-16,-22,118,40,18,55,14,-34,113,38,-59,71,-14,-43,-29,39,-58,10,40,-8,34,34,-39,11,-31,-12,-13,12,23,-14,93,-47,32,-14,4,-14,-16,89,19,-2,6,45,-93,34,6,-8,-20,-20,-58,-7,25,-16,10,46,-9,5,-6,-30,-37,9,-32,-3,17,-11,78,-31,0,48,-29,-57,13,37,49,60,-44,-13,13,-3,-19,1,-8,-7,3,40,-2,-8,38,23,17,24,-12,6,-13,-28,32,-22,-43,-1,-17,5,-14,45,55,-33,-32,-29,41,9,40,-10,-67,22,-35,-36,26,26,17,37,-32,-60,-1,1,68,53,47,-15,12,-62,-2,-15,8,49,-9,-10,14,-41,-39,-47,-3,58,-18,-14,-68,-56,43,-28,14,-37,-18,11,-50,35,-46,47,-4,16,-9,-72,80,-8,-13,18,-64,-14,0,-3,-38,26,0,8,4,-35,10,-12,-19,-7,-32,34,-24,-69,15,22,31,33,-18,53,26,53,33,35,73,-14,-77,35,23,-44,-37,38,8,0,19,2,22,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.63","t":"1. Briefly review patient’s mood and/or physical functioning (Five minutes). Elicit responses concerning the patient’s mood, and consider any and all discrepancies (e.g., change in strength or nature of usual mood, change from last week or beginning of treatment). Ask the patient to complete a self-report tool to measure symptom intensity and frequency. Medically ill patients may benefit from regular assessments and updates on their physical health symptoms and functioning. Also ask the patient to offer explanations for mood improvement or decline. This brief update allows you to gauge how the patient is progressing and identify positive and negative change. If medication management or physician collaboration is part of the patient’s treatment, this is also a good time to check on any side-effects the patient might be having from medication and make adjustments as needed. 2. Bridge discussion from previous session with the current session (Five minutes). In bridging sessions, you are checking the patient’s understanding of what was discussed in the previous session. Reinforcing what the patient learned in past sessions is essential to the improvement that the patient makes outside the therapeutic relationship. Having the patient complete a Bridging Worksheet can assist in this stage of the agenda. Some issues discussed during this phase could become items on the agenda for the current session. 3. Set the agenda for the current session and prioritize the items (Five minutes). First ask patients what they would like to discuss, and then offer an item. If patients bring several agenda items, they might need to indicate which is the most important to discuss first. When patients offer a situation as an item (e.g., fight with boyfriend followed by food binge), you can use the situation as part of their agenda item, that is, as part of the skill being taught. For example, you can use the above scenario to teach/review a thought record. 4. Review any homework given in the previous session (Five to ten minutes). Patients who do between-session homework improve more than those who do not. To reinforce and troubleshoot between-session learning, it is important to review homework. In-session review serves two purposes: it reinforces the importance of homework and allows you to assess skill acquisition. If you identify errors in homework, you can use additional session time to review the skill. Reviewing","e":[34,0,-161,-81,26,-33,37,-20,50,-24,29,19,43,34,20,-38,8,-73,-58,20,-34,-13,-48,-21,-28,59,-24,35,-38,31,39,-20,27,-23,-55,-58,70,49,-16,3,49,-43,35,-92,54,-28,86,-17,-34,-15,-19,-42,-9,-26,103,18,9,57,60,-50,138,-19,-50,56,41,-18,-30,36,-23,24,51,25,44,31,-52,23,-18,-15,12,-19,42,-19,88,-94,60,-19,-17,19,-11,83,-9,1,7,41,-87,20,-17,-13,-26,-38,-53,-3,-1,-37,25,52,-1,34,-12,-14,-45,2,-20,15,21,-7,66,-23,-9,45,-15,2,21,27,36,24,-42,-28,49,23,-22,-2,-41,36,-16,65,50,-39,-7,-30,43,1,-13,6,-16,-11,15,-32,-44,44,6,5,27,35,54,-53,-13,-14,53,43,67,1,-77,60,15,-23,37,48,28,26,-42,-48,1,-2,48,39,73,-52,2,-26,48,-38,7,26,-17,-15,47,-55,-62,-31,18,31,-46,-24,-42,-41,45,-39,8,-54,-29,8,-9,50,-33,71,5,-22,-24,-40,57,-18,10,0,-44,16,-32,-19,-28,33,35,-34,12,-40,25,8,-44,29,-42,4,-46,-56,33,-19,14,5,-49,33,-6,61,1,58,56,20,-92,-6,1,-28,-1,46,32,25,28,-5,31,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.64","t":"homework can take a small amount of time; or it can take the entire session, depending on what patients have learned from doing it and what difficulties they have encountered in completing it. 5. Discuss agenda items and set up homework (20-25 minutes). Discuss agenda items, starting with the first and most important. If you are running short on time, inform the patient that you will discuss the other items at your next appointment. Set up homework that is directly connected to what has been discussed in the session. 6. Summarize the current session and exchange feedback (Five minutes). Two types of summarizing are recommended. The first is a brief summary that should be done after the conclusion of each section of the agenda to reinforce what has been discussed. The second type is used to clarify and remind patients of the thoughts they have presented and how those thoughts changed as a result of the exercise. It is important to use patients’ specific words in summarizing their thoughts. At the end of the session, summarize the main points of the entire session. As the sessions progress, ask patients to do the summaries. Finally, exchange feedback about the session, skill, or progress of therapy. This is a time for you to encourage and motivate patients to continue working towards change.","e":[68,35,-161,-53,3,-17,35,-21,31,20,-32,22,41,69,2,-36,21,-67,-79,23,-11,-19,-53,-16,-4,39,-29,-16,-31,22,12,-10,-26,-14,-41,-72,47,19,-20,-1,22,-41,18,-73,55,-37,82,-37,14,-27,-22,-33,-38,14,57,44,-11,32,87,-26,133,-1,-82,90,15,-8,-31,52,-9,39,22,1,84,-3,-67,7,-11,-12,31,15,30,-17,68,-47,65,-6,-17,16,0,93,-18,-1,-25,15,-56,37,-17,45,-53,-27,-68,-2,15,-26,51,43,3,7,-8,-6,-51,21,-55,23,4,-6,83,-26,36,28,-24,-63,25,25,41,48,-32,-11,35,12,-2,-6,-69,36,-9,43,-10,-31,-13,-24,32,-6,-3,-2,-13,-13,21,-23,-24,22,4,14,21,13,47,-23,-5,-32,55,25,67,-18,-90,59,-14,-12,15,56,14,7,-31,-47,21,-4,30,25,66,-22,-4,2,38,-37,-8,26,-13,-11,37,-47,-57,-12,21,26,-1,-26,-50,-5,86,-42,16,-21,-18,15,-20,35,-23,76,11,-28,-21,-14,56,19,-28,19,2,-11,-36,6,-24,32,31,-47,27,-49,21,22,-39,0,-45,26,-51,-82,17,-22,31,9,0,43,-12,79,-10,29,69,7,-104,1,22,-24,-39,34,31,-4,18,28,11,-23]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.64","t":"TROUBLESHOOTING AGENDA SETTING In discussing agenda items, there are many pitfalls for a new CBT provider. It is your responsibility to keep the discussion on track and focused. To prevent unfocused discussion, gently guide patients back to the topic when they drift; emphasize key emotions, beliefs , and automatic thoughts; and often summarize and rephrase what patients say. You can also discuss at the start of therapy that one of your roles is to keep sessions on track; so, you may, at times, need to shift the focus of conversation. Getting patients’ agreement on this point at the beginning helps them feel more comfortable if you need to redirect or interrupt later in therapy. Pacing is also a concern for providers, but prioritizing and collaboratively agreeing on agenda items and times can help you and the patient stay within the allotted time. When guiding the conversation with your patient, you can use a mix of close-ended or open-ended questions in response to time constraints.","e":[46,31,-148,-60,57,18,52,-42,38,8,-2,-1,24,42,23,-28,15,-56,-39,22,-19,-20,-54,-13,-17,44,-6,12,-37,9,62,-5,4,-28,-39,-76,55,19,-34,23,69,-17,9,-129,27,-36,91,34,3,-48,36,-23,-28,-42,86,23,8,96,36,-60,130,15,-54,85,20,-42,-25,31,-33,34,49,12,61,48,-44,0,-21,-28,-24,12,22,-19,72,-50,36,31,17,29,-15,89,15,-17,-15,4,-70,59,-17,-4,-50,-32,-58,-12,-7,-11,2,32,-4,3,-4,-2,-56,15,-52,-21,-13,6,109,-15,41,35,-1,-29,21,45,32,71,-50,-42,51,2,-37,-33,-5,19,-11,35,12,-22,27,9,43,9,4,-17,12,-29,29,-52,-10,30,-12,17,-14,32,40,-43,-20,-17,57,-13,60,0,-57,15,-3,-18,8,46,38,8,-45,-39,-3,-15,75,62,84,-17,5,-46,-5,-20,0,38,-28,7,16,-79,-17,-56,5,37,-45,-11,-51,-39,78,-11,17,-33,-13,15,-33,30,-40,59,5,7,-30,-60,81,-12,-24,23,-39,-7,4,9,-30,60,20,-23,-19,-31,1,-10,-28,-13,-37,0,-31,-86,29,14,54,3,-18,21,-1,54,-2,40,57,-10,-80,-1,38,-26,-24,31,10,8,21,14,37,-33]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.64","t":"Patients and providers sometimes have difficulty setting the agenda together. Sometimes patients do not want to contribute to the agenda because of feeling hopeless or negative toward therapy. Occasionally, the patient may also be unfocused when setting the agenda (e.g., recount events of past week). It is often necessary to educate the patient about therapy by clarifying what kinds of issues constitute agenda issues and how session time may be optimally spent. 64","e":[26,65,-150,-59,58,43,9,-4,74,-6,-22,14,56,60,31,-19,10,-41,-57,39,-22,-24,-55,-32,-21,44,16,-39,-42,24,44,4,23,-27,0,-79,50,21,6,4,37,-13,-5,-126,-9,-31,74,37,4,-53,30,-60,-37,-19,85,34,-6,94,36,-26,119,17,-38,80,40,-31,-31,40,-16,0,34,-2,46,32,-46,35,-12,-28,-30,10,50,-10,65,-33,53,40,38,16,0,105,0,11,17,15,-110,21,-39,8,-56,-9,-62,8,15,-18,33,5,-9,23,-17,-3,-47,41,-45,-14,36,-17,89,-27,35,28,-7,-38,13,49,6,47,-7,-13,39,5,-14,-32,-31,23,27,38,4,-20,18,13,54,10,2,-28,-7,-20,11,-43,-29,32,-27,2,-4,58,39,-54,-15,-15,26,-26,99,4,-45,23,-10,-21,34,30,3,6,-9,-49,12,-5,91,52,69,9,11,-41,-7,-25,-10,-8,17,-9,20,-41,-43,-61,-12,52,-1,11,-51,-39,37,-29,6,-16,-16,4,-32,27,-51,60,-2,-5,-6,-64,52,-31,-28,14,-35,-21,4,-4,-35,49,28,-36,2,-45,22,6,-64,10,-39,4,-32,-105,33,33,40,-6,-22,46,27,44,-19,13,51,12,-67,4,24,-32,-39,29,-5,5,12,8,28,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.65","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 9 CBT suggests that change involves skill acquisition and not simply identifying distorted thinking. Therefore, recognizing an unhelpful thought can be enlightening, but you should also use session time to teach skills to address the problem (e.g., thought records, behavioral activation) and not simply discuss the issue with the patient or offer advice. The process of skill acquisition is what sets CBT apart from “talk therapies” (supportive therapy).","e":[22,22,-160,-63,96,17,39,-1,65,-10,-5,13,48,28,6,-32,7,-55,-33,29,-44,-3,-16,-6,19,21,-3,22,-25,11,55,-42,2,-23,-67,-55,69,5,-60,-6,44,-24,27,-72,42,11,108,19,9,-12,61,-66,7,-21,132,47,14,12,-16,-53,80,59,-63,60,-9,-21,-36,54,-52,-14,50,-14,33,59,-41,2,-38,-8,-19,25,21,-35,77,-22,51,-12,-19,-3,0,75,-7,-13,-2,37,-107,32,3,-13,-23,-30,-67,-40,13,-21,4,64,-24,-17,4,-20,-54,16,-24,-24,-16,-33,43,-17,1,29,2,-15,1,60,47,75,-30,-7,13,-37,-19,-6,-10,-9,10,50,0,-8,13,52,31,37,-7,-4,-6,-28,8,-30,-51,-16,-4,30,-3,14,59,-31,-4,-11,79,35,45,-9,-60,26,-39,-39,5,38,27,16,-32,-50,6,-9,75,35,45,-27,-6,-33,-5,-15,18,60,24,-7,38,-33,-38,-46,-26,29,-46,-10,-60,-54,26,0,12,-16,-13,34,-59,35,-37,48,-20,10,-15,-38,85,-12,-16,-4,-53,5,23,9,-25,16,33,11,-22,-9,3,-26,-24,-22,-14,47,-32,-83,12,9,19,31,17,37,19,47,45,47,31,-6,-91,22,26,-58,-12,34,3,43,7,-25,28,-1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.65","t":"EXAMPLE HOMEWORK ASSIGNMENTS 1. Create an agenda for next session, using the given outline. 2. Think about adjustments you would like to make to our current agenda and reasons why. 3. Crate a list of concerns/discomfort in the agenda-setting process. SUPPLEMENTAL READINGS Beck, J.S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press; Chapter 5 65","e":[64,1,-126,-56,28,-15,11,-24,43,30,-7,9,73,111,29,-31,-4,-55,3,23,23,-24,-50,2,8,57,-10,-21,-62,5,-1,-5,-37,-33,-37,-68,92,21,-41,-2,5,-27,-8,-77,43,-42,87,-12,51,-23,13,-33,-7,-27,82,31,25,23,66,-30,100,49,-48,73,25,-15,-36,80,-53,29,65,-6,61,1,-74,-19,-3,-26,3,50,29,2,88,-25,56,28,-9,12,-15,72,-9,10,-9,22,-42,15,-8,13,-50,-33,-56,4,24,-24,22,12,3,-5,-13,10,-56,51,-24,23,31,8,76,-26,49,57,-24,-44,7,40,27,46,-65,-29,19,-16,1,-30,-12,39,4,48,-42,-13,18,-14,51,-12,-21,-7,-15,-7,22,-19,-40,21,-21,6,34,5,59,-31,-14,-25,26,25,67,-13,-73,86,-14,-6,25,57,21,28,-47,-54,8,11,43,29,77,-19,23,-20,17,-16,21,7,-11,-44,14,-4,-54,-9,-17,21,7,-27,-89,-73,40,-32,31,-20,-5,2,-48,24,-51,71,-11,-18,7,-32,63,0,-15,22,-32,19,-14,-21,-35,13,-8,-42,19,-17,39,20,-25,9,-20,54,-42,-106,27,24,57,11,-8,54,15,59,-4,30,52,-5,-80,16,40,-30,-28,44,30,5,8,46,17,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.66","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 10 [This worksheet is to be completed by the patient prior to beginning the session (e.g., in the waiting room) to prepare for therapy and assist in collaboratively selecting agenda items.] BRIDGING SESSIONS 1. What main points did we reach in our last session? What did you learn from last session? Did anything come to mind in the past week about our last session that you’d like me to know or that you’d like to discuss? 2. Were you uncomfortable about anything we talked about in our last session? Is there anything you wish we had discussed that we didn’t? 3. How is your mood? (How is your physical health?) Compared with last week, is it better or worse?","e":[4,1,-146,-96,75,-1,58,-28,16,-50,-23,6,16,14,24,-49,9,-71,-16,5,-58,-22,-17,0,13,47,-6,36,-57,0,44,-35,31,-50,-54,-37,54,32,-51,-28,87,-32,19,-92,44,-21,116,15,9,-17,18,-31,-4,-11,112,22,17,14,15,-30,95,50,-43,92,8,-51,-47,68,-65,-8,62,-2,50,39,-59,-13,-16,-11,0,32,23,-18,55,-30,25,-11,-35,-20,-28,85,-10,-9,17,31,-96,59,-9,-14,-15,-43,-43,-24,27,-7,7,37,-4,-12,9,-25,-78,27,-31,8,-1,8,52,-14,13,29,-17,-20,26,31,46,56,-43,-10,30,-23,10,6,-35,19,12,56,7,-7,35,30,31,1,-41,4,-16,-39,11,-26,-42,29,-6,-8,29,39,35,-39,5,-29,69,28,50,-29,-46,40,-15,-42,23,15,61,49,-39,-68,9,-17,42,65,53,-30,1,-56,20,14,26,29,-15,-25,2,-35,-53,-17,-27,33,-44,-52,-91,-73,24,-22,48,-47,-12,49,-29,53,-30,78,-32,15,-14,-46,68,-6,3,5,-49,12,2,1,-47,32,8,-18,-5,-2,26,2,-18,-16,-49,49,-28,-106,15,-5,10,17,-7,37,3,52,55,37,43,-3,-69,49,-4,-42,22,42,-1,16,9,37,1,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.66","t":"4. What treatment goals would you like to work on today? What problems would you like to put on the agenda? 5. What homework did you attempt or complete for last session? What did you learn from doing it? 66","e":[15,5,-108,-24,43,4,35,-29,23,-33,-22,-5,67,37,0,-55,27,-75,-28,50,2,-58,-32,-56,6,73,-34,-15,-32,-9,4,5,16,-41,-17,-61,105,23,12,-46,65,-27,-31,-91,53,-30,39,4,57,-42,13,-31,-22,-1,54,40,-18,16,27,6,126,33,-86,75,49,-53,-14,55,-52,-10,43,9,66,21,-65,-19,-20,-18,-3,30,23,-4,72,-43,20,12,-42,29,12,77,-16,15,15,13,-66,1,-17,14,-41,-33,-52,-27,36,-28,71,45,40,28,-21,-30,-46,19,-29,30,-20,-2,70,-17,28,45,-4,-31,38,50,36,25,-57,-3,3,29,3,-30,-47,48,1,76,-20,-33,21,-18,101,-15,-21,39,-30,-36,26,-9,-27,4,-11,-12,30,7,59,-61,-36,21,33,6,60,-8,-76,61,-36,-23,-4,45,15,74,-42,-57,31,2,75,31,58,-12,-1,-24,45,-41,18,-2,-30,-46,29,-56,-70,4,-3,41,15,-40,-52,-64,40,-20,19,-22,-16,43,-60,47,-36,68,8,12,17,-29,48,-7,-15,12,-25,-6,-14,8,-52,61,-2,-30,-3,-2,51,49,-51,28,-7,31,-21,-102,22,25,11,16,-10,23,11,68,-21,36,54,-12,-48,25,-12,-6,-11,61,20,27,21,66,2,-25]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.67","t":"Homework is an essential and effective component of brief CBT. Because of the condensed number of sessions in brief CBT, assignments such as readings, behavior monitoring, and practicing new skills should be given to the patient to practice and use outside sessions. Homework assignments facilitate patient skill acquisition, treatment compliance, and symptom reduction by integrating the concepts learned in sessions into daily life. Homework is a key mechanism for facilitating between-session work and progress. When? (Indications/Contraindications)","e":[63,15,-149,-49,30,-8,33,-31,20,-19,-1,12,63,42,-15,-19,-5,-40,-31,-5,-5,-12,-12,-1,17,44,-11,-4,-12,8,14,-22,-16,-20,-53,-33,84,30,-52,4,21,-12,5,-69,53,-11,68,13,41,-10,3,-101,1,4,128,34,8,-6,12,-9,105,54,-70,97,10,-19,-30,56,-28,41,29,-5,81,42,-61,-21,-32,-20,1,40,59,-20,46,-12,91,-7,-26,-10,-39,87,0,2,24,12,-63,32,9,28,-25,-18,-72,-9,23,5,55,37,-1,-16,-9,-2,-55,53,-23,-17,33,19,68,-9,39,41,-10,-54,24,30,5,70,-57,-12,30,-22,-7,-19,-41,13,20,41,-43,-15,-3,-2,56,14,-6,47,-9,-1,-2,-35,-52,7,-8,-5,17,-24,43,-5,-2,-30,57,37,32,-16,-85,41,-17,-18,-2,44,19,55,-62,-56,21,3,31,44,42,4,15,-26,11,-30,10,28,-6,-6,7,-37,-49,-32,18,11,5,-19,-89,-46,23,-13,22,-34,-46,19,-8,19,-32,98,-29,-23,-4,-44,72,3,-25,6,-26,-17,-45,-3,-66,-4,10,-20,45,-50,13,46,-12,-4,-42,53,-26,-72,19,-2,33,39,30,22,1,80,-5,35,49,-26,-90,23,3,-49,-34,21,1,-31,14,18,13,11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.67","t":"Give homework assignments throughout treatment. The nature and frequency of assignments are left to your discretion. Consider patient characteristics when assigning homework, specifically, reading ability, cognitive functioning, cultural identity, level of distress, work/life balance, and motivation. During the beginning stage of therapy, suggest homework; but, as therapy progresses, encourage patients to generate their own between- session activities. This helps them to continue to use skills outside therapy and after the end of treatment. Some patients may be hesitant to participate in homework assignments, so it is your responsibility to be open to patient feedback about assignments, give reasons for each task, and personalize homework assignments for each patient. Also, patients may have a negative reaction to the word homework, which might prompt you to use practice or at-home exercises.","e":[61,19,-135,-46,29,8,35,-14,26,4,-26,7,43,48,-29,-14,42,-65,-27,38,-34,-25,-54,-6,17,60,-22,-2,-32,19,10,18,-25,-23,-34,-22,85,26,-20,21,20,-18,2,-82,27,-23,47,-8,55,19,26,-81,-41,8,100,34,-7,20,40,-34,96,54,-102,54,22,-5,-24,55,-27,17,42,25,81,27,-42,-13,-36,4,25,21,63,-3,74,-56,70,34,-22,16,-26,96,-10,1,7,15,-64,19,-9,24,-56,-55,-55,-4,36,-22,34,52,23,7,-29,6,-40,51,-30,-27,36,17,73,-46,38,41,-18,-36,-9,15,-3,66,-40,-34,17,-3,-9,-27,-63,34,-15,50,-27,-43,18,-32,61,9,10,27,-19,4,6,-38,-44,13,7,22,23,7,50,-51,-26,-3,25,20,62,-3,-62,69,-14,-35,-9,67,12,36,-46,-49,25,3,59,29,60,-5,33,-3,26,-54,29,-3,-1,-23,19,-3,-74,-11,23,38,6,-35,-83,-53,37,-46,9,-33,-31,36,-37,22,-60,76,-16,-17,-9,-37,52,-27,-22,26,-25,-11,-37,-27,-60,14,16,-26,39,-26,11,31,-48,15,-12,28,-32,-73,66,-11,40,12,-17,14,0,62,-41,37,65,7,-82,28,-3,-44,-43,18,-3,-3,-1,26,4,7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.67","t":"How? (Instructions/Handouts) SEVEN TIPS FOR SETTING HOMEWORK ASSIGNMENTS 1. One Size Does Not Fit All. Always tailor assignments to patients. Their reading level; desire to change; cognitive functioning; and, even, stage of life determine how much and what type of homework assignment fits them best. For example, a single, working mother who is also a full-time student may not have time to read a complete book as a bibliotherapy assignment. Assigning her a small part of the book or an article may be more reasonable. Breaking assignments down into smaller parts is also useful. Always consider the patient’s diagnosis and presenting problem when assigning homework and ask yourself: 67","e":[75,44,-128,-42,28,-12,2,-20,3,4,0,-31,64,46,-19,-9,20,-58,10,12,-19,-42,-66,-14,-10,51,-31,1,-44,11,7,15,-23,-28,-36,-38,67,38,-40,42,-4,-29,-2,-77,49,-22,76,-1,78,-1,11,-64,-29,21,87,41,-11,19,62,-31,103,35,-88,63,0,4,-28,65,-20,-13,36,-5,84,-18,-67,-1,-25,2,3,41,44,14,82,-33,65,44,1,3,-39,89,-31,9,25,26,-39,16,-18,52,-55,-50,-45,33,-1,-25,28,45,38,7,-8,-7,-43,20,-13,-24,25,45,102,-46,58,65,-18,-31,7,20,12,16,-71,-13,24,-15,-9,-36,-40,22,6,57,-38,-50,-7,-47,56,3,-5,14,-30,2,-13,-20,-34,39,9,13,3,2,28,-41,3,3,29,-13,43,-8,-77,57,-18,-2,-12,79,13,45,-54,-59,14,6,40,20,67,-5,26,19,40,-48,15,8,-19,-31,15,-24,-73,-13,8,11,7,-44,-69,-53,43,-39,2,-18,-46,6,-31,20,-26,77,-4,-11,1,-30,31,7,-22,18,-27,-15,-27,-11,-62,7,13,-34,41,-23,47,22,-29,6,-3,16,-26,-69,51,-3,15,-1,-12,19,4,66,-29,12,65,-10,-97,33,46,-83,-35,42,9,-15,11,26,-30,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.68","t":"2. Explain in Detail. Knowing the reason for an assignment and how it relates to overall treatment goals help patients understand why they are doing the assignment and also may encourage him/her to complete it. Most patients are interested in how certain activities may improve their situation or relieve their symptoms. Explain assignments in the context of treatment goals and the cognitive model to enhance patient buy-in to the tasks.","e":[21,34,-122,-29,58,-18,28,3,25,7,-6,25,97,29,12,-16,8,-33,-20,27,-4,-22,-8,-22,1,44,-12,-16,-48,22,27,37,15,-42,-40,-80,84,48,-46,-10,-5,-34,-13,-75,32,-20,55,3,32,-34,-23,-51,-31,32,111,50,11,47,18,-35,110,74,-36,59,46,-24,-6,37,-28,19,32,4,31,5,-79,-6,-23,16,-13,20,70,-19,61,-34,38,36,-2,-4,-32,76,-22,13,32,37,-109,11,-38,0,-19,-25,-58,6,3,-23,48,41,43,23,11,17,-15,56,-40,12,16,9,79,-39,13,39,4,-1,7,27,19,47,-34,-14,14,17,-18,-48,-56,35,4,51,-19,-43,-2,10,38,29,-9,19,-43,-13,40,-6,-41,22,4,20,8,4,55,-68,-20,-8,25,-2,72,30,-69,64,-39,-44,6,20,-5,10,-38,-42,32,34,101,51,74,12,19,-41,35,-65,45,20,-17,-12,14,-10,-85,-11,-11,12,-3,-8,-70,-53,6,-15,-14,-20,-48,-6,-77,10,-45,60,-8,-18,-8,-9,22,-24,7,13,-23,-31,17,-28,-28,18,11,-21,7,17,15,12,-39,32,-21,21,-11,-33,52,23,30,11,11,20,38,64,-21,13,47,-19,-64,45,24,-85,-23,54,-12,6,12,-4,33,-40]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.68","t":"3. Set Homework as a Team. Involving patients in designing and scheduling homework increases the chances they will complete it. It is also important to get the patient’s agreement to complete the homework. Suggest homework assignments, and then ask the patient if you can help make adjustments to it. Ask, for example, the following: In-Session Example 10.2 “Do you think this is reasonable?” “What would you change about the assignment?” “Let’s do an example together first. Then we can make changes if we need to.”","e":[34,40,-136,-16,35,-16,-17,-28,11,10,-6,14,46,61,-33,17,21,-74,-43,26,1,-46,-45,-3,20,15,1,-22,-47,29,19,14,9,-57,-43,-45,58,35,-30,1,15,-30,-5,-83,60,-43,65,-23,48,-4,6,-65,-51,13,99,45,22,27,52,-21,110,49,-67,64,10,0,-36,60,-23,26,11,27,93,4,-67,29,-12,-1,19,25,61,-12,63,-32,63,17,5,-6,-42,118,-20,1,26,-7,-60,13,-24,47,-35,-36,-54,-10,7,-21,0,41,27,22,3,5,-51,17,-14,-17,40,26,83,-21,31,50,-26,-41,2,35,-7,64,-54,-2,51,-7,-10,-17,-69,50,-18,44,-36,-30,12,-29,29,19,-9,-1,-18,0,-5,-10,-48,31,3,-10,37,-5,49,-53,-18,4,29,23,69,-28,-107,60,6,-19,41,69,12,50,-40,-44,32,13,48,24,44,13,1,-7,42,-41,25,-16,-29,-3,13,-39,-84,-17,9,36,36,-51,-46,-29,39,-19,6,-9,-59,0,-42,19,-28,76,-15,-19,-1,-37,39,19,-27,26,-24,8,-20,-15,-67,26,22,-43,22,-12,18,12,-39,0,-33,40,-15,-73,22,-9,57,11,-29,23,22,63,-13,13,43,-14,-70,41,21,-59,-42,45,27,-37,-15,7,6,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.68","t":"4. Create a Win-Win Situation. Do not scold a patient for not completing homework assignments, but also do not dismiss their value. If a patient does not finish homework, which is common, you may learn about the patient’s level of motivation, ability to follow-through, or level of distress (e.g., too depressed to complete it). Failure to complete homework is an opportunity for you to evaluate the patient’s reason for noncompliance. The patient may have been anxious about completing an assignment incorrectly or may question the utility of the assignment. These thoughts are helpful to discuss in session.","e":[96,34,-141,-49,43,44,29,-12,38,-13,-25,6,28,51,-12,7,45,-64,-72,21,2,-1,-42,18,18,47,-41,-56,-50,37,-7,15,5,-62,-68,1,70,15,7,15,35,-41,23,-97,44,-17,54,8,55,-10,26,-86,-24,7,49,21,28,3,44,-13,104,17,-38,69,27,-23,-44,67,-7,7,29,18,69,9,-76,29,-33,11,2,22,61,-3,59,-16,68,11,-19,-1,-36,88,0,6,43,-20,-73,32,-26,39,-54,-30,-46,-37,28,-46,62,22,38,19,3,-12,-37,43,-36,-28,38,30,77,-36,0,34,-25,-19,26,30,18,76,-8,8,63,14,-17,-40,-59,43,-4,22,-14,-28,20,-29,44,2,9,24,-16,-26,-6,-29,-51,19,-17,-20,13,0,49,-50,-12,-5,55,-9,89,-4,-75,76,10,-27,6,56,0,32,-46,-61,59,-14,53,24,56,4,-6,-34,27,-29,42,3,20,10,6,-8,-71,-21,7,19,46,-23,-59,-40,17,3,37,-7,-11,12,-20,0,-65,38,-42,-6,-1,-45,31,-10,-17,19,-23,-21,-23,-5,-56,10,15,-44,35,-50,40,51,-47,6,-34,12,-18,-90,27,-14,42,24,-2,33,11,54,-32,31,26,5,-68,21,-11,-38,-15,28,28,-10,35,20,11,23]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.68","t":"5. Start Homework In-Session. In the first few sessions after assigning homework, do a few examples with the patient in session, when possible. This gives the patient a clearer picture of what is expected and allows questions that he/she might have about the homework. It also gives the patient an idea how long the homework will take. In subsequent sessions, the patient may start the assignment with your assistance to troubleshoot questions about it. 68","e":[53,11,-150,-36,26,-7,20,-20,5,-21,-41,24,43,58,-25,-26,24,-75,-34,-2,6,-37,-59,-25,11,39,-47,-30,-16,37,30,-9,4,-23,-26,-56,47,11,-23,10,-6,-52,27,-77,55,-32,78,7,43,4,12,-39,-58,13,89,52,20,-13,80,-28,105,39,-63,45,-3,-1,-34,73,-7,41,36,11,79,-5,-75,-5,5,3,10,27,42,7,88,-58,59,31,-31,-4,-43,95,14,10,5,19,-67,10,-26,65,-30,-43,-51,-16,32,-47,35,66,9,13,-11,-1,-63,19,-29,3,11,33,84,-18,39,53,-37,-34,-5,39,32,53,-33,-21,38,6,4,-19,-60,39,2,55,-25,-41,25,-42,22,18,-14,13,-20,-11,10,-27,-45,39,-11,-4,31,0,68,-54,-19,-12,61,-16,75,-31,-82,73,-19,-27,8,46,25,19,-29,-75,-6,-10,28,33,56,-13,18,5,44,-43,6,14,-16,-27,13,-32,-79,-18,16,30,1,-31,-55,-40,54,-15,8,-25,-12,0,-33,17,-43,71,-15,-25,-7,-12,65,15,-24,23,-28,12,-19,-17,-45,24,11,-20,30,-55,25,42,-17,-5,-22,35,-39,-76,19,-29,57,-2,-5,20,-17,45,-23,41,60,-12,-101,19,19,-67,-32,24,37,-15,21,30,7,-16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.69","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 10 6. Ask About and Review Homework. To emphasize the importance of homework, always ask about and review homework the session after you assign it. If the patient did not complete homework, use session time, if possible, to complete the assignment, which may also help identify the aspects of the skill that need to be reviewed. If you do not review homework in session, patients may stop completing it.","e":[40,-4,-151,-39,49,-4,47,-21,21,-8,1,20,44,44,-18,-32,1,-68,-13,0,3,-32,-21,4,47,26,-20,29,-25,16,28,-31,-8,-55,-55,-36,65,2,-88,-5,63,-10,12,-85,82,4,101,8,20,-19,22,-63,2,-12,111,39,17,-11,34,-9,108,37,-44,86,-16,-28,-43,62,-38,23,11,7,75,53,-74,-6,-33,-1,1,44,38,-2,90,-30,43,-10,-16,-16,-28,82,3,-18,28,25,-59,54,9,14,-23,-41,-54,-29,-7,-31,32,50,-11,9,0,-14,-57,26,-29,3,17,36,73,-20,0,54,-42,-38,24,25,35,74,-37,-11,17,-19,-28,-5,-32,8,-11,40,-36,-16,16,-29,24,2,-3,40,-7,-30,-5,-38,-54,3,-12,-21,21,-15,66,-18,-7,-6,52,52,35,-22,-88,66,-16,-19,1,38,44,51,-51,-45,24,-20,31,33,36,-12,11,-31,21,-19,23,53,-24,16,17,-20,-36,-24,10,44,-12,-36,-67,-33,34,-15,11,-48,-50,16,-20,34,-51,53,-13,0,-22,-49,83,6,-23,41,-38,-2,-15,-21,-55,29,-3,-18,27,-28,19,34,-12,-14,-28,44,-28,-79,37,11,28,27,12,40,15,49,1,68,68,-24,-80,27,7,-36,-15,26,19,-5,19,26,6,6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.69","t":"7. Anticipate and Prepare for Problems. With the first few homework assignments, help problem solve the assignment by eliciting feedback about it and planning when and how it will be completed. Assignments can be scheduled for a particular day and time to overcome barriers, and foreseeable problems for completing the assignment at that time can be discussed. For example, if the patient’s behavioral activation is to walk for 15 minutes on Wednesday at 4pm, discuss what to do if it rains or other factors prevent completion. Agree upon and schedule a second option (e.g., using treadmill for 15 minutes).","e":[55,17,-160,-22,60,-6,46,-32,28,-13,-6,4,62,70,-37,-12,41,-59,-50,12,35,-21,-40,2,-5,44,-23,-31,-23,15,-3,0,-18,-69,-37,-61,55,22,-29,-34,13,-45,32,-66,79,-50,61,-6,34,-1,5,-48,-39,23,73,54,35,-25,41,-33,147,40,-62,54,31,4,-28,75,-21,35,19,-6,61,-6,-51,8,12,15,22,48,42,1,91,-43,78,19,-27,15,-23,94,-26,29,12,5,-64,31,-29,55,-55,-59,-41,-12,4,-27,18,26,21,4,-2,8,-55,54,-32,-22,18,37,75,-36,35,48,-45,-19,-11,29,1,62,-37,-4,31,-4,0,-12,-39,21,-33,47,-33,-5,-2,-2,50,13,-10,17,-33,7,-8,-32,-29,30,-17,14,5,0,59,-49,-26,-16,51,2,61,-20,-76,70,-22,-31,-3,50,39,22,-55,-48,22,24,41,25,56,-32,11,-10,41,-40,6,9,-27,-30,34,-21,-73,-33,14,29,-6,-36,-53,-49,42,-39,2,-15,-25,-6,-31,31,-27,71,0,-17,8,-14,62,9,-9,13,-26,-21,-28,9,-28,14,4,-53,11,-14,9,36,-48,3,-39,5,-5,-80,57,-1,51,-4,3,22,15,31,-15,42,65,7,-75,19,41,-47,-31,47,18,-19,10,28,15,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.69","t":"USING SELF-HELP RESOURCES AS HOMEWORK Assigning the patient reading materials relevant to brief CBT presenting problems is a useful tool for brief CBT because it allows patients to read about their disorder or CBT between sessions. This emphasizes the self-management focus of CBT and can accelerate therapeutic progress and maintenance of changes. Reading materials may be websites, book chapters, or sections of CBT patient manuals. Some common examples of CBT bibliotherapy are Mind Over Mood (Greenberger & Padesky, 2016) and Feeling Good Handbook (Burns, 1999).","e":[42,26,-162,-78,22,-39,21,-17,11,6,34,-4,55,32,3,-18,-9,-50,-25,2,-49,-18,-35,-5,-8,65,-32,5,-26,-2,23,-29,-11,-19,-41,-18,85,9,-35,28,43,-26,10,-73,49,-22,74,29,38,-15,25,-94,41,-27,142,-2,2,10,0,-49,98,59,-57,73,58,-9,-29,59,-54,15,71,24,70,45,-62,-25,-39,-12,-27,29,40,-7,43,-35,92,6,2,21,-39,46,4,9,23,16,-72,49,-15,-15,-28,-40,-68,-13,-4,5,4,51,20,-11,-24,6,-56,35,-31,-13,11,19,77,-21,25,50,-7,-16,-1,39,23,45,-76,-16,43,-28,-17,-33,-36,-1,17,43,-7,-3,15,0,49,-15,-15,43,1,-2,-16,-34,-46,5,-11,10,10,13,58,-11,10,5,55,1,37,-2,-95,32,-17,-8,13,37,22,63,-80,-62,5,4,59,30,75,-5,19,-28,33,-46,41,35,19,-1,7,-19,-25,-30,5,7,-38,-33,-108,-45,36,12,35,-32,-16,39,-27,21,-45,73,-9,-10,2,-48,66,-15,-17,25,-30,-9,-27,-7,-50,8,21,-34,15,-50,30,21,-24,-9,-22,28,-57,-81,39,3,26,20,15,30,-11,75,18,25,39,23,-87,14,9,-59,2,37,10,-9,19,-1,8,15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.69","t":"HOMEWORK TROUBLESHOOTING Practical Problems Occasionally, providers may encounter a patient who waits until the day before a session to do the homework. This is problematic because certain assignments, such as monitoring automatic thoughts, are most effective and most accurate when completed in the moment. There are many reasons patients may put off doing homework; and your role is to explore these reasons in a proactive, nonjudgmental, nonpunitive way.","e":[74,20,-160,-48,39,17,33,-21,10,1,2,-9,23,53,-22,-9,50,-46,-60,-1,15,-36,-36,-8,-4,33,-6,-23,-7,34,14,-31,-12,-61,-48,-42,76,26,-4,3,46,-18,38,-103,50,-34,59,22,45,-45,21,-80,-44,14,88,47,32,18,34,-22,140,33,-53,83,0,-29,-39,47,-7,18,32,0,63,24,-45,15,-25,13,4,33,52,6,65,-25,66,27,-3,15,-20,91,4,-10,7,2,-92,33,-15,46,-70,-15,-30,-28,-6,-20,22,6,8,12,-14,2,-34,43,-26,-12,34,33,49,-48,6,48,-33,-37,0,66,16,87,-25,22,39,10,-5,-1,-52,28,-14,64,-34,-29,7,-6,62,-6,-5,1,-12,-22,-15,-29,-52,28,-6,-10,13,9,60,-20,-17,12,55,-9,48,-17,-84,41,-7,-35,-4,51,16,30,-63,-46,41,-21,48,31,73,-31,31,-48,-1,-52,25,2,-7,-20,-1,-18,-55,-31,11,13,15,-24,-94,-47,52,3,18,-5,-36,-9,-43,22,-22,83,-15,-32,-23,-33,82,34,-9,17,-6,-25,-23,-10,-45,40,0,-45,17,-36,27,32,-15,-8,-40,15,-36,-96,33,12,57,10,-5,20,29,50,-3,47,25,17,-77,-12,15,-31,-42,25,14,-26,7,21,18,1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.69","t":"Sometimes patients may simply forget to do homework. They may have a busy schedule or have trouble remembering to complete homework. Using a calendar and scheduling time to do homework are useful in this situation and provide the opportunity for time-management skill building. You can also work with the patient to download self- management apps on his/her smartphone or tablets.","e":[25,33,-164,-21,27,-20,15,-62,71,0,-19,-6,69,43,-35,5,28,-45,-59,30,18,-26,-51,-5,-19,42,-9,-27,-19,42,36,22,-12,-61,-9,-50,54,17,16,20,43,-32,27,-68,83,8,44,-3,28,-14,11,-98,-32,2,90,6,34,19,41,22,160,42,-27,78,12,-11,-31,48,-18,12,40,15,90,12,-59,43,-25,7,23,23,61,-15,56,-24,82,15,3,1,-25,108,-16,-6,24,31,-54,45,18,33,-43,-22,-59,-12,18,-6,53,17,7,-5,-16,-1,-15,40,-15,-11,50,39,58,-36,30,41,-45,-34,9,41,6,86,-30,-7,53,8,-10,-11,-61,31,-5,26,-24,-15,3,-10,57,-10,7,6,-49,-9,-29,-33,-65,31,-16,-2,27,25,54,-37,-29,2,63,18,68,-19,-65,43,-1,-60,18,42,-18,36,-41,-49,18,-21,59,10,37,-7,31,-39,37,-45,-14,4,-32,-11,24,17,-58,-16,12,18,29,-28,-70,-23,27,1,-8,-17,-55,-21,-22,7,-14,63,-3,-28,-7,-34,70,32,-23,-2,-16,-24,-45,-27,-39,26,15,-66,35,-46,56,13,-40,27,-43,20,-19,-85,25,17,55,12,-16,37,-2,68,-14,14,47,-25,-69,23,9,-37,-30,31,19,-13,-15,5,21,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.69","t":"A few assignments described in this text might be difficult for some patients. If a patient is having trouble completing an assignment because of the level of difficulty, it is your job to explain how to complete it and gauge the patient’s understanding. Some assignments may need to be broken down into smaller steps until the patient can fully grasp how it is to be completed. 69","e":[35,51,-139,-24,41,24,16,-18,21,-10,-23,-10,33,22,-5,-25,54,-61,-23,17,0,6,-34,-20,10,36,-23,-65,-44,24,18,6,27,-64,-44,-64,48,50,-2,23,13,-46,1,-101,32,-33,51,27,18,-29,3,-69,-23,24,107,44,-2,41,43,-11,106,65,-36,49,45,-18,-16,56,-16,10,31,-4,52,13,-88,-1,1,-1,13,29,58,-4,82,-5,64,32,-7,23,-20,117,-13,12,45,13,-120,-8,-51,43,-44,-51,-66,-28,24,-26,42,52,41,17,20,11,-24,58,-43,-10,56,26,73,-43,15,54,-1,8,-8,43,6,43,-5,20,61,-5,-6,-21,-15,11,-10,47,-21,-20,16,-15,40,24,-8,11,-11,-26,-3,-24,-37,26,37,1,20,-6,47,-40,-8,31,28,-14,73,6,-82,68,4,-30,-13,40,28,11,-28,-48,54,32,53,49,65,-4,11,-12,35,-50,20,-20,-27,-33,24,-29,-58,-37,-2,37,17,-27,-50,-63,26,-16,7,-33,-3,2,-37,23,-41,64,-57,1,-22,-12,20,-25,-20,13,-14,-29,3,-7,-48,28,17,-39,13,-6,18,9,-43,16,-37,23,-4,-68,57,8,25,-11,-12,36,3,54,-24,-22,46,-14,-63,43,35,-75,-12,51,4,-37,12,36,16,-16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.70","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 10 Psychological Problems Patients who don’t complete homework might have unhelpful thoughts about themselves, the homework assignment, or therapy that need to be addressed. In these cases encouragement, thought testing, and listing the advantages and disadvantages of doing homework may be useful. Though outside the scope of this manual, techniques, such as motivational interviewing (Rollnick, et al., 1999), may also be used to address the ambivalence a patient may feel about homework. Patient perceptions of importance and confidence are very important for noncompliance issues.","e":[68,29,-138,-53,62,37,34,-17,31,8,-12,-18,19,63,-31,8,21,-62,-33,17,-8,-4,-17,5,23,42,-32,-5,-48,24,4,-28,-21,-55,-63,-27,84,9,-38,20,45,-36,26,-95,27,12,78,23,39,-6,26,-98,38,-1,99,24,18,9,20,-31,102,38,-47,88,13,-28,-38,47,-49,6,36,-1,71,52,-74,-1,-40,-2,12,35,66,-10,40,-22,92,6,-7,-6,-35,77,-22,0,13,-5,-79,47,-9,-4,-47,-29,-67,-13,8,-16,18,20,-6,7,0,14,-66,45,-26,-18,26,27,58,-27,15,55,6,-21,26,32,9,82,-36,-14,26,-18,-4,-29,-30,14,-19,29,-38,-14,18,-10,46,5,-5,36,5,-29,-28,-27,-75,11,-27,-6,46,-6,48,-27,-13,-15,52,24,56,-1,-57,48,-4,-19,3,62,39,42,-50,-51,42,-6,58,24,56,-6,25,-38,20,-7,41,39,3,-11,19,2,-62,-38,11,33,-12,-21,-100,-48,30,-15,28,-35,-32,33,-20,21,-49,56,-27,-26,-17,-55,64,-10,-20,24,-26,-17,-20,-13,-49,20,8,-32,33,-20,21,35,-14,-12,-39,22,-19,-105,50,5,41,28,-1,45,11,72,0,56,37,21,-68,-1,1,-29,-29,39,8,-6,2,-1,23,18]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.70","t":"Many patients have negative reactions to the word homework. They may feel overwhelmed by the perceived time or energy it will take to complete or concerned that therapy is like schoolwork. In giving homework, address any concerns the patient may have about time constraints; and explain how long each assignment should take, while working with the patient to generate reasonable tasks. If the patient dislikes the term homework, work with them collaboratively to select another label, such as practice, between-session progress, task, or experiment.","e":[86,58,-132,-50,16,25,4,-28,33,10,-6,24,50,71,-17,-25,41,-49,-43,37,-7,-11,-51,-10,-10,17,-36,-43,-15,20,3,-1,-27,-18,-65,-27,59,28,-23,24,31,-23,24,-88,48,-25,27,-2,60,-28,19,-101,-38,23,104,19,14,15,34,-18,100,42,-72,88,52,-11,-40,40,-6,22,36,13,75,35,-51,4,-23,-14,34,22,52,-6,40,-7,100,10,-40,16,-21,100,-25,-28,27,-12,-97,29,-7,39,-80,-50,-51,-5,21,-42,30,40,3,-1,-2,5,-36,53,-30,-26,35,5,75,-45,29,24,3,-28,-22,28,2,54,-39,9,20,6,-24,-22,-48,24,-12,55,-44,-34,-2,-22,59,0,7,20,-30,-7,-5,-40,-45,21,10,-1,13,7,57,-25,-3,-12,37,26,68,1,-66,55,-4,-25,15,51,6,29,-48,-55,26,8,41,31,50,5,-11,-15,-2,-54,21,-2,25,-2,26,-17,-67,-45,27,13,18,-19,-74,-39,19,-18,20,-6,-22,23,-33,24,-32,79,-20,-9,-9,-31,47,-9,-21,40,-18,-27,-31,-9,-76,27,12,-46,35,-48,41,18,-49,6,-46,26,-23,-92,42,-19,16,12,1,37,-25,59,-45,27,38,2,-89,12,26,-39,-50,29,12,4,-9,-1,30,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.70","t":"Homework may be problematic for patients who are perfectionists or those who desire to please the provider because they may spend too much time on an assignment or be overly concerned about getting the “right answer.” Clarify that the exercise is not about getting the “right answer,” and that they should concentrate on recording real feelings and thoughts and not concern themselves with spelling, grammar, or appearance of the assignment.","e":[77,76,-134,-9,31,26,17,-37,52,28,-6,1,39,60,-27,-25,45,-67,-18,27,-11,-23,-24,7,-1,35,-22,-41,-60,40,14,4,-25,-51,-55,-40,69,40,7,31,48,-22,9,-84,18,1,40,12,71,-23,34,-105,-22,-6,93,50,2,9,38,-34,102,32,-70,97,19,-48,-33,35,5,6,41,16,86,28,-60,6,2,-8,24,-2,58,-11,53,-15,90,34,14,3,-26,78,4,-24,57,12,-83,16,-1,40,-63,-17,-55,13,6,-20,22,7,35,23,3,-5,-27,56,-22,-25,22,44,67,-31,23,59,0,-48,3,56,-17,55,-26,6,40,-4,-28,-30,-43,8,-12,33,-53,-5,-3,-47,53,34,2,13,-15,-35,3,-25,-57,21,3,2,0,-26,29,-12,-22,15,57,9,52,-8,-70,60,-5,-27,-2,48,-1,38,-31,-48,44,-8,64,26,52,-9,35,-44,12,-36,26,-23,0,-11,12,-19,-69,-35,30,42,18,-31,-70,-36,33,-18,0,4,-35,-7,-26,21,-55,66,-33,-16,-18,-44,43,3,-20,49,-11,-54,-36,-5,-53,22,-2,-53,20,-28,16,22,-25,-27,-64,26,-9,-81,75,5,41,25,-9,24,-8,46,-26,51,44,2,-48,10,25,-40,-34,6,21,-17,-16,23,11,3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.70","t":"Provider Homework Bias Although completion of homework is primarily the patient’s responsibility, sometimes your thoughts about an assignment or approach to homework play a role in noncompliance. Check your own thoughts about assigning homework, and determine whether there is anything you can adjust in your approach that could better encourage the patient. Ask yourself, “Is the assignment too difficult?,” “Did I explain the assignment thoroughly?,” or “Have I led the patient to believe that homework is unimportant to therapy?”","e":[69,39,-136,-54,43,40,51,-9,43,28,-9,-1,40,76,-28,7,59,-56,-18,12,-21,-26,-46,-10,40,33,-22,-61,-50,17,17,12,-9,-64,-55,-28,60,8,-17,38,14,-25,17,-104,31,-29,63,49,70,-26,9,-68,-19,32,76,21,6,15,24,-35,102,51,-52,75,18,-10,-39,42,-25,10,17,13,73,36,-65,-10,-32,-4,21,21,61,3,51,-13,67,21,-5,15,-36,108,3,5,13,3,-83,21,-28,19,-39,-35,-78,9,12,-19,40,39,15,35,-11,0,-42,48,-17,-40,43,16,74,-36,12,69,-7,-35,-5,55,-2,59,-44,17,27,-11,-1,-47,-39,40,-21,13,-18,-18,11,2,46,23,13,16,-16,-42,0,-33,-50,7,11,-6,13,1,40,-45,-33,-1,50,-14,70,4,-51,57,16,-45,9,57,11,39,-44,-49,52,-24,71,31,48,-20,28,-5,16,-21,47,-3,10,-48,17,-13,-67,-32,12,45,24,-13,-77,-56,31,-18,17,-32,2,14,-37,23,-44,60,-26,-8,-28,-59,39,10,-25,29,-10,3,-24,-5,-63,17,23,-35,59,-32,19,37,-34,2,-20,14,9,-98,58,9,54,19,-14,20,22,49,-10,30,28,-1,-68,2,22,-47,-18,52,10,-9,-5,28,34,11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.71","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 Module 11: Identifying Unhelpful Thinking OBJECTIVES: • To understand the role of unhelpful thinking patterns in brief CBT. • To learn methods for educating the patient about unhelpful thinking. What Is Unhelpful Thinking, and Why Is It Important in Brief CBT? The cognitive-behavioral model suggests that three layers of unhelpful thinking exist in individuals struggling with psychosocial difficulties: automatic thoughts, intermediate beliefs, and core beliefs (depicted below in Figure 11.1). Figure 11.1 Layers of Unhelpful Thinking Automatic Thought Intermediate Belief Core Belief 71","e":[20,43,-139,-59,90,19,49,-21,28,-17,-5,-8,52,75,-10,-15,2,-35,25,8,-60,-7,-6,-16,48,55,-20,23,-53,19,37,-58,1,-53,-63,-57,83,29,-35,0,29,-16,18,-72,22,42,96,15,25,-29,40,-43,67,-18,95,29,-8,2,-12,-25,72,57,-22,43,-19,-24,-52,36,-46,-12,39,-39,13,37,-52,-8,-29,-2,-1,51,58,-25,63,4,21,19,-26,17,-14,63,-7,-3,-1,20,-106,50,-20,-20,-39,-12,-69,-25,5,-26,4,40,1,23,10,-28,-59,58,-19,-17,-3,2,62,7,22,45,-4,-28,41,73,29,71,-8,-5,15,-31,-12,-14,-18,-33,30,62,-1,13,28,40,14,11,-29,14,-4,-44,22,-6,-41,-32,-20,25,1,7,32,-47,-25,-30,56,-9,33,8,-35,11,-62,-20,8,23,66,32,-59,-37,28,12,82,-8,38,-27,10,-33,14,0,39,61,-13,-42,35,-13,-27,-29,5,20,-42,-24,-85,-26,1,-11,32,-40,17,6,-45,44,-72,43,-43,30,-23,-27,70,-18,-25,-17,-8,-1,14,-7,-25,3,35,11,8,1,5,-10,-34,-17,-32,9,-30,-123,33,19,22,5,27,33,-9,60,-20,48,36,33,-84,1,13,-62,-15,48,-17,17,3,13,28,12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.72","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 Automatic thoughts are immediate internal reactions that occur in response to situations and/or events. We are often unaware of automatic thoughts because of their almost instantaneous nature. Sometimes automatic thoughts are helpful, as they help us navigate our environments. However, automatic thoughts become unhelpful when they are attached to symptoms of psychopathology (e.g., social isolation, depression, anxiety, etc.) and negatively impact people's quality of life. One way that we gain insight about these automatic thoughts is by understanding our emotional reactions to them.","e":[46,8,-133,-73,89,19,77,8,2,-17,-3,27,58,40,-12,-46,-14,-20,12,24,-27,-16,-19,2,58,76,-24,8,-22,7,19,-62,-29,-48,-66,-17,72,9,-36,23,33,-18,49,-88,32,53,61,-2,31,-20,30,-69,6,-43,148,47,27,52,-19,-19,79,41,-13,39,22,-32,-47,45,-16,31,39,-42,-12,22,-32,-19,-41,22,37,67,23,-58,56,-7,73,18,-9,19,-8,72,26,-17,-7,27,-95,35,-18,-13,-38,-25,-81,-42,-20,-21,15,29,-25,-11,8,35,-16,46,-19,-34,6,-1,52,-25,21,70,37,29,-16,54,51,84,-23,-4,37,-46,-4,-20,15,1,29,55,3,-47,6,33,34,-3,-31,32,-28,-44,10,-43,-65,10,8,-26,-20,3,44,-22,-47,21,34,7,19,15,-52,35,-55,-30,36,42,50,8,-41,-56,8,23,62,6,77,-42,23,-58,6,-37,27,19,10,-36,-13,9,-6,-30,34,12,-40,-25,-120,-12,15,-8,28,-36,-8,14,-48,3,-43,89,2,-1,-23,-42,110,8,-31,17,5,11,-8,-35,-2,13,19,13,-13,-13,-31,-20,-29,-23,-2,27,-8,-91,46,-4,-15,6,-10,19,-1,60,13,46,33,42,-110,-24,15,-40,-33,13,-13,26,-42,-16,52,-23]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.72","t":"Unhelpful thinking styles are distorted reflections of situations that are often accepted as true. In essence, these unhelpful thought styles are real-time manifestations of negative beliefs (i.e., about oneself, the world, and the future) that are triggered by situations or exaggerated by psychiatric symptoms (e.g., anxiety or depression).","e":[44,55,-176,-56,91,40,18,17,31,-23,28,4,53,77,-8,4,1,-25,25,28,-90,6,-26,-33,17,49,-13,-27,-27,5,1,-23,-16,-27,-70,-18,53,3,52,11,6,8,21,-72,29,12,52,11,30,-57,47,-60,59,-29,100,11,14,18,-18,-17,45,30,-14,34,-28,4,-75,10,-15,-42,53,-10,9,-19,-46,38,-4,1,3,6,31,-47,27,-2,47,31,-3,31,-17,76,-8,-30,-1,5,-119,36,-35,-3,-35,-23,-68,-21,10,-50,13,35,-35,17,-4,-34,-33,94,2,-44,-6,-35,44,24,16,38,17,-18,18,114,-2,32,4,-6,21,-35,-27,-24,-20,-8,7,73,12,-25,-12,45,57,-11,-16,-36,-1,-68,38,-30,-35,-26,-41,33,0,30,17,-31,-28,15,69,-47,54,27,-15,9,-24,-31,11,63,7,16,-66,3,34,-1,102,-54,94,-34,-6,-34,-26,-17,24,11,9,-36,52,-8,-33,-43,25,30,-25,-28,-36,-55,11,16,41,-28,24,2,-40,13,-50,54,-9,26,-27,6,43,-13,-11,-28,-5,8,9,0,-36,29,74,40,-10,12,38,-27,-61,-1,9,-20,-42,-106,40,24,22,6,44,44,23,23,-22,58,-8,15,-78,-5,7,-75,-16,12,-6,23,3,-22,24,12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.72","t":"Intermediate beliefs are attitudes or rules that a person follows in life that typically apply across situations (not situation specific as with automatic thoughts). Intermediate beliefs can often be stated as conditional rules: “If x, then y.” For example, “If I am thin, then I will be loved by others.” Individuals create these assumptions by categorizing the information they receive from the world around them. These rules guide thoughts and subsequently influence behaviors.","e":[31,13,-173,-75,54,37,28,-20,4,-22,-16,8,10,47,19,24,-2,-43,36,75,-63,10,-25,4,39,54,-21,-10,-43,-10,-24,-55,52,-27,-40,-86,36,42,46,-53,-17,29,14,-81,49,-29,59,7,38,-16,-14,-44,47,15,93,32,17,32,9,-10,85,21,-44,31,39,-32,-64,44,-48,-31,40,2,-39,18,-23,1,2,11,11,38,29,-31,67,-5,-11,12,8,5,-43,50,14,-27,13,-12,-83,-29,-26,19,-4,3,-45,-58,25,-17,15,39,-9,-16,-33,22,-50,54,-37,-15,-8,-21,77,13,40,31,-6,19,29,85,26,60,-53,3,0,-38,25,3,-24,3,-9,33,28,-34,-11,47,30,-7,-8,-11,5,-58,42,-39,20,19,4,17,16,40,-11,-26,-4,15,80,-46,41,31,-30,40,-30,-5,16,78,-8,15,-60,-24,-12,8,85,-7,40,-44,-7,-46,-15,3,66,4,14,-47,37,-24,-57,-48,9,-1,-43,-9,-52,-35,15,24,32,-52,7,9,-15,16,-36,61,-14,19,-6,-2,72,-29,-4,47,-10,21,-18,-2,-33,-23,43,-30,2,14,17,-30,-87,4,14,9,-13,-117,28,20,24,9,-9,5,84,20,-23,31,20,39,-47,52,19,-68,-8,94,16,21,7,-16,18,-72]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.72","t":"Core beliefs drive rules and automatic thoughts. For example, the belief, “I am unlovable,” may be driving the conditional rule, If I am thin, then I will be loved by others, which may drive obsessive thinking about one’s appearance, excessive exercise, or disordered eating habits. Core beliefs are often formed in childhood and solidified over time as a result of one’s perceptions of experiences. Because individuals with psychological disorders tend to store information consistent with negative beliefs but ignore evidence that contradicts them, core beliefs tend to be rigid and pervasive. Although automatic thoughts are often tied to a specific situational trigger, intermediate and core beliefs are more global and cut across domains. Individuals tend to have core beliefs that involve either interpersonal (“I’m unlovable”) or achievement issues (“I’m incompetent”).","e":[54,37,-167,-68,58,69,18,21,15,-26,-21,17,42,58,-2,16,-31,-39,20,89,-69,-35,2,-43,25,57,-24,-21,-31,7,32,-35,41,-62,-32,-88,46,15,49,-23,18,33,32,-73,30,2,56,7,76,22,30,-72,39,-34,105,36,-3,40,-14,-38,93,10,-29,52,39,-30,-51,58,-34,-40,23,-33,-7,16,-16,5,-39,14,23,57,59,-25,41,-1,60,41,-6,14,-1,85,33,-6,-11,-7,-95,-8,-12,-8,-49,7,-68,-56,-16,-10,17,44,-17,11,-17,39,-38,62,-32,-24,-37,-1,79,-27,14,39,-6,17,14,119,15,38,-32,-15,23,-21,-13,-39,-46,-23,0,49,-6,3,-2,33,25,11,2,-2,-28,-75,13,-54,-32,44,-3,35,-31,19,-4,-30,-41,10,66,-58,44,3,-34,36,5,-8,15,67,25,40,-39,-11,-20,11,79,-16,59,-64,38,-54,-2,-26,9,43,14,-25,31,-23,-39,-38,-33,13,-41,15,-61,-63,24,11,39,-52,6,-9,-32,31,-35,45,5,13,-18,1,70,-15,-37,25,8,20,-13,5,-33,24,24,-13,0,13,17,-25,-45,1,-13,-8,-25,-148,79,32,24,20,-15,32,19,2,-16,36,23,12,-51,-28,3,-38,-11,56,-11,57,-16,-5,41,-37]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.72","t":"When? (Indications/Contraindications) Identifying unhelpful automatic thoughts is the first step in the cognitive component of therapy. The focus of intervention in brief CBT is the unhelpful automatic thought. Patients must master identifying and challenging thoughts to be able to grasp the concept and techniques of challenging beliefs. Because of the interrelated nature of thoughts and beliefs, an intervention targeting automatic thoughts may also change underlying beliefs (depicted below). Therefore, brief CBT can result in belief modification, even if the target of treatment was automatic thoughts. 72","e":[59,43,-143,-70,68,14,67,11,26,2,16,22,57,47,-9,-34,6,-55,6,11,-46,7,-35,-31,34,40,-8,28,-42,18,61,-23,-6,-28,-57,-55,110,12,-29,-6,18,13,35,-75,20,36,77,36,30,-26,41,-53,35,-34,108,57,2,30,-15,-18,61,38,-29,40,4,-32,-52,28,-40,-3,29,-39,25,41,-35,-7,-42,-5,5,51,34,-53,66,-36,53,16,-5,11,2,74,8,-16,-27,29,-79,28,-27,-27,-31,-25,-84,-25,-21,-12,3,39,5,7,3,3,-40,58,-14,-49,-10,1,67,4,25,47,-4,-9,12,85,22,56,-43,5,41,-58,-21,-24,14,-8,32,48,29,-21,-1,45,6,21,5,21,-16,-45,24,-32,-54,5,-2,4,-18,-8,43,-18,-44,-4,49,-8,32,14,-68,24,-37,-21,27,42,41,18,-54,-32,9,5,90,29,57,-25,35,-39,6,-39,24,51,6,-13,-1,-10,-26,-31,26,4,-66,-7,-109,-16,40,-8,33,-40,2,26,-57,20,-58,79,-8,-1,-34,-34,85,9,-37,-1,-26,-16,4,-21,-39,4,40,27,19,-32,-16,1,-34,-11,1,15,-18,-85,36,-1,20,-8,37,10,5,54,-8,50,26,46,-98,-23,30,-68,-40,33,-30,14,-10,-25,49,12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.73","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 Figure 11.2 Brief CBT and Unhelpful Thinking Automatic Thought Intermediate Belief Core Belief Because patients progress through treatment at different rates, you may be able to identify and challenge some beliefs late in brief therapy (sessions 5-8) for some patients. For other patients, work will be limited to automatic thoughts. Highlight 11.1","e":[9,27,-166,-75,74,1,40,-14,25,-27,-14,5,22,28,2,-9,6,-57,19,23,-50,-5,-20,-39,30,48,-13,43,-69,19,61,-53,25,-48,-62,-70,82,2,-31,-13,41,-8,40,-75,24,31,93,34,-1,-18,23,-55,45,-20,102,50,-21,28,-14,-18,94,39,-29,62,-2,-27,-50,57,-56,-22,40,-36,19,45,-36,6,-40,5,-8,51,50,-38,73,-12,25,0,-37,15,-5,68,9,-22,0,38,-90,35,-10,-19,-34,-27,-73,-26,22,-14,-13,39,-10,-1,-6,-13,-59,30,-37,-11,-8,-22,63,-2,9,25,-11,-16,24,76,31,75,-13,0,16,-39,-6,-18,-24,-9,19,52,39,3,11,52,-1,6,-12,7,-11,-45,23,-23,-38,0,0,9,6,45,35,-34,-27,-8,54,-3,5,3,-42,4,-39,-27,10,52,44,21,-57,-47,10,6,95,23,43,-29,-5,-50,2,-7,21,72,13,-26,23,-16,-37,-34,7,22,-57,-10,-84,-46,18,-8,36,-41,19,25,-52,38,-58,59,-37,15,-10,-46,78,-5,-32,18,-29,9,5,-10,-33,24,48,19,12,-21,-10,-8,-37,0,-11,29,-27,-111,25,12,16,0,13,38,15,72,1,50,29,16,-87,16,12,-53,-9,64,-13,23,-9,4,23,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.73","t":"Because skill building to alleviate symptoms and prevent relapse is a central focus of CBT, mastery of skills is paramount. Focus on building a skill set with patients that they can generalize to different situations, thoughts, or beliefs. It is less important to identify and modify deep-seated childhood beliefs. For most patients in brief CBT, this will not be necessary for symptom reduction. However, some patients may benefit from this work.","e":[28,12,-151,-28,58,3,60,18,59,-49,-27,5,77,-8,-1,-3,-45,-68,-4,38,-56,-34,7,-22,-20,61,-13,2,-8,-2,55,-35,7,-40,-48,-33,51,39,-20,-30,20,3,22,-113,21,-9,96,4,23,-19,33,-90,21,-55,124,24,-1,30,-4,-60,91,73,-78,94,-1,-32,-55,59,-56,2,14,-23,19,33,-34,-6,-38,-5,-15,48,49,-27,51,4,28,9,2,-2,-36,100,27,-6,3,26,-59,18,2,-33,19,21,-73,-27,11,-36,4,42,-2,-23,9,17,-76,9,-35,-13,-23,18,64,-23,-4,26,-2,-45,31,78,35,99,-67,-9,42,-16,-2,-36,-32,17,48,80,-26,5,18,24,25,34,6,20,-9,-44,26,-15,-39,18,-15,8,9,17,52,-17,-33,-24,86,-15,18,16,-54,13,-20,-54,31,44,13,33,-40,-52,-3,-14,72,20,62,-15,8,-67,12,-9,10,87,13,18,27,-25,-26,-49,29,40,-70,-6,-89,-50,32,-2,1,-36,-37,11,-35,19,-33,70,-29,1,-21,-17,59,-4,-23,3,-45,-22,-15,-24,-36,34,1,6,-28,-25,2,7,-19,-18,0,20,0,-69,44,45,30,2,-14,31,36,66,18,30,51,-16,-40,25,7,-43,-34,16,-39,22,1,-1,34,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.73","t":"Although you may not discuss beliefs directly with patients, as part of the case conceptualization, they should constantly be forming hypotheses about what beliefs may be driving the thoughts (see Module 4: Case Conceptualization and Treatment Planning). In identifying thoughts and beliefs, ask yourself several questions. • Is the thought/belief secondary to another thought/belief? • How much does the patient believe it? • Does it affect the patient’s life negatively? 73","e":[48,34,-111,-60,76,18,5,-12,4,-39,14,15,35,74,-48,-23,-28,-60,6,49,-97,-11,-29,-15,5,47,-17,12,-46,49,16,14,48,-34,-74,-101,40,12,-5,-1,48,-2,38,-125,45,-3,58,0,28,-5,28,-59,19,-6,73,55,20,73,30,-36,106,51,-58,48,22,-50,-72,39,-28,-27,37,22,24,-5,-47,28,10,24,17,43,81,-65,94,-48,19,49,-17,-6,-11,76,2,-19,19,25,-91,15,-38,-17,-8,-18,-82,-33,-18,-23,49,46,-4,45,4,20,-61,-5,-57,-13,2,-25,76,-46,16,6,-22,28,36,82,49,37,-12,-48,9,-32,4,-36,-44,10,-3,32,22,-22,-15,10,54,17,17,24,4,-52,30,-55,-32,26,-7,16,25,20,40,-26,-51,24,65,-4,52,16,-15,43,-7,-27,14,67,4,1,-10,-64,13,25,128,23,49,-34,6,1,3,-25,2,13,28,-49,42,-9,-51,-33,-9,31,-42,-21,-59,-54,14,11,57,-43,-13,9,-40,28,-37,57,-19,-25,-32,-26,50,-24,-9,37,-18,6,-11,6,-36,46,22,-20,2,1,9,-7,-61,24,-9,9,-9,-99,46,-9,34,4,-40,6,41,54,15,38,43,16,-41,16,14,3,-27,69,-3,46,-7,-11,46,-25]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.74","t":"EXPLAINING AUTOMATIC THOUGHTS TO YOUR PATIENT It is important for patients to understand he rationale for identifying automatic thoughts before gaining skills to address their own thoughts. Using the situation-->thought--> feeling triangle introduced in Module 7 (Orienting the Patient to Brief CBT) can be helpful in explaining automatic thoughts. Completing the triangle with the patients’ recent or current automatic thoughts can facilitate their understanding.","e":[37,37,-143,-96,76,3,51,-26,21,-17,0,42,66,32,7,-22,-20,-54,-2,43,-32,-9,-43,-8,18,52,-17,26,-37,3,66,-40,10,-52,-73,-47,70,5,-39,45,65,-11,28,-71,42,39,73,-2,1,-3,-21,-53,19,-41,120,69,27,75,25,-17,75,56,-22,39,37,-6,-30,44,-47,17,48,-2,30,45,-75,13,-47,3,23,54,36,-39,58,-51,72,12,10,-24,-11,76,1,-11,13,43,-102,20,-37,33,-37,-50,-80,-19,-36,-20,5,21,-5,3,26,35,-39,59,-42,-12,-13,8,85,-27,17,42,22,36,-11,71,61,67,-25,-27,33,-43,17,-42,-19,11,22,40,8,-36,2,16,36,13,-14,2,-11,-29,-10,-19,-62,19,14,8,-6,-10,37,-28,-28,-12,27,1,31,3,-52,24,-16,-32,26,24,10,-9,-46,-53,15,-13,77,31,46,-45,15,-24,30,-51,34,45,10,-40,-3,-16,-36,-16,27,24,-70,-14,-103,-19,41,-11,22,-11,3,1,-45,9,-51,82,4,-21,-18,-40,82,12,-50,8,-32,6,19,-30,-30,26,11,-39,-23,-9,-7,-29,-28,6,-19,4,-17,-89,51,1,23,-13,-4,37,6,40,24,32,42,29,-97,0,16,-48,5,37,-13,-9,-14,-28,55,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.74","t":"In-Session Example 11.1 Provider: “So, Pamela, how have you been feeling this week?” Patient: “Just really sad…as usual. It seems like I’m always feeling that way.” Provider: “Did anything in particular trigger this sad feeling this weekend?” Patient: “Yes, I had to go to my cousin’s wedding; and it was really difficult because I started thinking about how I will never get married.” Provider: “Pamela, that’s what we call an automatic thought. It’s something that just pops into our heads over and over again without our really thinking about it or examining the truth of the thought. It affects the way we feel and act in a negative way. Maybe we should look at some of your automatic thoughts a little closer.”","e":[18,8,-150,-88,14,25,10,-23,30,-17,-26,43,23,53,10,-13,14,-62,-31,43,-33,-34,-44,9,49,69,-28,25,-58,32,35,-36,5,-53,-83,-28,44,30,5,29,73,-28,58,-68,18,-18,87,16,10,-40,15,-76,-7,-12,122,41,59,95,27,-20,108,-11,3,75,45,-64,-61,32,-31,11,52,5,-5,1,-46,36,-33,-13,21,47,36,-32,72,-29,49,14,3,28,-8,87,7,-11,-10,22,-87,12,-45,10,-56,-39,-47,15,-33,-30,11,22,-28,28,21,14,-8,56,-20,-34,8,1,61,-34,28,50,0,8,-33,82,70,59,-35,12,10,-22,10,-53,-14,50,0,38,22,-56,15,19,43,9,-38,-10,-11,-27,32,-56,-48,50,19,-13,3,16,71,-40,-31,19,54,9,58,15,-47,41,8,-35,27,70,23,10,-1,-87,-9,-25,59,20,20,-36,14,-44,34,-27,22,-18,15,-45,-11,-20,-18,-50,-18,18,-41,-38,-91,-26,40,-38,40,-16,26,19,-18,32,-44,54,-15,-27,-44,-22,90,-2,-23,25,-23,24,22,-34,-27,34,44,-27,-12,-41,5,3,1,15,-35,-16,-40,-106,34,19,21,-11,-23,29,-10,45,31,42,-1,15,-98,-4,-2,-11,15,36,6,-9,17,-16,64,-22]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.74","t":"Using the patient's example, describe the association between thoughts and feelings to build awareness of the connection. This is a good time for the patient to write down the thought and begin using the cognitive-behavioral model (Figure 11.3). In-Session Example 11.2 Provider: “So, let’s write down this automatic thought that you are having. I will never get married. Your going to your cousin’s wedding was the situation that triggered the thought, ‘I will never get married.’” Patient: “Yes, that’s true.” Provider: “When you were at the wedding and that thought came to you, how did you feel?” Patient: “I felt really sad and hopeless.” 74","e":[29,19,-133,-74,49,35,28,-24,29,-13,-48,28,49,69,-6,1,15,-47,-38,35,-58,-18,-19,0,20,30,-48,5,-95,32,46,4,2,-72,-75,-87,12,17,25,-10,89,-17,32,-82,48,-18,94,0,43,24,14,-45,23,-11,125,65,59,70,-2,-10,109,40,-27,58,66,-27,-65,60,-19,28,44,4,13,6,-46,24,-2,-25,34,33,54,-39,79,-46,60,21,-1,-10,-6,77,-12,5,12,25,-76,12,-71,-8,-25,-56,-53,-26,-33,-47,-6,40,2,29,10,17,-54,39,-39,-42,-5,-2,44,-12,31,45,9,19,-2,71,29,65,-29,-5,15,-31,12,-42,-8,38,-3,41,0,-26,4,26,39,-5,-18,-8,-25,-34,14,-44,-29,34,2,19,10,10,37,-39,-14,-1,45,-9,67,6,-21,37,-10,-53,38,29,31,14,-36,-60,-6,-19,81,11,16,-22,3,-38,46,-24,43,19,19,-37,16,11,-52,-48,-32,9,-33,-30,-90,-32,27,-4,42,-27,6,38,-44,50,-52,61,-30,-28,-39,-9,58,18,-39,24,-25,-5,17,-4,-58,33,31,-29,15,-44,30,-3,-38,9,-36,1,-28,-93,42,-1,30,17,-28,18,-12,47,-3,46,19,7,-78,-3,-3,-32,13,55,26,26,9,-6,71,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.75","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 Provider: “So, can you see how our thoughts can affect our mood and change the way we are feeling?” Pamela: “Yeah, I guess if I hadn’t had that thought, I wouldn’t have felt so bad.” Figure 11.3 Example Patient Cognitive Model “I WILL NEVER GET MARRIED” THOUGHT SITUATION FEELING COUSIN’S SAD/HOPELESS WEDDING ELICITING AUTOMATIC THOUGHTS It is important for providers to teach patients how to identify automatic thoughts during and outside of session.","e":[21,-2,-137,-64,61,47,29,-13,35,-30,-33,28,44,59,11,-2,14,-39,-10,35,-49,-29,-26,3,40,54,-25,38,-72,20,40,-41,-10,-64,-78,-58,56,24,-22,24,81,-25,29,-86,35,11,123,26,16,-7,12,-72,49,-37,130,48,37,70,-11,-12,93,26,-27,77,12,-61,-53,44,-39,21,51,-3,-10,39,-37,9,-41,-8,4,38,51,-39,85,-24,40,1,4,-5,3,75,1,-13,-4,30,-72,26,-28,-26,-25,-49,-64,-15,-32,-35,-19,39,-7,-6,19,-2,-41,42,-30,-31,-10,-13,41,-25,15,52,14,-3,-3,72,65,83,-44,-1,17,-56,0,-38,-2,12,2,33,12,-18,24,40,38,9,-25,10,-30,-43,15,-38,-66,9,5,-6,15,37,55,-28,-20,5,35,0,44,20,-31,30,-17,-44,36,35,39,47,-53,-71,-3,-23,64,38,6,-27,26,-41,14,-7,27,36,8,-41,-6,-2,-32,-35,-20,33,-46,-29,-103,-40,3,-19,34,-21,-5,33,-27,35,-70,66,-15,-18,-31,-40,93,1,-30,17,-24,16,14,-26,-35,30,24,6,-6,-12,-10,11,-13,-6,-27,15,-10,-97,39,30,3,29,-6,29,5,61,26,52,31,14,-94,0,4,-19,6,42,11,-1,9,-5,39,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.75","t":"AUTOMATIC THOUGHTS IN SESSION Be aware of patients’ hot thoughts during sessions. Hot thoughts are automatic thoughts that occur in combination with a change in emotion or mood. Hot thoughts are particularly poignant or strong thoughts that are often associated with unhelpful core beliefs and should be targeted in therapy. Hot thoughts and the accompanying situation and emotion are tracked on the first three columns of the thought record (see p. 81).","e":[52,7,-177,-66,38,13,18,14,-10,-13,6,46,50,57,-6,-27,-3,-23,-14,25,-45,-42,-31,-47,28,40,-19,-9,-36,-9,41,-15,-11,-16,-67,-34,75,0,-30,13,51,-16,97,-74,25,7,40,9,24,29,44,-67,-29,-66,119,22,53,66,8,15,104,17,-24,32,50,-12,-67,29,-27,1,57,-3,28,8,-34,-2,-30,-11,18,37,36,-48,69,-12,71,11,-10,58,12,68,46,1,27,27,-108,25,-28,7,-47,-29,-70,-53,-38,2,4,35,-34,56,4,34,-4,71,-32,-46,2,-26,36,-10,20,44,40,23,-14,83,44,47,-19,-8,-6,-41,-20,-34,-14,51,22,47,42,-35,6,21,51,-4,-14,-19,-10,-57,31,-59,-32,36,17,5,-3,-4,8,-52,-70,29,58,6,22,17,-46,11,0,-50,17,49,14,-5,-42,-47,-8,-26,61,9,96,-48,57,-76,-16,-54,14,-19,11,-28,12,-10,-64,-17,-20,10,-15,-26,-97,-25,51,-17,37,-15,28,1,-69,11,-29,93,18,7,-31,-59,82,32,-4,0,11,4,-9,-29,-12,42,40,36,-12,-22,-18,-12,-47,-32,1,22,-43,-104,54,-4,5,-26,-2,42,-1,69,11,17,19,1,-105,4,2,-45,-30,22,19,-2,-28,-34,44,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.75","t":"To identify which automatic thoughts are “hot,” listen for verbal cues, such as the language used in the thought (see Cognitive Distortion worksheet, p. 83), and watches nonverbal cues, such as increased volume of speech or fidgeting. Changes in facial expression, shifts in position, or hand movements can be helpful in determining whether a patient is experiencing an automatic hot thought. Listening to tone, pitch, volume, and the pace of a patient’s speech is also beneficial. When you notice these actions, this is an opportune time to bring it to the patient’s attention and assist them in identifying an automatic 75","e":[56,7,-175,-59,56,16,56,24,16,-9,9,50,58,105,34,-50,-11,-68,-9,23,-22,-21,-28,-35,25,22,-21,22,-27,1,38,-11,1,-20,-61,-64,74,13,-34,64,29,-11,100,-56,55,28,26,16,48,31,17,-74,-37,-32,91,24,14,52,33,-5,90,39,-43,6,38,-1,-77,38,-21,22,30,-8,35,20,-55,11,-17,-11,11,67,51,-48,118,-19,83,12,-7,24,1,54,43,-1,54,56,-77,24,-23,40,-25,-46,-80,-6,-30,-18,20,51,-20,31,17,18,-12,35,-27,-52,-4,-24,46,-25,14,63,28,6,-27,47,39,36,-38,-34,8,-36,-8,-17,-13,16,30,64,10,-23,6,15,58,12,11,-44,-22,-30,1,-49,-31,34,3,27,23,-27,23,-52,-39,25,43,-5,44,-8,-37,62,-2,-47,10,63,3,5,-56,-26,-1,-32,57,-10,67,-79,47,-35,2,-50,17,25,10,-33,1,1,-40,-5,-27,-14,-44,-38,-64,-17,40,-10,22,-35,-32,-27,-46,-15,-29,88,17,-8,-50,-38,73,53,-2,-16,-2,43,-6,-19,-23,34,25,16,1,-35,-7,-29,-58,-20,-3,24,-2,-107,65,8,6,-30,13,47,-7,39,5,32,20,7,-86,-5,7,-28,-46,35,11,27,-22,-16,43,-1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.76","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 thought associated with the shift in emotions. In these instances, you are simply an observer of the behavior and make a note of your observation to the patient (“You are speaking more loudly; what is going through your mind right now?”). The patient then provides an explanation of the behavior. In-Session Example 11.3 Patient “My boss reprimanded me again yesterday” (sighs heavily.) Provider: “Tell me more.” Patient: “Well, we were at a meeting; and I had just made my presentation, and he said he had expected a better product for the client.” (voice gets softer, beings wringing hands).","e":[34,13,-166,-75,76,20,43,-21,18,-34,-15,29,38,67,38,-10,25,-58,-15,16,-38,-1,-14,-9,35,68,-24,68,-50,0,30,-21,12,-40,-91,-56,58,26,-60,23,59,-30,11,-105,41,-5,84,23,10,-29,-12,-78,28,-16,140,58,27,25,23,-23,82,22,-30,65,11,-12,-62,63,-42,-2,50,-14,-5,35,-27,-7,-53,-5,7,30,62,-39,73,-13,52,-16,-13,23,-5,83,16,-16,18,37,-107,35,-1,-23,-10,-46,-68,-33,10,-26,6,46,-43,-3,10,-27,-35,26,-26,-24,8,4,56,-15,-4,62,-13,-15,7,51,72,63,-35,-5,13,-33,21,-12,-26,-9,14,36,18,-1,45,27,54,28,-8,-1,-16,-40,26,-30,-35,10,-5,10,28,21,49,-28,-25,15,45,46,60,-9,-54,41,-7,-55,19,59,40,31,-45,-58,4,-9,49,52,50,-22,1,-51,8,-9,39,30,7,-30,-3,-36,-33,-54,-42,30,-29,7,-70,-46,-6,-45,16,-20,-2,14,-34,38,-51,60,-25,-8,-36,-49,93,-15,-20,-16,-30,21,9,-13,-28,26,20,-7,-5,-1,-4,-19,-10,-15,-25,28,-25,-79,36,26,16,21,-27,40,1,53,31,40,31,-5,-89,31,43,-41,12,51,-24,-8,31,-17,34,-1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.76","t":"Provider: “Your voice changed a little when you said that; tell me what is going through your mind right now?” Example continued: Patient: “I just feel like a failure at everything. My work has always been the one thing I was good at, and now I am failing at that, too.” Provider: “Let’s take a look at that line of thinking and the feelings it creates. It seems that when that thought entered your mind, your mood changed very quickly. Did you notice that?” Patient: “Yeah, I guess it did upset me pretty fast.” You usually will also need to use specific questions to elicit an automatic hot thought. These questions are found in Module 12.","e":[34,-5,-166,-68,59,36,21,-1,20,-39,-27,42,52,101,6,-18,38,-85,-23,36,-45,-59,-61,-16,32,19,-38,5,-49,19,49,-24,21,-30,-90,-40,47,24,-27,43,78,-49,92,-85,62,-1,46,19,14,-30,2,-79,-19,-26,87,28,9,51,34,-22,99,13,-7,52,37,-12,-60,56,-46,-7,42,-1,28,10,-51,25,-34,-34,28,27,58,-58,83,-21,40,7,3,37,-12,99,15,5,4,49,-74,6,-38,-14,-36,-52,-82,-32,-32,-38,1,70,-7,38,25,5,1,32,-36,-40,12,-3,63,-32,4,54,8,11,-1,37,70,24,-29,-7,12,3,-2,-30,-32,44,3,49,19,-22,10,-20,69,-2,-4,-23,-12,-40,23,-31,-36,20,7,16,26,-4,35,-47,-16,23,58,-17,65,12,-47,60,31,-32,2,50,37,36,-25,-43,13,-24,65,23,54,-65,34,-39,26,-39,17,-6,25,-32,5,-22,-34,-41,-45,0,-34,-16,-69,-31,38,-53,22,-6,18,13,-30,33,-63,77,-17,6,-46,-48,114,1,-20,0,-31,39,10,-30,-25,39,14,-1,-2,-31,11,-28,-23,-21,-37,-3,-18,-104,53,7,25,6,-22,33,-24,43,13,31,12,7,-108,-3,23,-38,1,42,10,6,14,-19,52,-22]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.76","t":"AUTOMATIC THOUGHTS BETWEEN SESSIONS In brief CBT, a principal characteristic is the work the patient does outside of session. Because identifying automatic thoughts is a novel concept to many, practicing outside of session will facilitate movement and change in therapy. In fact, Burns and Nolen-Hoeksema (1992) found that patients who completed homework had significantly better treatment outcomes than those who did not. Practicing key skills between sessions allows session time to be used for new skill acquisition and troubleshooting. Initially, when a specific situation is brought up in session, always ask, “What was going through your mind at that moment?” This helps the patient build awareness of an automatic thought, both within and outside of session.","e":[35,-6,-182,-74,22,7,87,-30,5,-8,8,22,23,26,-8,-39,16,-82,-14,20,-32,-9,-10,-6,43,50,-7,19,-19,-8,55,-63,2,-32,-66,-37,85,19,-19,-14,33,-5,28,-95,45,-6,59,-17,-2,-32,25,-64,-16,-25,139,38,40,66,34,-38,84,41,-31,52,20,-21,-33,44,-29,-12,36,3,37,50,-34,0,-39,1,27,64,24,-43,69,-23,100,24,1,19,-16,92,2,-14,28,44,-110,15,4,20,-35,-14,-69,-31,-18,-14,19,36,-14,-9,-4,24,-22,47,-40,-11,0,-24,35,-40,32,42,-10,-23,-12,62,37,110,-26,-19,20,-21,-8,-15,-33,25,33,44,3,-15,-13,45,53,7,-31,18,1,-30,-5,-43,-60,27,8,23,-17,11,46,-22,-25,9,52,12,22,-23,-54,25,-11,-37,13,57,32,5,-45,-44,-3,-19,56,39,68,-38,34,-35,7,-33,13,27,6,-7,-12,-33,-27,-42,15,12,-46,-21,-114,-58,45,-8,18,-54,-24,22,-56,26,-26,94,-19,1,-19,-33,88,35,-38,10,-25,-5,-14,-31,-44,51,26,22,-4,-40,-16,-12,-6,-4,-38,41,-43,-77,42,28,26,22,11,27,2,62,41,36,19,11,-72,12,13,-37,-11,22,15,6,8,-20,19,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.77","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 Because automatic thoughts may occur outside awareness, asking for a more detailed description of the situation is also helpful in pinpointing unhelpful thinking. For example, you could \"take the patient back\" to when it happened, using imagery (e.g., Where were you when this happened? What time of day was it?). If the patient reverts to past tense, remind them to tell the story in present tense to help bring back the thoughts and feelings that occurred in this situation.","e":[49,-18,-164,-74,73,25,41,2,27,-8,-4,24,53,53,1,-36,14,-55,-15,28,-16,-21,-13,5,34,29,-20,44,-79,2,82,-41,-7,-63,-49,-55,48,20,-40,-5,72,-17,22,-55,64,33,81,14,-3,-22,-8,-58,-3,-28,142,20,42,25,23,-8,92,49,-2,47,0,-23,-79,71,-39,6,29,-20,13,49,-50,0,-46,-13,13,42,52,-26,74,-11,57,12,14,3,-24,76,12,-17,25,32,-79,34,-7,-4,-27,-21,-90,-42,-4,-19,-15,45,-6,-1,1,-27,-28,40,-36,-6,1,16,56,-15,12,42,-24,-3,5,53,49,74,-37,3,41,-40,-16,-15,-10,1,3,49,27,-20,28,36,44,-6,-15,-11,-18,-27,22,-17,-44,-7,-7,-1,-1,51,57,-49,-27,5,38,11,46,-7,-48,25,-24,-45,16,28,36,10,-52,-46,22,-15,56,29,21,-31,35,-47,21,-14,27,58,-14,-42,-16,14,-34,-37,-1,21,-46,-12,-107,-45,15,-2,21,-9,0,11,-28,28,-44,48,-16,-12,-24,-51,79,11,-42,9,-29,23,7,-2,-26,32,-6,19,18,-6,-20,-10,-12,-2,-43,20,-28,-86,27,22,47,18,-11,51,-3,45,-4,43,40,29,-78,13,33,-61,1,45,-14,-1,17,-22,26,-9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.77","t":"With continued questioning, it is possible that there may be more than one automatic thought associated with a problematic situation. Elicit and record all automatic thoughts given for a particular situation. In-Session Example 11.4 Provider: “Craig, what else were you thinking during this phone call with your wife?” Craig: “I was thinking that she knows how bad I feel for not coming to the party and she wants me to feel even worse.” Provider: “So you weren’t thinking only that they were using you. You were also thinking that they knew you felt bad, and they wanted you to feel worse?” Craig: “Yes.”","e":[52,6,-156,-53,84,10,17,-26,-2,18,-57,30,28,86,-5,-26,36,-76,-3,14,-43,-10,-57,-6,45,34,-17,2,-60,16,43,-29,-17,-51,-106,-68,55,15,-34,-1,63,-3,5,-79,15,-31,66,14,49,-45,31,-44,-18,-8,85,52,35,36,-6,-42,84,9,-3,48,60,-38,-37,61,-46,-11,55,-18,-12,11,-40,15,-7,-11,43,54,49,-58,74,-41,37,37,10,9,-7,90,5,3,32,55,-72,25,-12,11,-50,-34,-73,-9,-25,-15,15,37,-30,25,16,39,-14,37,-40,-20,-8,3,48,-31,30,39,4,15,-32,34,50,57,-29,7,18,-28,-1,-24,-10,22,16,11,14,-18,-10,14,74,25,-19,19,-26,-45,50,-40,-62,15,2,0,0,1,54,-24,-45,-1,43,35,30,-2,-43,62,-12,7,25,42,43,12,-32,-55,-1,-41,84,39,65,-81,29,-12,18,-20,34,8,19,-37,-13,-13,-17,-41,7,25,-74,-20,-83,-41,45,-13,40,-18,-5,10,-57,25,-44,65,-12,-29,-27,-34,88,8,-17,38,-31,-21,34,-29,-20,26,7,13,-21,5,2,-12,-31,10,-32,12,-31,-122,58,5,20,9,-43,27,-15,49,12,36,13,19,-77,7,4,-5,24,53,-3,12,0,-26,61,-22]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.77","t":"Provider: “So, that is really three different thoughts that you were having that were creating feelings of anger?” Craig: “I guess so.” Remember that a patient’s automatic thoughts should be the actual words or images that go through their mind. Patients (or providers) may often interpret or rephrase thoughts; however, the goal is to get unprocessed thoughts verbatim.","e":[73,41,-127,-67,80,9,9,0,4,1,9,31,46,38,-24,0,34,-62,-5,41,-66,-38,-43,-39,43,37,-32,-17,-78,34,69,-1,-30,-57,-83,-69,54,32,-17,15,66,5,25,-74,13,9,10,16,69,-14,16,-91,-3,-29,98,61,44,38,17,4,73,24,-16,41,45,-3,-45,42,-7,-10,79,-9,24,15,-44,-23,-33,-20,25,42,55,-57,69,-41,78,9,31,25,-1,95,-7,-1,19,55,-85,8,-34,19,-40,-35,-121,-28,-22,-50,29,23,0,29,-10,20,-15,44,-4,-26,17,4,61,-33,16,71,38,-8,-19,62,53,24,-8,-16,19,-20,0,-37,-15,26,5,27,26,-34,11,25,63,24,-10,-20,-14,-88,18,-31,-45,69,5,-4,-5,17,29,-24,-54,38,30,18,34,9,-37,58,0,-66,33,31,19,7,-30,-25,2,-44,65,30,50,-29,44,-44,2,-42,11,15,30,-20,-6,-15,-46,-9,21,54,-50,-1,-82,-21,1,-22,53,-10,20,9,-61,6,-43,66,1,-24,-16,-52,71,25,-22,12,-10,-10,4,-31,-51,12,20,8,-9,-44,-9,-17,-30,-4,-28,-6,-2,-114,68,-8,36,16,-15,15,-5,71,-8,62,41,31,-87,-7,41,-43,-13,29,-27,10,-9,-11,46,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.77","t":"DECIDING WHICH AUTOMATIC THOUGHTS TO FOCUS ON Once patients become aware of how many automatic thoughts they have, they may feel overwhelmed by their sheer number. Uncovering one thought may lead to another and so on. Therefore, it is important to focus on the most important automatic thoughts and the hot thoughts that are likely to bring about the greatest change. There are several things patients can do once they have identified an automatic thought. They can decide to focus on that thought, choose another thought associated with the situation, or move on to another topic if they feel that there is a more powerful thought that they would like to tackle. 77","e":[30,35,-130,-28,81,17,35,-8,8,6,-2,13,69,55,5,-28,8,-64,4,29,-28,-28,-40,-21,12,43,-1,-12,-50,45,43,-28,-9,-42,-58,-66,76,21,5,11,15,-7,63,-100,41,8,63,2,69,-22,50,-37,-35,-23,83,46,37,60,43,-20,118,38,-48,34,29,-16,-52,41,-14,-6,22,-11,38,17,-46,16,18,-11,26,71,44,-79,94,-35,37,32,19,11,-1,72,45,10,30,70,-103,24,-11,10,-40,-46,-75,-22,-21,-28,34,30,-10,58,18,31,-18,16,-26,-44,-20,14,71,-15,26,57,16,4,2,70,61,43,-40,-11,49,-14,0,-31,6,30,24,69,-5,-26,18,22,48,19,-7,19,-18,-34,5,-27,-54,38,13,-7,-6,-2,46,-59,-50,14,37,-35,36,18,-59,38,-15,-41,39,32,13,6,-25,-38,18,-20,108,0,89,-52,41,-25,-6,-55,0,30,7,-15,-9,-1,-40,-11,7,21,-6,-41,-101,11,47,-21,26,-38,-16,6,-68,24,-50,94,12,-6,-52,-62,80,45,-36,19,-10,6,-16,-22,-30,55,30,23,3,-26,-12,-22,-39,-33,9,20,1,-75,68,7,4,-20,-17,29,4,57,10,19,39,5,-93,-12,10,-25,-40,38,9,20,-30,-5,54,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.78","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 You can help the patient choose automatic thoughts to focus on by frequently checking: • Goals for this session • Patient’s agenda items and addressing those problems • The importance of the thought chosen in reaching therapeutic goals Another technique is to identify a few automatic thoughts and then rate them on a scale of 0-100, based on how intense the associated feeling is (rate the feeling from 0-100), and how much patient believes the thought (rate believability from 0-100). This helps to quantify which automatic thoughts are most important. The thoughts with the strongest ratings should be considered first.","e":[15,26,-146,-57,79,-4,57,-15,4,-8,6,2,63,29,-5,-12,-2,-77,25,21,-32,-31,-21,-22,49,62,-31,35,-67,19,36,-41,-11,-55,-67,-41,69,41,-40,18,33,-27,43,-78,41,42,90,6,23,-12,3,-54,12,-38,131,69,0,51,10,-19,99,39,-40,55,28,-26,-45,47,-46,23,25,-35,11,57,-70,-12,-42,0,31,63,46,-61,88,-18,54,-1,-10,14,-3,81,7,-18,11,49,-90,45,-4,-5,-15,-40,-73,-3,-25,-41,-1,31,-1,12,12,-3,-31,16,-30,-15,-11,12,60,-15,-1,50,10,1,31,68,41,72,-37,9,24,-34,5,-31,-15,-14,5,68,25,-26,14,23,13,5,-15,25,-31,-44,5,-19,-41,6,10,-22,12,13,39,-43,-16,10,35,9,35,9,-46,37,-22,-39,26,35,43,27,-48,-55,14,-10,79,16,48,-24,35,-44,38,-17,33,62,-15,-30,13,-26,-17,-9,28,22,-54,-23,-103,-18,40,-31,30,-43,-10,35,-56,13,-80,66,6,5,-44,-59,79,17,-50,25,-32,8,-7,-22,-38,36,27,19,-1,-11,-20,-8,-31,-11,4,34,-9,-91,40,20,0,15,-17,27,12,67,39,41,38,14,-108,2,19,-25,-10,30,-21,19,-22,-10,36,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.78","t":"Unhelpful automatic thoughts often fall into certain categories. These are common \"cognitive distortions\" or thinking errors. Identifying patterns of cognitive distortions in the patient's thought records or speech is instrumental for choosing a hot thought, conceptualizing the case, and planning treatment. A patient often has one or two common patterns of unhelpful thinking. Identifying these patterns helps him/her identify them when they come up and provides you an opportunity to intervene on a thought triggered in multiple situations. Therefore, changing a particular thought that is part of an unhelpful thinking pattern (e.g., tendency to ignore the positive) may have multiple benefits for the patient. For a list of common thinking errors, see the Unhelpful Thinking Styles at the end of this module.","e":[59,49,-158,-73,78,31,52,29,25,4,24,-7,56,78,1,-10,9,-45,14,28,-51,-14,-50,-35,39,58,-24,-36,-67,13,47,-21,2,-49,-71,-49,79,-1,32,33,34,2,36,-65,35,44,66,16,45,-40,57,-58,16,-6,95,20,23,30,6,-26,70,42,-19,20,-28,6,-71,42,-23,-2,40,6,17,17,-63,21,-20,5,5,35,28,-46,69,-12,66,22,4,33,-23,74,0,-22,11,40,-100,34,-20,0,-67,-20,-71,-26,5,-19,9,48,2,35,5,5,-20,59,1,-32,4,-28,56,-10,32,53,11,-17,13,70,12,52,-26,-13,44,-40,-26,-8,2,2,10,71,38,-13,17,20,50,-1,7,-26,7,-57,14,-32,-56,17,-15,17,2,11,29,-44,-47,11,51,-6,62,5,-74,34,-37,-55,34,48,19,25,-35,-28,36,-6,89,-22,70,-66,25,-24,-9,-27,17,21,4,-28,27,-16,-54,-18,41,19,-36,-17,-79,-45,16,10,33,-32,14,-5,-65,9,-39,66,-4,18,-50,-30,69,5,-10,5,-9,-5,-9,-17,-18,10,51,10,8,-15,5,-26,-28,-10,-8,-17,-34,-122,55,-6,40,-10,-4,36,2,23,-26,43,-8,15,-88,-14,-7,-75,-25,51,-5,47,0,-23,60,17]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.78","t":"INTERMEDIATE BELIEFS To identify an intermediate belief, you must first know how to recognize patients’ automatic thoughts. You can do this by identifying an automatic thought and then attempting to identify an attitude or assumption patients feel about themselves, the future, others, or the world. These assumptions can be identified by listening for themes in the patient’s thoughts and behavior. You can use several techniques to identify an intermediate belief: • Look for an intermediate belief that comes in the form of a patient’s automatic thought. • Provide the first part of an assumption (“If x...”), and enlist the help of the patient to complete it. • Elicit a rule or an attitude from the patient and change it into an assumption. • Look for themes in the patient’s automatic thoughts. Either come up with a hypothesis or ask the patient to identify a theme. • Ask patients directly about their beliefs. • Have patients complete a questionnaire or inventory that will help identify their beliefs.","e":[35,-2,-168,-76,55,-4,33,-10,25,1,-6,31,27,59,8,-2,19,-58,27,39,-46,-21,-22,-9,34,40,-53,37,-37,4,19,-34,45,-35,-43,-96,39,43,10,6,16,-2,27,-67,19,13,61,-15,57,-6,8,-42,34,4,78,59,14,53,58,-41,93,37,-42,28,21,-36,-57,29,-37,-6,34,21,5,37,-57,9,-3,15,19,48,78,-32,99,-33,27,19,-2,4,-21,48,13,-20,13,38,-90,14,-33,31,-33,-39,-81,-22,-30,-43,10,47,-13,7,-7,16,-42,33,-33,-22,0,-5,69,-1,46,44,-13,22,13,77,40,56,-48,-25,28,-7,19,-15,-20,9,13,46,37,-26,-5,42,11,17,7,1,10,-44,8,-30,-33,49,7,29,15,40,19,-45,-35,-1,59,-19,54,7,-41,56,-7,-36,25,74,9,7,-30,-29,2,2,92,4,43,-67,18,-11,39,-19,42,28,2,-32,20,-15,-32,-38,29,30,-68,-23,-61,-1,22,-1,26,-49,4,20,-34,22,-51,62,6,-27,-36,-21,56,-16,-36,47,-6,57,-10,-14,-22,2,47,-28,1,-4,5,-6,-80,23,2,2,0,-115,45,-4,50,-12,-25,26,34,39,-18,25,40,41,-76,26,16,-48,5,73,13,54,-19,-19,52,-59]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.79","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 CORE BELIEFS Throughout therapy, hypothesize core beliefs that may be underlying unhelpful behaviors and thoughts. These hypotheses aid development of the case conceptualization and treatment plan (see Module 4). A belief that is likely to be core will appear in several different areas of the patient’s life (i.e., relationships, work, parenting). If time permits in Brief CBT, after you have collected enough evidence to support the alleged core belief, present and discuss it with the patient. In-Session Example 11.5","e":[22,29,-154,-73,61,10,34,-18,32,-39,5,-3,27,38,-20,2,-24,-15,11,31,-73,-19,-5,-24,24,43,-15,53,-41,8,35,-25,36,-69,-54,-97,66,25,-28,-24,25,-10,27,-89,28,23,95,17,-3,5,9,-69,69,-45,118,45,-1,43,-24,-40,104,54,-50,55,-1,-22,-73,64,-42,-23,49,-41,28,37,-47,-10,-41,14,4,46,79,-25,71,-24,21,18,-42,0,0,65,16,-10,-19,18,-92,20,-15,-38,-25,-14,-65,-37,18,-4,-12,57,-19,6,4,1,-50,47,-34,-14,-15,-18,65,-9,1,25,-26,-3,19,90,29,73,-33,-19,5,-25,12,-17,-45,-29,14,52,21,3,20,53,4,14,3,6,1,-48,24,-34,-30,-5,-4,38,7,45,35,-32,-44,-18,60,-4,32,6,-12,17,-19,-32,-1,62,44,33,-38,-47,1,7,96,24,52,-28,16,-24,2,14,26,60,3,-9,37,-21,-41,-45,-40,15,-44,9,-66,-69,-2,-10,36,-41,10,12,-42,51,-48,52,-17,17,-17,-40,80,-20,-20,34,-23,22,-9,7,-31,16,31,7,8,3,-12,7,-22,-12,-8,15,-26,-123,51,27,32,18,-5,36,19,60,7,59,32,5,-62,4,18,-41,-3,62,-25,36,-7,-5,29,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.79","t":"“I’ve heard you say several times that you either didn’t do a good job, or that someone else put in more time and energy. It seems to me that you feel inadequate a lot of the time. Is that right?” At this point, you can elicit earlier life experiences consistent with the belief. This helps identify the possible origin of the belief and helps you explain it to the patient.","e":[42,25,-187,-51,22,66,20,-15,28,-23,-23,11,33,91,-1,-2,38,-51,1,50,-46,-37,-35,7,-3,23,-55,2,-51,-17,43,-11,43,-54,-48,-13,41,42,72,-33,11,-11,44,-102,20,-38,43,23,21,-52,-7,-83,-4,16,124,23,10,17,41,-6,107,50,-27,31,65,-19,-29,57,-22,-18,42,-15,-14,12,-88,66,-32,33,9,29,77,-6,74,-15,49,19,17,36,-11,110,35,2,24,2,-99,-2,-33,3,-58,-8,-68,-32,-22,-45,55,31,-11,3,-28,26,-46,11,-12,-31,-9,-13,97,-50,-34,41,-17,34,-7,41,34,43,-33,-24,4,5,25,-54,-15,9,6,22,-6,-1,-3,14,93,7,29,-9,-14,-44,-7,-41,-59,52,13,32,9,6,40,-55,-48,12,53,-30,70,21,10,43,17,-8,4,69,31,40,-16,-37,13,-47,51,35,46,-44,-12,-66,8,-30,1,-18,9,-53,36,-35,-67,-61,-1,24,12,-17,-69,-27,23,-42,14,-15,15,1,-13,38,-22,56,-46,-5,-21,-58,67,18,5,35,-36,-15,2,-3,-33,15,-23,-8,39,-13,53,-12,-35,-14,-60,-6,-14,-100,49,-7,28,37,-27,32,16,28,-9,25,14,-12,-67,20,29,-40,27,15,19,34,11,-19,18,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.79","t":"In educating the patient about core beliefs, make several things clear: • Core beliefs are only ideas. Feeling them strongly does not make them true. • These beliefs started developing during childhood and are formed over time. Patients believe them today because they have stored evidence to support them and rejected evidence to contradict them. • These beliefs can be tested and changed through use of the techniques that will be taught in therapy. 79","e":[33,40,-143,-77,52,48,12,14,41,-36,-3,32,31,39,-18,4,-37,-23,10,69,-67,-26,-15,-64,-17,19,-55,17,-29,22,55,-12,63,-58,-29,-129,32,25,48,-40,23,26,11,-78,13,-27,44,-25,35,8,-1,-101,42,-22,110,68,-20,83,12,-64,99,36,-65,60,29,10,-74,58,-6,-2,59,-21,3,20,-24,-12,-30,-2,12,48,90,-30,45,-21,46,29,-14,4,7,109,22,-31,-4,19,-86,-24,-29,2,-6,6,-73,-49,15,-15,17,29,6,9,-4,2,-25,45,-46,-6,-20,5,88,-18,14,0,-22,14,19,110,40,39,-1,-38,1,3,-7,-32,-67,-22,20,48,18,-2,5,44,17,25,15,0,16,-61,16,-34,-4,56,39,47,14,46,1,-40,-17,8,70,-1,64,26,-20,20,19,-13,-7,56,26,30,-33,-20,8,7,92,32,64,-46,46,-26,-7,2,-2,41,20,1,26,-45,-61,-38,-45,8,-50,19,-68,-78,-2,5,51,-17,4,33,-28,23,-31,58,-9,-9,-15,-11,53,-5,-39,47,-24,-5,-14,18,-29,25,23,-18,7,-4,-4,-12,-33,13,-3,8,-35,-117,43,37,64,14,-41,27,39,20,-1,10,35,0,-50,4,19,-45,-14,44,-8,68,0,17,29,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.80","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 EXAMPLE HOMEWORK ASSIGNMENTS 1. Keep a notepad with you and attempt to list automatic thoughts you have during the day. 2. Use the triangle diagram to dissect three to five situations when you experienced a strong emotion. 3. Create a list of assumptions and evidence for and against those assumptions. 4. Complete the first three sections of the Thought Record for one to two situations.","e":[36,-17,-154,-69,74,-3,46,-31,10,-18,-13,-4,71,53,-7,-3,-4,-57,20,18,-26,-17,-21,7,23,45,-22,38,-68,1,-2,-32,-23,-59,-79,-48,56,17,-53,5,53,-42,5,-64,52,7,103,-13,31,-6,3,-48,55,-45,111,59,28,-8,46,-19,88,46,-50,60,1,-5,-51,82,-49,15,55,-9,50,39,-61,-18,-45,-4,20,54,49,-21,71,-18,73,-7,-16,-18,-15,61,-6,9,14,36,-49,47,0,3,-14,-46,-59,-23,-18,-34,-5,12,-5,-5,2,-10,-73,35,-41,-5,16,43,64,-35,15,42,-29,-12,7,32,30,61,-54,-16,5,-47,9,-42,-34,14,2,45,-22,-11,22,19,31,-3,-43,18,-21,-6,-3,-37,-56,-8,-15,6,42,-12,51,-10,-5,-24,41,24,39,-16,-44,58,-15,-23,31,52,48,44,-71,-61,-5,-4,33,14,33,-20,24,-14,32,10,41,43,-21,-32,9,-2,-39,-17,7,30,-35,-5,-95,-44,27,-40,16,-28,-20,8,-15,41,-64,75,-28,-7,-18,-48,95,8,-35,21,-34,15,-14,-19,-33,13,2,-8,11,-25,1,30,-11,-10,-28,41,-21,-87,55,-8,32,22,-14,43,-5,55,17,49,60,11,-92,21,35,-36,2,47,-7,-9,19,4,7,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.80","t":"SUPPLEMENTAL READINGS Beck, J.S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press; Chapters 9-14 Safran, J. D., & Greenberg, L. S. (1982). Eliciting \"hot cognitions\" in cognitive behaviour therapy: Rationale and procedural guidelines. Canadian Psychology/Psychologie canadienne, 23(2), 83–87. https://doi.org/10.1037/h0081247 Greenberg, D. & Padesky, C.A. (2016). Mind over mood: Change the way you feel by changing the way you think. New York: Guilford Press; Chapters 5, 6, 7, 8, and 9. 80","e":[58,24,-168,-52,1,3,31,22,34,-11,0,13,71,66,14,-48,-19,-25,6,11,-53,-31,-29,-35,15,11,-23,16,-70,-9,24,25,-20,-22,-71,-49,121,-11,-58,21,29,-1,61,-93,20,-17,65,-3,10,20,15,-35,21,-68,92,4,1,36,11,-40,83,56,-64,19,35,-19,-76,58,-54,-16,58,-17,20,31,-28,-17,-46,-25,9,26,53,-16,81,-54,46,20,-24,20,4,44,29,27,7,41,-29,21,-12,-44,-40,-56,-63,0,30,7,18,40,-3,-5,-8,11,-49,46,-11,-34,10,-8,30,-22,34,54,0,-11,4,40,11,15,-68,-21,-8,-28,-7,-26,-18,27,-19,50,13,13,4,6,71,-13,7,-33,7,-15,5,-19,-43,-22,6,43,21,25,37,-52,-28,6,31,30,50,-1,-25,70,20,-21,2,40,2,34,-74,-43,-1,-18,41,25,94,-27,16,-35,8,-22,43,27,45,-29,-3,29,-58,-10,-51,-1,-49,-29,-86,-81,34,-30,57,-17,12,8,-61,6,-44,86,-6,11,-15,-46,32,6,37,8,-25,-8,13,-22,-38,45,5,19,7,5,-7,4,-16,2,42,48,-33,-113,22,1,26,19,17,77,28,64,24,63,2,28,-61,4,1,-32,-26,33,13,10,9,-2,46,5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.81","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 11 THOUGHT RECORD (1) (2) (3) (4) (5) (6) (7) Situation Automatic Emotion(s) & Evidence Evidence Alternative Rate Thought(s) Mood That That Thought Mood Supports Doesn’t Now Thought Support Thought Out of breath I’m too old to Defeated when I played play with her. in the park with my I can’t do Sad granddaughter what I used to do. Sad I can’t be her caregiver. Disappointed I have Hopeless nothing to offer my family any Hopeless more. Worthless I am a burden Hopeless (80) to my family. Hopeless (90 I am no good to my family.","e":[7,4,-167,-93,78,30,29,-26,14,-39,-46,-5,35,42,28,-15,-3,-30,-4,32,-9,-51,-23,12,56,65,-40,35,-59,33,31,-47,15,-34,-83,-42,57,13,2,12,48,-11,25,-63,22,11,110,52,49,-9,22,-47,55,-30,107,55,-11,5,-23,-26,89,32,-75,61,44,-21,-51,56,-41,-15,48,-16,22,44,-53,-10,-48,8,19,42,71,-25,85,-10,42,-31,-12,18,-34,69,-8,4,0,16,-75,40,-27,-12,-13,-23,-54,-37,16,-38,-2,32,-20,1,-5,-27,-58,33,-29,-1,-12,-20,41,-30,21,13,-4,28,27,50,34,56,-29,20,10,-38,-8,-14,-18,-12,9,33,-9,-16,16,38,35,7,-3,-17,-15,-35,21,-37,-78,-29,7,-4,19,38,23,-48,-21,29,34,14,33,24,-62,46,-29,-27,17,54,49,46,-41,-80,2,14,62,8,34,11,-1,-58,37,-8,49,27,-6,-35,28,-1,-25,-37,-7,23,-51,-6,-64,-47,13,-38,37,-39,13,35,-39,16,-66,47,-22,17,-8,-47,79,-20,-28,14,-31,-3,5,-22,-36,26,18,10,5,2,5,17,-18,1,-18,29,-37,-114,29,24,6,29,-25,41,4,55,22,56,34,7,-74,40,-6,-16,21,64,-14,25,14,-5,38,4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.81","t":"What actually What What What has What has What is 0-100 happened? thought(s) emotion(s) did happened happened another Where? What? went through you feel at the to make you to prove the way to How? When? your mind? time? Rate how believe the thought is think of this How much intense they thought is not true? situation? did you were (1-100). true? believe it? (1-100) 81","e":[58,10,-164,-49,102,33,40,19,21,-44,-46,22,63,43,-23,-71,-19,-60,-8,55,-22,-64,-53,-14,17,14,-61,2,-70,-13,-11,-30,17,-46,-57,-59,6,5,96,-35,39,-35,1,-53,45,-7,34,41,62,-16,26,-35,26,4,108,81,16,25,45,3,38,25,-8,-2,43,14,-68,99,-24,-23,48,-17,-16,4,-67,-15,-12,13,-19,20,79,-13,91,-30,53,14,-30,24,2,82,38,-4,30,7,-94,-14,-37,11,-25,-27,-58,-35,-16,-57,75,16,-10,44,10,17,-36,7,-51,-22,13,23,92,-29,12,42,-4,50,5,57,13,-10,-17,-14,-10,-52,-11,-54,-27,24,-15,58,4,-29,3,34,95,0,-22,-16,-28,-42,44,-32,-25,-12,50,37,6,34,10,-53,-20,48,19,30,66,40,-7,14,-30,-16,-1,43,1,32,-51,-55,29,-7,36,15,41,-20,3,-9,42,-39,44,-17,21,-82,54,10,-51,1,-21,20,-11,-50,-69,-31,47,-3,41,-42,12,27,-85,26,-42,82,6,-10,-4,-25,50,-4,-33,27,-44,9,27,-25,-16,31,27,1,1,-16,43,-5,-47,-3,5,55,-17,-81,38,7,1,19,-22,-15,25,28,13,29,-2,-12,-48,-17,17,-30,42,49,-18,-11,17,9,31,-4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.82","t":"• What happened? What • How were you feeling • What was going through were you doing? before this happened? your mind before you started to feel that way? • Who was there? • How did you feel while it was happening? • What made you feel that • Who were you speaking way? to? • What mood were you in after this happened? • Do you have any other • When did this happen? thoughts? • Can you rate your mood • What time of day was it? on a scale of 1-100? • Which thought bothered • Where did this incident you the most? occur? • What images did you have with these thoughts? • What are you afraid might happen? • What if this is true? What does this say about you? • What could happen if this were true? • What other ways could we think of this?","e":[55,-16,-144,-58,59,43,65,-12,29,-64,-18,39,47,74,-7,-72,15,-46,-8,54,-90,-37,-50,1,10,14,-45,6,-48,2,3,-3,5,-68,-54,-54,4,9,44,-15,92,-28,-7,-106,27,-1,31,-7,34,-42,2,-4,-4,-36,104,40,73,27,60,28,76,19,2,10,32,-28,-44,80,-26,-42,66,-3,1,16,-70,0,38,-14,9,9,62,-13,104,-36,28,10,-39,30,-16,72,21,-15,37,11,-97,-12,-49,17,-28,-64,-44,-41,-15,-25,49,38,-25,17,-11,-26,-44,22,-3,16,5,1,80,-35,43,36,1,39,-31,42,28,21,-23,-5,-7,-29,31,-43,-12,35,-22,75,-10,-3,11,30,109,-10,-22,-11,-22,-36,25,-41,-22,-6,14,17,26,24,22,-51,-31,45,23,17,60,17,8,31,-4,-29,6,34,24,72,-39,-44,11,-26,39,46,43,-31,46,-9,35,-32,43,-23,-9,-99,40,-17,-47,-8,-34,0,-23,-64,-70,-55,22,5,27,-52,6,11,-67,60,-37,94,3,14,2,-24,57,-11,-3,18,-44,42,27,-6,10,47,-16,-23,-27,16,33,12,-20,-12,-22,30,-37,-77,38,19,-21,48,-18,14,9,20,3,17,58,-13,-71,7,15,-29,58,38,-6,2,27,7,38,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.83","t":"1. All-or-nothing thinking: Viewing situations on one extreme or another instead of on a continuum. Ex. “If my child does bad things, it’s because I am a bad parent.” 2. Catastrophizing: Predicting only negative outcomes for the future. Ex. “If I fail my final, my life will be over.” 3. Disqualifying or discounting the positive: Telling yourself that the good things that happen to you don’t count. Ex. “My daughter told her friend that I was the best dad in the world, but I’m sure she was just being nice.” 4. Emotional reasoning: Letting one’s feelings about something overrule facts to the contrary. Ex. “Even though Steve is here at work late every day, I know I work harder than anyone else at my job.” 5. Labeling: Giving someone or something a label without finding out more about it/them. Ex. “My daughter would never do anything I disapproved of.” 6. Magnification/minimization: Emphasizing the negative or playing down the positive of a situation. Ex. “My professor said he made some corrections on my paper, so I know I’ll probably fail the class.” 7. Mental filter/tunnel vision: Placing all one’s attention on, or seeing only, the negatives of a situation. Ex. “My husband says he wishes I was better at housekeeping, so I must be a lousy wife.” 8. Mind reading: Believing you know what others are thinking. Ex. “My house was dirty when my friends came over, so I know they think I’m a slob.” 9. Overgeneralization: Making an overall negative conclusion beyond the current situation. Ex. “My husband didn’t kiss me when he came home this evening. Maybe he doesn’t love me anymore.” 10. Personalization: Thinking the negative behavior of others has something to do with you. Ex. “My daughter has been pretty quiet today. I wonder what I did to upset her.” 11. “Should” and “must” statements: Having a concrete idea of how people should behave. Ex “I should get all A’s to be a good student.”","e":[75,3,-128,-59,60,39,14,-27,30,-9,8,-5,98,100,4,-12,-19,-54,-2,66,-16,-10,-19,30,10,34,-50,-29,-67,26,-22,-24,-15,-48,-96,-4,61,61,29,-48,34,10,47,-70,36,-59,66,-8,35,-36,23,-80,23,-15,104,33,22,16,14,-32,78,28,-56,49,48,-5,-83,54,-10,-16,49,-7,-23,-6,-53,11,-22,26,41,45,60,-29,67,-31,34,10,-15,-19,-14,69,-10,39,-17,33,-73,42,-13,-6,-23,-40,-54,-40,-5,-52,3,34,4,-9,17,-15,-53,44,-52,-30,-19,-5,86,-38,13,61,17,39,-11,7,6,41,-47,-26,-21,-11,16,-47,-9,23,-4,81,-7,-25,14,19,83,14,-34,30,-29,-38,8,-37,-37,-3,-6,22,13,26,41,-44,-18,16,41,7,71,21,-58,53,-56,-14,-2,41,20,27,-53,-51,36,-28,53,2,59,-70,-43,-12,-1,-21,51,28,18,-49,51,20,-24,-9,60,28,-21,-1,-59,-99,27,-12,31,-69,-6,-12,-22,37,-23,45,-5,25,-14,29,55,-21,-1,5,-16,-20,22,-25,-48,14,7,-16,-15,18,27,38,-12,4,-54,24,-48,-99,55,28,21,22,17,17,2,64,-16,49,5,8,-63,5,38,-52,-2,25,4,50,12,-13,39,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.84","t":"Several techniques can be used to challenge unhelpful thinking. Most are used in conjunction with a thought record. Challenging thoughts and beliefs in a collaborative, Socratic way allows patients to use their own statements to counter unhelpful thinking. Generating counter-statements based on the data patients bring to session increases the believability of the thoughts/beliefs and, thus, the effectiveness of the counter thoughts/beliefs. When? (Indications/Contraindications)","e":[68,57,-173,-64,71,-9,21,2,36,17,27,-19,38,85,-15,-6,30,-56,-9,26,-61,-21,-32,-13,15,10,-23,-28,-55,43,20,-11,34,-21,-51,-47,58,-13,-7,-17,10,-18,27,-86,50,16,65,-3,25,-51,26,-81,31,-12,69,30,-15,14,1,-37,54,30,-18,16,24,-5,-60,35,-43,-11,78,-24,51,-10,-55,41,-13,21,-15,0,68,-91,64,-32,40,23,-2,26,-28,87,11,-45,15,14,-92,52,-25,-25,-65,-12,-84,-14,8,-28,-20,10,26,35,-2,-4,-27,34,-36,-24,22,5,74,-10,-6,2,-20,6,17,78,-8,47,8,-24,13,-46,5,-10,-33,0,0,54,-3,-4,23,12,44,22,-12,2,-6,-73,7,-44,-54,25,-3,28,0,23,10,-31,-45,31,29,-5,62,2,-43,17,-28,-18,4,72,30,10,-67,-46,10,8,95,-14,47,-60,4,-35,19,-12,24,22,1,-26,71,-18,-39,-34,4,34,-39,6,-63,-51,21,1,61,-29,-4,5,-57,36,-38,74,-33,2,0,-33,68,7,21,-1,-21,-7,48,-17,-27,17,49,-3,7,-12,10,-27,-71,5,-28,1,-29,-125,25,-22,51,2,39,39,14,45,-13,16,3,27,-74,9,34,-65,-31,33,-3,24,-14,-15,38,11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.84","t":"Typically, unhelpful automatic thoughts are the first targets in the cognitive component of CBT. Following the introduction of the cognitive model (see Module 7: Orienting Patient to Brief CBT), and skills for identifying automatic hot thoughts and their accompanying emotions (see Module 11: Identifying Unhelpful Thoughts), introduce techniques for challenging hot thoughts. These techniques should immediately follow the session on identifying hot thoughts, to build continuity and familiarity with the skill set and instill hope of change after identifying problematic thinking patterns. Although intermediate and core beliefs will be challenged in advanced stages of therapy, the techniques are similar for challenging thoughts. Many techniques below can be used interchangeably for challenging thoughts or beliefs. Brief CBT session time is best used for modifying thoughts or beliefs that are tightly held and strongly believed.","e":[47,11,-170,-71,73,24,51,6,26,-9,3,13,58,59,-3,-22,6,-49,3,17,-52,-26,-6,-45,22,28,-27,22,-40,16,52,-27,-13,-40,-48,-36,93,-7,-42,6,46,-19,78,-69,40,35,79,29,20,-3,44,-65,28,-73,104,42,-2,49,-6,-10,84,37,-23,45,-10,-26,-67,41,-56,3,44,-35,36,27,-55,-11,-42,-14,0,35,32,-53,63,-14,51,9,-22,46,7,67,27,-10,10,25,-78,49,-27,-10,-45,-24,-65,-32,-13,-17,-20,33,-11,12,9,2,-46,55,-34,-34,-12,6,45,-5,18,38,26,4,9,73,34,63,-33,-9,16,-51,-22,-20,4,11,12,47,21,-9,7,29,18,0,3,-7,-1,-42,11,-47,-45,7,5,19,5,-6,34,-44,-26,-2,52,-4,21,8,-37,6,-17,-31,14,46,53,9,-71,-53,-3,-11,86,10,63,-34,33,-51,1,-39,21,64,11,-9,8,-4,-25,-26,1,-2,-70,-4,-95,-28,40,-5,42,-33,13,13,-57,28,-51,85,-6,2,-31,-48,83,19,-24,1,-25,-5,1,-10,-31,28,36,34,5,-38,-21,-11,-38,-20,-2,17,-20,-105,39,3,27,-3,40,33,-8,56,-5,47,29,28,-99,-11,26,-50,-30,27,-17,4,-24,-28,30,-1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.84","t":"How? (Instructions/Handouts) Socratic questioning is a provider stance for questioning unhelpful thinking. This process involves asking a series of open-ended, brief questions that guide patients to discover their idiosyncratic thoughts, feelings, or behaviors associated with a particular situation. Socratic questioning is nonjudgmental but is based on the provider’s insight that the original premise of a thought or belief may be untrue; therefore, the questions are designed to expose the unhelpful thought or belief so that it may be challenged.","e":[73,46,-142,-59,66,18,41,-34,48,47,54,-11,52,50,-34,-59,48,-73,-4,37,-84,-19,-48,17,70,-11,3,-19,-1,3,1,18,31,41,-22,-58,101,0,-52,14,13,-73,24,-105,67,-30,50,-5,10,-90,8,-89,7,-20,36,46,30,72,-38,5,53,17,-6,23,11,-8,-28,18,-51,5,56,-13,73,4,-70,7,-12,28,-3,7,52,-50,34,-29,33,66,-26,-21,3,73,16,-35,26,17,-82,58,-18,-17,-14,-22,-69,-35,-3,2,-1,51,-2,47,13,-30,-37,59,-35,-20,7,3,69,24,43,-1,-23,46,14,90,2,58,-39,24,-20,-12,26,-48,-36,-25,-29,51,-11,-14,14,10,61,-5,-9,1,32,-46,20,-49,-56,-22,-15,11,-6,-11,35,-33,-15,26,51,8,38,4,-56,28,-30,9,1,0,24,6,-42,-76,19,3,84,12,79,-81,26,-20,-4,-18,32,1,0,-26,62,-19,1,-59,-12,-20,-10,-3,-73,-46,52,6,28,-19,12,-16,-44,32,-43,46,-21,2,-7,-24,87,-52,19,-19,-21,3,62,-16,-11,4,30,-50,-21,13,5,24,-78,-5,-15,24,-61,-123,39,13,19,19,17,29,39,-5,-1,19,10,17,-62,-20,18,-44,-2,7,-12,33,1,-11,44,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.84","t":"The Thought Record is the staple of cognitive work in brief CBT. The first three columns (see Thought Record handout at the end of Module 11) are used for identifying troubling situations and the accompanying emotions and unhelpful thoughts. These three columns are used in conjunction with Module 10 in that when the situation-->thought--> feeling triangle is unfolded, it forms the first three columns of a Thought Record. 84","e":[21,15,-176,-102,83,-33,55,-10,-28,-26,-9,-5,50,31,2,-41,-9,-45,8,24,-30,-6,-61,-4,24,92,-37,-9,-44,57,49,0,1,-8,-61,-102,61,-36,-8,7,42,-23,18,-70,61,40,59,24,35,5,-3,-36,40,-26,104,59,11,9,-3,-13,69,30,-46,70,25,-31,-33,64,-47,13,51,-18,52,60,-58,16,-37,-1,16,37,57,-61,35,-9,41,17,4,-7,-23,75,-21,-26,-7,13,-74,43,-13,-31,-5,16,-70,-59,-6,-34,14,36,-53,5,12,-22,-46,46,-22,-4,-10,15,57,-2,44,32,-17,-11,45,62,-4,51,-12,-8,40,-52,-37,-35,-38,-3,18,66,-30,-4,5,48,52,-16,-27,16,15,-34,22,-63,-50,3,-7,2,10,7,17,-19,-4,17,61,12,46,9,-55,58,-19,-39,25,14,31,7,-52,-74,18,1,58,9,54,-5,39,-44,-8,-16,32,17,-4,-39,25,-21,-32,-33,17,17,-69,11,-84,-46,0,-24,16,-24,19,21,-49,50,-51,77,0,16,-29,-22,101,5,-11,26,-50,3,18,-25,-16,33,29,8,18,-28,12,4,-39,-5,-10,20,-57,-84,33,19,47,-12,9,30,3,46,8,31,6,3,-85,-2,12,-56,21,47,-18,-22,20,-8,57,-32]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.85","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 12 A seven-column Thought Record is used to challenge unhelpful thoughts and beliefs. Instructions for completing columns 4-7 are described in detail below. Once a hot thought and its accompanying emotion have been identified and rated, the hot thought is questioned to generate evidence for and against it. Building evidence may be introduced in the following way: In-Session Example 12.1","e":[26,23,-199,-89,73,3,31,6,-7,-50,-19,-14,52,51,13,-30,4,-49,1,20,-26,-24,-40,-20,44,27,-22,4,-50,25,35,-26,12,-33,-61,-72,55,-14,-61,-19,40,-25,47,-62,51,58,95,23,6,4,13,-52,55,-45,87,54,7,12,-13,7,90,34,-50,44,7,-19,-57,71,-42,-3,46,-36,56,17,-56,11,-40,2,-2,46,77,-42,82,-3,43,-10,-5,23,-21,43,7,-8,25,9,-64,66,-29,-39,-17,-4,-67,-48,2,-29,-23,32,-38,30,33,-32,-66,37,-48,-9,-1,11,60,3,-5,29,-12,-1,24,65,24,31,3,-8,10,-72,-13,-13,-29,3,26,53,-18,-1,20,26,27,5,-35,-11,14,-24,21,-72,-37,8,-10,16,11,7,17,-47,-11,-12,52,5,36,-4,-24,45,-25,-36,-5,63,47,21,-44,-75,9,-7,53,-16,38,-36,43,-33,-4,-4,27,42,11,-32,35,-7,-25,-21,-31,29,-58,-13,-63,-53,11,-20,23,-26,13,4,-43,35,-58,58,-31,35,-26,-45,98,-15,2,27,-29,-9,17,-20,-22,36,18,28,-15,-28,0,-11,-32,-41,-21,21,-52,-125,48,-4,6,-8,26,59,1,45,13,33,11,-1,-74,7,27,-37,-2,75,-17,5,4,-24,28,-3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.85","t":"Example: We have identified a thought that is very powerful for you. You rated this thought as 90 out of 100 for sadness. Before spending a lot of time and energy on this thought, I want to know whether or not it is true. Often when people are depressed or anxious, they take thoughts like this at face value, without first asking whether they are true. Accepting thoughts like this as true would certainly lead to the symptoms you’ve been struggling with. If I thought, “I am worthless and can’t do anything right,” I wouldn’t want to get out of bed in the morning either, and I would probably feel pretty hopeless and sad. When we test a thought like this, we are going to generate evidence for and against the thought. It is as though the thought were on trial, and you were a lawyer for the case. Remember, you have to be able to prove the evidence you are generating. So, now let’s see how your thought stands up....","e":[67,50,-147,-68,86,20,0,35,20,-9,-3,17,37,69,-41,11,19,-61,0,47,-51,-53,-67,5,-4,38,-58,-28,-40,24,-12,-15,25,-48,-86,-24,51,43,68,-37,30,-1,15,-79,30,-24,72,29,58,-34,38,-59,27,-9,96,62,30,27,20,-22,81,42,-16,31,72,0,-48,49,-2,-28,61,1,9,4,-59,24,7,22,6,28,75,-67,72,-28,50,-3,1,-3,20,97,38,-5,39,50,-75,0,-19,27,-33,-27,-51,-40,-34,-35,4,17,3,33,-8,-20,-55,13,-37,-34,-1,-7,77,-44,-13,41,8,55,2,62,39,17,-13,-13,-9,-33,-15,-44,-52,22,0,63,-11,-21,-14,15,48,2,-13,11,-17,-50,3,-38,-57,28,-17,6,53,-13,31,-59,-39,57,64,22,81,24,-21,21,-13,-19,17,80,22,3,-49,-60,13,-17,78,-40,79,-6,9,-27,46,-32,29,-21,12,-42,70,-19,-50,-38,9,9,-11,-1,-64,-66,52,-17,46,-38,13,28,-20,41,-52,40,-7,-21,-22,-46,69,-1,-7,41,-14,26,0,5,-27,24,21,2,-1,10,17,6,-89,-32,-34,9,6,-132,59,8,24,7,-37,6,33,56,-6,19,6,16,-59,34,-2,-48,24,45,-7,35,26,-10,40,1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.85","t":"DEVELOPING BALANCED THINKING These instructions might be useful to help patients develop balanced thinking: 1. Help the patient question automatic thoughts by asking: • What evidence is there that this thought is true? • What evidence is there that this thought is not true? • What would I tell someone I loved who was in this situation and had these thoughts? • If my automatic thought is true, what is the worst that could happen? • If my automatic thought is true, what is the best thing that could happen? 2. Once you and the patient have generated evidence, combine it to form a more balanced thought. This thought will likely be much longer and more nuanced than the original hot thought.","e":[56,28,-147,-61,92,16,21,3,36,-26,3,1,41,68,-11,-5,26,-77,2,34,-37,-33,-62,-25,37,21,-63,24,-94,18,20,-22,25,-18,-65,-38,76,1,-2,-9,32,-4,35,-83,21,-16,60,-14,38,-15,37,-37,11,-13,77,33,21,38,20,-71,84,35,-58,35,66,-14,-49,54,-7,19,54,-9,47,4,-53,22,1,1,15,47,64,-42,83,-43,41,21,2,-6,-23,95,40,-16,49,18,-70,23,-46,12,-58,-38,-75,-10,9,-8,1,50,14,30,-2,-7,-26,-16,-50,-12,13,0,82,-1,29,44,23,44,-2,31,38,48,-34,-18,27,-28,24,-18,-47,11,-1,72,27,-3,9,-10,40,4,-1,-16,-3,-44,15,-16,-48,52,-23,14,7,-29,39,-67,-25,26,52,-10,65,17,-72,44,-6,-37,18,68,33,14,-49,-50,29,8,70,2,66,-66,5,-25,9,-40,23,33,22,-31,20,-21,-63,-46,7,26,-62,-29,-81,-42,66,-23,59,-5,-6,3,-48,35,-49,72,-25,1,-25,-43,62,21,-13,22,-36,29,3,8,-51,32,26,7,-25,-29,1,-9,-29,-25,-32,4,-38,-109,41,-17,64,-19,-30,37,4,55,4,37,43,37,-65,26,35,-56,-4,27,42,36,0,-11,16,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.86","t":"3. Rate the believability of the alternative thought between 0-100%. If the thought is not more than 50% believable, more work is needed to identify an alternative thought. Go back to the evidence and keep working. After the patient has generated an alternative thought, they should rate how much they believe the thought from 0-100% (0% = no belief at all, 100% = greatest belief). If the alternative thought is not rated at more than 50%, this may indicate that the patient has actually provided a more deeply rooted belief (as opposed to an automatic thought) as the initial automatic thought. It is important to recognize the difference between beliefs and automatic thoughts because patients have to be motivated to change their thinking during the cognitive restructuring process. This motivation to change is less likely to happen if patients don’t believe in the change that they are trying to make.","e":[56,62,-162,-68,75,13,20,37,34,6,3,10,30,60,-13,14,7,-83,13,50,-64,-33,-44,-29,30,29,-70,0,-64,21,52,-2,18,-48,-71,-42,51,32,32,-27,1,9,54,-64,53,16,83,10,65,-19,5,-40,3,6,92,82,-22,48,19,-25,79,28,-35,41,21,12,-46,60,-27,-31,3,1,-4,17,-77,-3,-19,-1,14,41,79,-59,98,-3,47,-2,22,2,-2,114,-2,-19,21,33,-74,0,-26,16,-21,-13,-76,-25,-23,-30,-2,52,6,19,-5,19,-25,-13,-35,-49,15,-24,61,-25,19,45,-1,7,23,64,20,19,-22,15,42,-32,9,-26,-39,8,-6,47,48,-34,-24,50,30,0,34,21,-2,-57,14,-29,-36,46,24,15,44,1,5,-55,-25,34,36,5,69,3,-46,33,-7,-19,5,50,-7,14,-47,-27,27,5,85,-19,46,-51,12,6,40,-7,30,57,42,-23,41,24,-48,-15,33,15,-77,-27,-85,-47,47,0,54,-35,16,48,-42,-1,-51,40,-13,4,-35,-36,60,37,-15,33,-10,-3,28,-10,-25,39,32,-18,16,1,33,-18,-62,-13,8,16,18,-104,42,11,26,12,-10,16,61,27,9,31,-2,19,-71,0,32,-66,4,52,-19,52,1,6,50,13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.86","t":"4. Once a believable alternative thought is generated, re-rate the mood associated with the hot thought (0-100%) after reading the new thought. Reducing a thought/belief to a rating of 0% is not a realistic goal. Instead, a reduction of 30-50% often provides relief. Often patients will generate new emotions from the alternative thought. However, it is most important first to re-rate the old mood before generating new emotions. The same strategy of generating an alternative thought for an unhelpful thought is used when challenging a core belief. Once the belief is identified, the evidence is weighed, and a new more balanced belief is generated. Highlight 12.1","e":[53,43,-189,-58,53,21,4,45,29,-26,8,21,47,71,-15,24,3,-57,-8,44,-73,-59,-21,-55,10,39,-54,3,-61,21,26,5,10,-27,-74,-28,39,27,7,-33,17,5,80,-51,51,-3,77,-2,65,-18,31,-32,25,-41,98,58,-36,25,27,-10,66,30,-34,32,42,0,-68,55,-44,-33,13,-4,-13,13,-68,0,-3,-29,-5,34,82,-54,94,5,57,-18,6,25,-30,84,26,-19,49,13,-74,11,-30,2,-24,-12,-53,-32,-5,-44,-31,70,10,26,7,10,-50,8,-28,-47,15,-30,71,-33,-11,44,-12,17,22,59,19,6,1,12,18,-42,-16,-45,-40,24,-2,38,30,-20,-11,29,53,1,16,-21,-16,-33,19,-41,-26,34,-2,12,42,15,-6,-68,-32,29,50,-11,95,-22,-5,23,4,-18,-9,36,-18,9,-66,-29,2,-12,85,-38,71,-29,4,-26,21,-18,53,67,36,-34,61,8,-59,-30,-11,40,-69,-27,-61,-52,29,2,21,-16,28,30,-31,-12,-56,44,7,10,-19,-46,52,15,2,-1,-11,6,18,4,-23,35,23,27,0,-3,29,-7,-76,-30,-2,3,17,-119,40,-1,3,-3,12,26,37,25,-4,46,30,37,-65,11,37,-49,-4,56,0,21,0,-13,43,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.86","t":"Summary: Completing Thought Records 9 Identify situation and corresponding thoughts and feelings. 9 Identify unhelpful thinking styles in thoughts (e.g., all or none thinking). 9 Use Socratic questioning to identify hot thought. 9 Elicit and rate emotions associated with hot thought. 9 Rate believability of hot thought. 9 Generate evidence for and against hot thought. 9 Generate alternative thought from evidence. 9 Rate believability of alternative thought. 9 Re-rate emotion of hot thought that is elicited by alternative thought. 86","e":[63,16,-175,-59,78,-3,30,31,20,5,11,4,92,93,-33,-44,4,-63,-5,43,-56,-24,-33,-4,55,-2,-30,-42,-36,2,-1,5,12,0,-65,-59,73,-30,-7,12,34,-54,64,-72,68,-12,40,-6,52,-3,34,-41,28,-49,62,57,21,33,34,-5,63,25,-43,24,44,19,-58,50,-52,-9,46,-14,39,6,-69,16,-2,7,8,32,72,-52,83,-12,67,25,-36,11,-8,56,4,-4,60,37,-63,68,-20,-5,-40,-30,-58,-55,-15,-45,15,40,-10,50,24,-7,-48,45,-48,-33,9,-11,40,-13,-3,39,-6,54,7,72,-6,26,-8,-14,-17,-31,9,-60,-13,25,-1,58,-15,-12,5,12,67,-13,-20,-33,-4,-19,2,-46,-56,-4,-3,37,-2,15,-1,-57,-23,27,51,4,45,-28,-25,28,-12,-21,-7,14,15,9,-57,-55,2,-10,67,-14,80,-53,50,-24,6,-31,65,25,6,-57,77,16,-38,-37,-29,3,-33,-30,-49,-58,35,-7,4,-36,23,12,-71,9,-45,57,-4,20,-12,-23,74,12,14,-4,-32,12,35,-22,-9,22,23,17,-20,-1,3,28,-91,-22,2,21,-39,-134,53,-13,19,10,53,50,12,42,-14,8,-7,-3,-63,-1,18,-34,-11,44,8,50,6,-11,41,-12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.87","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 12 TROUBLESHOOTING THOUGHT/BELIEF MODIFICATION Some patients can see the benefits of doing a Thought Record immediately, but others might need to be motivated to be engaged. It is helpful to use positive reinforcement to praise the effort of completing a thought record, point out the sections completed correctly, and review skills for the sections completed incompletely or inaccurately. If a thought record is assigned for homework, it must always be reviewed during the subsequent session. Taking session time to review the thought record emphasizes its importance to the patient.","e":[28,16,-173,-86,66,-21,42,9,12,-36,1,-12,19,63,9,5,21,-61,-24,16,-11,-44,-40,18,42,42,-16,14,-45,36,42,-50,-4,-44,-55,-52,68,-4,-31,-23,49,-6,21,-97,57,17,107,-9,21,-15,16,-50,36,-11,124,61,19,3,-15,-34,99,29,-67,54,1,-9,-18,58,-29,27,35,4,40,48,-46,21,-35,27,-16,30,64,-46,72,-34,35,-13,12,8,-39,57,-7,-32,4,35,-82,51,5,-15,-19,21,-75,-54,17,-24,-18,59,-18,4,1,-2,-64,-6,-33,-4,10,6,68,-19,12,42,-33,-11,25,50,14,73,-31,-27,44,-30,-23,-18,-41,5,16,40,15,-21,21,15,34,16,-5,32,8,-41,2,-51,-50,7,-10,-17,2,9,45,-29,-23,10,73,28,31,2,-69,51,-2,-15,7,46,42,25,-24,-54,27,-7,47,18,39,-35,11,-52,1,-18,31,43,17,-15,32,4,-54,-30,21,25,-54,-6,-75,-52,32,-35,25,-36,-19,22,-35,29,-39,40,-15,9,-50,-39,95,0,-6,43,-35,-23,5,-19,-20,28,15,17,2,-36,12,-1,-12,-28,-28,16,-46,-86,4,15,40,7,14,35,6,50,13,61,24,20,-86,25,31,-30,-7,44,22,14,10,-30,48,-17]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.87","t":"Introducing the Thought Record as an “experiment” helps alleviate any performance anxiety the patient may have about completing it and may generate interest (“Give the thought record a try this week, and we’ll see how it works for you. Let me know next session how the experience to complete it was. That will help us decide whether or not this is a useful tool for you.”)","e":[-2,82,-177,-74,80,-3,43,25,15,-23,-7,39,16,58,3,-28,24,-85,-34,-6,-21,-46,-62,6,6,56,-28,-39,-59,107,56,-7,26,-1,-28,-69,42,-5,2,-31,17,-17,31,-79,63,19,49,5,48,-10,36,-32,14,17,126,57,10,31,29,-19,86,-4,-43,27,36,-39,-13,80,-4,24,52,10,45,2,-48,57,8,0,-3,23,50,-53,40,-6,38,7,-2,-21,-66,90,-6,-40,8,36,-79,23,-18,20,-35,22,-66,-13,29,-19,-16,29,-22,42,-4,21,-17,34,-18,-12,-11,28,41,-43,41,1,-20,35,40,42,2,54,10,-4,31,-36,-27,-39,-64,16,33,59,-16,-26,17,19,45,8,-18,-3,-20,-26,25,-43,-75,33,-8,-14,27,22,11,-36,-23,39,75,20,53,1,-36,52,-42,-46,33,31,29,-7,-15,-75,36,16,60,-4,48,-11,29,-47,33,-60,11,-44,-20,-42,48,1,-77,-41,31,-8,-48,-29,-82,-34,43,-18,42,-17,-11,35,-57,3,-37,64,-15,-17,-45,-43,91,-5,16,55,-17,-10,32,-39,-18,58,24,10,-16,-2,14,-31,-51,2,-46,-3,-37,-100,-5,-13,55,-2,-9,12,-15,42,2,35,10,-1,-77,-7,-19,-17,-1,27,-5,17,2,-27,66,-26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.87","t":"Occasionally, a patient will show disinterest in doing the Thought Record or get tired of it after a while. For instances like this, there are other ways you can suggest that the patient can continue to attempt the Thought Record: • If a patient complains of never having time to do a Thought Record when certain situations occur, suggest that they carry a blank Thought Record in a wallet or purse. • Patients can use their cell phone to record Thought Records or voice/audio record their thoughts. • If a patient has done the Thought Record for a while and is becoming disinterested, suggest doing a “mental” Thought Record, since they are familiar with the process. • Suggest reading old Thought Record that have similar situations and automatic thoughts of their own. • The patient can verbally dictate a Thought Record to someone and have that person write it down. • Instruct the patient to incorporate completion of the Thought Record into their daily routine, either at the same time of day or in an easily accessible location.","e":[35,24,-166,-84,50,-2,9,9,25,-21,-44,8,9,76,-6,-10,26,-98,-26,25,-12,-25,-78,3,-16,20,18,-7,-80,87,56,-19,26,13,-19,-61,43,-40,22,13,54,-31,11,-90,63,12,50,5,38,-22,18,-45,-13,-11,87,25,9,-2,17,-29,112,-11,-24,54,41,-12,-49,62,2,11,65,6,41,18,-22,70,-21,7,16,16,42,-55,80,-44,54,8,32,-10,-14,111,-29,-28,35,31,-69,21,1,31,-39,5,-81,-58,13,-38,18,44,-22,33,-2,-10,-10,2,-18,-11,11,36,47,-32,43,14,-46,29,29,34,-1,51,-2,-32,48,-1,-29,-14,-57,32,14,56,20,-19,18,4,61,-6,8,9,-7,-38,11,-59,-36,25,-4,-14,43,17,41,-52,-26,31,71,2,54,13,-58,66,10,-45,2,49,8,-21,-11,-44,24,23,84,10,39,-22,8,-48,20,-40,4,1,-6,-3,19,-11,-43,-50,5,25,-33,6,-66,-17,42,-31,34,-28,-6,2,-40,26,-56,36,-25,-21,-32,-42,81,10,-34,19,-43,-4,15,-34,-20,52,48,7,18,-27,37,-27,-63,-3,-22,-2,-41,-98,4,-14,45,-14,-41,37,-14,48,-17,19,12,27,-81,-18,-17,-25,5,35,15,13,24,-30,58,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.87","t":"There will not always be an immediate change to a patient’s mood after a Thought Record is completed. It might be necessary to assess why there is no change. It could be attributed to the patient’s deeply rooted belief in the automatic thought, to an unchanged underlying core belief, or to additional automatic thoughts that have not been evaluated. It is necessary to ask: Why was there no mood change after completion of the Thought Record? These other questions will also be helpful: • Have I described the situation in enough detail? • Did I identify and rate the right moods? • Is the thought I am testing an automatic thought? • Do I believe an unhelpful core belief is driving this thought? • Did I list multiple thoughts? Do I need more information for each individual thought?","e":[61,-2,-152,-81,51,17,69,38,-2,-48,-20,47,20,53,9,8,35,-53,-19,39,-33,-45,-67,-19,9,68,-11,-3,-44,68,49,-11,25,-36,-33,-89,63,-10,34,18,67,11,17,-85,34,11,47,21,42,-31,21,-36,1,-23,104,67,14,60,8,-29,73,-11,-15,60,30,-39,-18,31,-17,-13,24,24,-9,33,-12,29,-5,20,-6,3,54,-49,73,3,60,-2,14,11,5,118,22,-42,-6,25,-94,-16,-34,38,-15,15,-87,-72,-25,-24,25,38,-37,35,7,-1,-36,19,-24,2,2,-7,65,-20,15,39,-12,29,20,80,22,24,7,7,43,1,-19,-19,-51,51,33,20,21,-17,19,4,43,10,14,27,-25,-53,29,-59,-30,28,8,-34,35,23,18,-37,-45,44,45,6,73,6,-64,33,22,-31,35,34,-16,-5,-43,-36,23,17,93,42,86,-44,44,-37,17,-28,26,-26,28,-24,11,-18,-87,-19,25,10,-58,-4,-78,-14,0,-22,17,-25,13,30,-50,21,-67,73,25,-22,-31,-58,75,19,-44,20,-16,17,18,-10,10,47,32,6,-9,-19,4,-24,-30,-14,-13,2,-22,-98,30,14,20,-4,-15,27,22,23,-21,4,13,45,-71,-17,1,-50,6,69,32,26,-9,-10,77,-43]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.88","t":"If thought/belief testing is ineffective in reducing negative mood, you can also explore the advantages and disadvantages of maintaining a thought/belief. As we know, there are many disadvantages to negative beliefs we have, but there are also advantages. The patient’s perceptions of the advantages may be obstructing the change process. Understanding the function of the thought/belief for the patient may be useful in clarifying why certain thoughts/beliefs are resistant to modification. The provider should evaluate both the advantages and disadvantages of a patient’s assumptions and beliefs but, in doing so, work to diminish the advantages and highlight the disadvantages.","e":[38,51,-126,-47,80,28,40,13,36,-29,15,29,32,71,-7,5,19,-32,6,34,-57,-20,-36,-35,11,59,-22,6,-52,43,40,-28,20,-52,-58,-41,49,29,35,-23,50,5,53,-97,57,14,72,18,53,-46,51,-93,32,-1,133,24,-15,31,6,-55,78,34,-89,29,53,-44,-51,33,-10,26,35,32,-7,-21,-51,22,12,-11,-21,17,52,-55,64,-9,52,40,35,-22,-18,80,8,-18,29,41,-98,47,-9,-14,22,31,-49,-38,6,-18,-6,60,-1,19,-12,26,-67,6,-48,-32,18,-36,68,-31,-5,16,-16,75,-6,75,6,31,-36,-21,33,-14,-7,-33,-48,16,15,42,19,-14,11,15,53,27,5,17,-9,-73,14,-45,-52,34,-2,-20,40,19,36,-60,-27,32,48,-12,65,32,-31,29,-8,-35,32,64,9,22,-37,-54,22,-2,91,2,28,-25,-10,-18,-22,-17,7,42,38,-25,55,-12,-96,-49,-3,-2,-52,-22,-86,-85,2,28,56,-8,-26,21,-17,-6,-26,0,-1,-28,-20,-30,47,5,18,22,2,1,-10,8,-12,16,35,-36,7,-16,25,-16,-51,7,-36,-33,-25,-94,52,-11,26,10,-3,9,15,68,-29,26,39,33,-46,8,2,-29,-3,84,3,70,-12,-7,48,-4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.88","t":"Often, when working to modify thoughts and beliefs, the patient may find evidence that supports the negative belief instead of evidence that contradicts it. If there is a good amount of evidence to support that negative core belief, then problem solving, rather than thought testing, is an appropriate strategy (see Module 15). Highlight 12.2","e":[49,65,-123,-42,66,19,7,-6,45,-14,30,-6,40,62,-42,13,-2,-42,0,51,-54,-42,-23,-50,24,11,-35,2,-25,62,40,-17,22,-82,-64,-74,52,36,35,-21,23,23,32,-122,44,-15,71,10,48,-46,33,-63,22,-21,96,58,-7,19,-1,-62,96,36,-61,23,53,-17,-55,39,-25,-3,37,6,29,-3,-47,-19,23,19,-20,43,69,-55,73,-20,69,17,10,5,2,66,17,-18,37,26,-106,43,-6,-4,-31,15,-54,-50,19,-18,-19,57,0,11,-10,21,-64,1,-33,-53,18,-19,84,-35,-6,47,-15,22,-27,82,27,15,-51,-34,40,-14,8,-42,-54,1,17,36,3,-3,14,20,38,34,31,29,-9,-67,-8,-33,-50,41,-23,16,9,3,38,-46,-26,45,73,-19,91,-6,-37,44,15,-16,-4,90,22,33,-39,-37,21,-2,104,4,34,-33,8,-8,-12,-26,12,44,45,-8,50,-19,-61,-31,12,22,-46,2,-76,-78,22,16,60,-33,-3,28,-34,34,-33,4,-27,-15,-20,-20,38,16,-9,42,-20,-13,7,26,-46,29,1,-19,-25,-24,45,4,-34,-12,-31,2,-19,-103,35,5,62,6,21,23,43,60,-24,34,15,22,-36,29,5,-39,-12,46,16,64,-9,-1,45,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.88","t":"Seven Tips for Effective Thought Records 1. You must have mastered the use of Thought Records before introducing it to patients. 2. Reinforce and make sure that the patient believes in the cognitive model being used. 3. Teach the Thought Record in two sections: (1) The first three columns; Situation, Automatic thought(s), and Emotion(s), and (2) the last four columns; Evidence for and against thought, Alternative response, and New rating of emotion. 4. Use the patient’s exact words when recording thoughts and feelings. Working with thoughts verbatim preserves the emotions or personal meaning for each thought. 5. The patient should be able to adequately complete the first three columns of the Thought Record before learning about the last four columns. 6. Completing a Thought Record is a skill and, like other brief CBT skills, requires practice. Success depends on the patient’s understanding of the steps. Encourage the patient to take time with the skill and work through any frustration. 7. If the patient is not collaborative in completing the Thought Record in session or does not complete Thought Record homework, it is possible that they might have automatic thoughts about this type of exercise. Ask the patient to create a Thought Record of the Thought Record experience","e":[12,21,-155,-79,85,-32,35,-2,2,-4,-14,-13,23,53,2,-16,12,-88,-2,20,-26,-23,-58,10,-6,53,-53,16,-58,45,58,-20,1,-15,-55,-78,30,-33,-8,-7,83,-19,12,-87,71,33,57,-21,43,5,7,-55,32,-33,103,68,-9,36,26,-32,95,-2,-63,51,23,-11,-42,101,-8,46,63,9,47,22,-57,37,-39,-3,21,29,59,-38,51,-47,47,-11,3,-4,-30,82,-26,-33,18,57,-42,34,-32,6,-34,14,-98,-42,10,-47,16,52,-30,25,3,7,-47,13,-19,-5,-33,37,53,-14,35,18,-18,41,46,36,9,30,-4,-42,52,-11,-39,-48,-44,23,28,61,11,-6,30,4,55,18,-9,-4,-4,-55,-17,-53,-59,37,2,-10,14,25,17,-34,-21,9,71,11,33,3,-69,52,12,-36,28,16,21,15,-24,-68,27,19,67,11,50,-25,22,-52,27,-44,10,11,-14,-22,21,-22,-41,-38,31,19,-59,-1,-80,-25,45,-41,29,-17,-4,24,-44,42,-33,75,-12,-22,-25,-23,75,6,-14,23,-59,11,7,-27,-42,36,22,17,0,-40,-5,-3,-43,9,-17,11,-50,-76,3,-26,25,-14,-32,21,-19,65,12,30,22,3,-93,-4,13,-35,5,32,12,14,26,-39,52,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.89","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 12 EXAMPLE HOMEWORK ASSIGNMENTS 1. List the advantages and disadvantages of keeping a Thought Record. 2. Use an old Thought Record and analyze it using the Automatic Thought Questions we have discussed. 3. Complete the first three columns of a Thought Record for homework, and complete columns 4-7 with you in session. SUPPLEMENTAL READINGS Beck, J.S. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press; Chapters 9-14 Greenberger, D., & Padesky, C. A. (2016). Mind over mood: Change how you feel by changing the way you think (2nd ed.). Guilford Press. 89","e":[39,-10,-141,-67,47,-1,36,-19,1,-13,-20,-6,43,77,6,-36,-2,-61,28,16,-8,-33,-31,16,30,45,-22,18,-66,16,24,-37,-13,-33,-66,-56,87,-5,-57,-6,49,-20,9,-79,57,14,112,-6,37,11,20,-46,42,-22,108,36,22,7,14,-23,85,40,-64,62,11,-28,-36,89,-44,11,58,-4,47,31,-53,-18,-35,-11,13,45,50,-24,81,-28,66,4,-13,5,-19,72,-13,-14,12,40,-50,51,-13,-29,-3,-20,-66,-27,14,-35,13,43,-28,-17,-13,16,-75,27,-28,8,3,25,68,-12,29,36,-32,-10,3,31,22,65,-51,-24,31,-40,-12,-34,-25,13,7,50,-25,7,27,5,37,-15,-28,32,-8,-10,11,-47,-72,-3,-1,-16,28,12,46,-22,-20,-18,49,28,30,-6,-45,65,-11,-26,25,50,35,32,-41,-64,17,25,43,26,43,-19,35,-26,16,14,37,27,6,-28,9,2,-37,-7,-5,24,-36,-12,-91,-65,23,-30,23,-18,-3,20,-43,35,-56,58,-19,3,-26,-54,91,15,-20,26,-32,11,0,-21,-33,32,-5,-1,15,-24,8,7,-6,-2,-5,62,-32,-103,32,11,28,30,-5,52,12,82,34,53,41,-3,-86,19,14,-32,4,50,4,7,27,0,26,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.90","t":"My family I can still Because of Hopeless Out of breath I’m too old to Defeated has to look in babysit my my COPD (10) when I played play with her. on me more grandkids. and because in the park often than I am getting Worthless with my I can’t do Sad they used to. I contribute older, I have (5) granddaughter what I used to my new more physical to do. family in new limitations Sad ways, such as than I used I can’t be her offering advice to, and I do caregiver. and support. need my Disappointed family’s help I have Hopeless I still live form time to nothing to independently. time, but I am offer my able to offer family any Hopeless I am able to do them many more. Worthless many things valuable physically, things and I am a burden Hopeless (80) though I do contribute to my family. Hopeless (90 have more to my limitations than grandkids’ I am no good I used to. lives. (80) to my family.","e":[46,26,-185,-52,30,76,-13,-12,20,-53,-57,-18,37,38,34,7,-25,-31,-17,51,-31,-66,-17,8,31,44,-15,23,-65,57,48,-28,25,-38,-50,-23,57,20,137,7,17,14,18,-67,-4,-59,47,39,70,-46,46,-46,-51,-1,68,10,-38,-18,-26,-48,63,30,-28,45,81,-7,-62,13,-24,-20,48,-25,23,6,-66,43,-46,37,3,23,70,-11,50,-13,61,8,5,28,-39,83,27,16,39,41,-46,20,-36,46,-22,-38,-32,-38,35,-36,19,16,43,37,-15,-24,-78,49,-40,-27,-24,-35,47,-56,5,20,-29,12,-8,46,10,36,-40,-3,42,-20,-15,-22,-20,-7,9,11,-39,-6,-3,8,52,-9,52,-25,4,-36,34,-41,-67,-39,-9,29,12,32,12,-81,-43,64,7,-13,34,35,-60,52,-45,-14,-13,59,23,47,-17,-47,34,-8,70,-22,37,-2,-35,-76,45,-57,16,-10,-10,-11,15,-14,-54,-62,-9,31,-24,-22,-39,-12,22,-53,34,-39,-3,-3,-6,13,-33,40,-5,22,22,0,67,-36,-19,-8,-23,-19,-3,-36,-54,26,34,-18,22,5,49,-12,-37,-5,-4,29,-6,-120,49,39,13,19,-39,29,3,18,5,7,42,-12,-48,58,-27,-46,12,52,-1,16,41,-2,29,16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.90","t":"What actually What What What has What has What is 0-100 happened? thought(s) emotion(s) did happened happened another Where? What? went through you feel at the to make you to prove the way to How? When? your mind? time? Rate how believe the thought is not think of this How much intense they thought is true? situation? did you were (1-100). true? believe it? (1-100) 90","e":[60,11,-165,-50,98,35,43,20,20,-49,-47,26,60,42,-24,-68,-20,-59,-11,54,-23,-65,-49,-10,17,11,-60,1,-73,-13,-14,-29,17,-45,-59,-59,9,2,93,-36,38,-36,6,-52,48,-8,35,42,62,-14,32,-39,20,3,111,80,18,29,46,5,39,21,-8,-1,46,11,-70,98,-26,-23,47,-11,-17,6,-70,-9,-14,16,-18,19,79,-16,92,-26,52,14,-29,22,7,82,38,-7,29,9,-92,-10,-36,12,-24,-27,-59,-34,-17,-55,74,19,-6,42,12,16,-35,5,-51,-25,13,23,95,-30,15,45,-3,54,4,60,14,-5,-18,-11,-12,-54,-6,-52,-31,23,-16,58,5,-30,4,34,91,1,-25,-14,-30,-44,50,-31,-28,-12,49,36,7,30,12,-47,-14,44,19,34,67,40,-8,13,-26,-16,4,44,0,28,-57,-54,30,-4,35,17,40,-21,2,-11,38,-37,42,-13,22,-79,56,13,-51,4,-21,20,-11,-49,-73,-29,45,-3,39,-44,10,27,-84,27,-40,81,9,-13,-1,-26,50,-7,-32,27,-43,7,24,-20,-18,29,33,1,7,-21,43,-7,-47,-2,2,60,-15,-82,32,9,0,20,-21,-13,26,24,15,28,0,-13,-48,-16,17,-31,39,48,-20,-12,16,7,30,-4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.91","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 13 Module 13: Behavioral Activation OBJECTIVES • To understand the important clinical components and applications of behavioral activation strategies in brief CBT. • To learn skills and techniques to effectively use behavioral strategies for positive patient change (especially related to increasing pleasant events)","e":[-36,7,-151,-23,79,-48,80,-18,63,-23,-31,38,75,30,7,-63,-10,-27,-6,7,-27,10,-5,-7,43,35,19,44,-38,-18,20,-41,9,-44,-65,-37,47,12,-78,-29,12,-15,34,-58,24,26,111,18,7,1,23,-45,35,-33,135,24,-3,-3,-29,-26,94,46,-45,48,22,-30,-46,51,-54,6,60,-20,45,28,-25,0,-48,-19,0,50,45,-24,85,-8,86,-22,-19,-10,-19,42,10,55,8,31,-132,33,10,-40,41,-28,-69,-13,25,5,1,40,8,-22,4,-3,-53,50,-16,-3,-10,1,47,-14,-25,66,-4,-26,-9,13,21,49,-45,-5,18,-38,13,-19,-27,-43,20,17,15,15,40,18,-2,-10,-24,34,-16,-8,22,7,-34,5,-28,0,40,2,61,-55,-12,-37,27,17,39,3,-34,36,-43,-54,11,-1,49,54,-43,-48,12,-1,67,42,22,-17,8,-56,16,-17,26,67,-11,-35,33,-7,-34,-23,0,42,-52,-37,-69,-38,0,-26,34,-29,-17,5,-35,20,-58,20,-23,39,-9,-35,60,-19,-21,-19,-38,-5,-13,-20,-12,-5,22,26,-24,9,0,-3,-1,-5,-22,37,-28,-55,16,13,-15,42,19,45,0,18,30,56,62,31,-85,29,-24,-36,-4,25,9,9,-2,7,32,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.91","t":"What Is the Behavioral Connection, and Why Is It Important? Behaviors represent the “B” in CBT interventions, and it is important that patients become aware of the connection between thoughts, emotions, and behaviors (see Figure 13.1 below). Patients may not be as aware of the impact that thoughts and emotions may have on their behaviors. For instance, helpful thoughts (e.g., “Today is going to be a great day”) may be related to more positive emotions (e.g., happiness, excitement, etc.) and subsequent behavioral engagement (e.g., socializing with others, completing meaningful activities, etc.). On the other hand, unhelpful thinking (e.g., “My life will never get better”) may be linked to negative emotions (e.g., sadness, anxiety, frustration) and avoidant behavioral coping (e.g., social isolation, not going to work or attending school, not attending important family events). Thoughts, emotions, and behaviors may influence each other at any given moment throughout the day, and this relationship is bidirectional.","e":[31,38,-141,-37,87,17,72,-13,38,-72,-17,26,44,57,0,-20,-11,-19,-45,35,-48,8,-1,-7,10,59,-38,28,-53,19,45,-3,-2,-63,-86,0,39,46,16,-15,52,26,3,-99,29,-42,80,11,51,-13,27,-40,38,-36,145,46,66,33,-44,-48,98,50,-50,40,56,-19,-57,49,-62,29,49,-7,13,66,-18,0,-4,-9,14,27,50,-25,28,-40,82,11,-17,-2,-33,88,16,-25,19,37,-102,29,-19,-29,-2,-43,-77,-17,-14,11,3,25,-9,12,-17,18,-98,25,-14,-32,-18,20,49,-55,7,31,21,7,11,40,14,66,-34,-14,11,-32,-31,-45,8,5,4,41,-2,-6,9,29,60,14,-5,24,-40,-13,5,-58,-22,-2,-5,19,-15,27,51,-44,-32,6,71,-6,36,-1,-19,6,-17,-66,28,27,18,44,-40,-66,9,3,67,29,51,-24,23,-39,24,-25,41,4,3,4,2,-29,-65,-52,-9,12,-44,-11,-106,-47,20,-14,41,-64,-26,45,-30,42,-22,47,-25,5,-36,-50,44,-28,-27,7,-24,-16,-1,-8,-34,44,28,-20,12,-27,-7,-1,-9,-12,-42,23,-30,-56,44,14,19,28,9,13,-7,68,25,48,49,38,-48,34,6,-44,-16,38,8,34,10,-17,67,9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.91","t":"Figure 13.1 Thoughts, Emotions, and Behaviors THOUGHTS EMOTIONS BEHAVIORS Helping patients understand the connection between what they do (behavior), what they think, and how they feel can help them gain insight, increase motivation for change in therapy, and improve therapy outcomes. Just as it is important to understand how past experiences have impacted patients’ problems, it is equally as important to focus on things patients can do now to change their emotional experiences as they move forward in life. However, it may be more difficult to influence behavioral change if patients are not aware of the connections between these three components of the cognitive-behavioral treatment model. 91","e":[8,38,-136,-57,91,-3,61,-3,38,-38,-10,42,40,59,-7,7,11,-22,-37,56,-50,-21,-23,-25,15,73,-39,25,-80,17,44,-2,-8,-58,-70,-46,55,30,11,2,57,18,4,-96,18,-45,69,-57,57,0,27,-35,-3,-12,118,53,51,57,26,-46,91,49,-60,37,42,-7,-38,37,-57,-6,54,16,16,36,-35,-2,-6,-5,17,4,75,-15,48,-62,60,25,-24,8,-6,72,-8,3,17,39,-103,20,-30,-17,17,-32,-88,-21,3,-22,21,34,-18,49,10,44,-82,36,-20,-10,2,-10,54,-22,17,62,19,23,-2,41,32,26,-44,-26,-5,-17,-32,-49,-24,21,-2,53,-6,-20,8,20,84,33,-17,24,-34,-30,-6,-37,-20,1,1,33,2,33,34,-66,-36,16,44,-2,32,30,-11,42,-1,-44,47,23,8,34,-41,-45,6,12,91,37,66,-35,25,-31,3,-51,45,-9,3,-24,4,-39,-75,-53,-23,41,-44,-16,-59,-45,3,-46,50,-36,-25,29,-62,37,-36,50,-4,-21,-37,-45,60,-36,-1,23,-25,11,1,-30,-24,36,15,1,8,-16,-6,-6,-34,-10,-13,9,-34,-46,32,-2,25,2,-30,22,6,84,33,62,42,20,-61,34,-3,-30,-3,54,24,30,2,-21,53,-29]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.92","t":"Behavioral activation includes a set of procedures and techniques aimed at increasing patient activity and access to reinforcing situations that improve mood and functioning. From this behavioral standpoint, depression, for example, contains a host of characteristics that function to maintain depressive affect (e.g., passivity, fatigue, feelings of hopelessness) and decrease the chance of adaptive coping by increasing avoidance. The key here is that difficulty with mood often serves to increase avoidance of adaptive coping, including pleasant events, which help to alleviate and avoid depression. Re- introducing pleasant events (one form of behavioral activation) can serve to improve mood in many different ways - 1) reversing avoidance, 2) increasing physical activity, 3) increasing self-confidence and 4) increasing feelings of usefulness and purpose.","e":[17,37,-164,-37,74,-32,107,0,73,-40,-19,46,87,34,25,-55,-18,-32,-26,27,-15,0,-11,-25,21,70,26,1,-21,0,-1,-23,24,-23,-23,16,24,73,7,-1,-8,2,37,-38,16,-20,82,-2,32,-42,22,-64,-12,-73,135,-8,35,20,-2,-49,92,60,-38,20,81,-17,-43,43,-39,-23,60,14,-5,21,-11,24,-26,-22,0,-6,57,-56,70,-53,108,0,6,1,-28,54,25,28,25,50,-126,27,20,-19,-8,-22,-44,-5,34,11,-7,46,-12,-11,-15,38,-62,81,3,-48,-14,-3,40,-17,-17,18,-8,11,-23,11,6,22,-20,-2,37,-29,-9,-26,-18,-10,20,26,-8,-14,-8,24,47,14,-17,1,-36,-27,14,-9,-28,8,-12,8,33,-10,51,-58,-18,-2,39,8,92,12,-43,42,-14,-39,10,28,14,32,-38,-45,-21,-16,63,15,91,-51,28,-61,10,-50,23,24,-20,-45,32,-9,-72,-57,-4,4,-49,-42,-87,-44,1,6,49,-26,-6,-15,8,-13,-18,42,24,10,-5,-18,36,-16,27,-12,-13,10,-27,-38,-4,-32,30,-14,-28,24,15,16,-19,11,-29,29,-26,-63,53,-13,17,28,-28,7,-5,13,3,54,47,43,-48,21,-56,-10,-13,2,3,11,-19,-22,61,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.92","t":"An important point for providers: Behavioral activation (alternatively referred to as increasing pleasant activities) consists of a host of possible behaviors including, but not limited to: 1. Reintroducing prior pleasant activities 2. Introducing new pleasant activities 3. Active coping or mastery activities (e.g., taking some form of behavioral action) to alleviate or reduce a life stressor; examples of active/behavioral coping that are not pleasant-event driven include † Filing or getting taxes done † Cleaning out a messy closet † Calling an estranged family member The goal of active coping is to decrease stress through accomplishment or overcoming avoidance.","e":[39,49,-172,-30,47,-33,102,-19,97,-9,-31,34,79,35,19,-61,-30,-37,-42,7,-9,-4,2,8,20,58,23,1,-20,-24,15,-27,8,-13,-36,29,57,79,-12,-31,2,-3,56,-36,16,-46,85,-12,47,-12,24,-65,-36,-29,141,6,22,12,-19,-56,92,34,-3,17,68,-14,-36,65,-51,-10,64,-10,8,18,-11,11,-36,-15,13,22,41,-24,90,-46,105,-5,5,3,-18,38,23,41,43,20,-121,19,20,-18,-42,-23,-34,-3,37,19,15,21,-1,-17,-23,35,-39,81,8,-48,-20,11,78,-32,0,32,15,-4,-29,14,6,22,-39,1,32,-39,-1,-37,3,2,31,33,-26,-23,1,22,44,-9,-28,28,-14,-25,31,-25,1,15,-6,20,11,4,38,-46,-42,-9,28,7,69,-13,-29,41,-12,-15,1,34,23,3,-25,-63,-11,-15,48,4,94,-42,14,-48,-2,-50,46,29,1,-39,18,26,-46,-39,-8,7,-57,-60,-85,-55,17,17,44,-39,3,-25,-12,-18,-6,50,-3,5,-9,-13,62,-27,-4,-8,-22,-5,0,-17,9,-32,37,-37,-26,-14,37,3,-19,-1,-53,29,-18,-39,38,5,13,-9,1,43,-2,24,13,50,47,44,-39,43,-44,-20,-35,13,3,2,2,-22,61,-3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.92","t":"When? (Indications/Contraindications) Because of its relatively simple and straightforward approach, behavioral activation is a good technique for initial stages of treatment and can be highly effective for patients with limited insight into their difficulties. Activation is also easily measured (e.g., number, frequency, or duration of activities) and, therefore, can be used to document and convey progress to patients (e.g., to increase treatment investment and improve patient self- confidence and influence over symptoms).","e":[33,50,-164,-22,42,-36,100,12,81,2,9,49,87,32,-3,-105,-6,-42,-18,16,-16,7,-30,-27,25,13,7,11,-9,-14,26,7,40,-40,-44,-43,20,38,-35,-33,10,10,46,-68,24,-18,81,23,23,-25,17,-64,-16,-18,158,18,17,28,-14,-67,91,61,-52,-7,95,13,-50,29,-21,-8,43,-31,29,17,-19,18,-19,-18,4,47,55,-76,93,-60,103,16,19,1,-16,55,20,36,-1,34,-124,1,-11,-36,-17,-31,-47,11,9,4,2,36,23,-26,-20,15,-41,54,19,-39,-19,14,71,-22,0,19,-12,-1,-6,27,-1,11,-49,4,21,-23,-13,-15,-9,-11,19,56,30,-24,-7,12,39,41,-19,22,-15,-11,10,-18,-5,25,0,24,15,-3,44,-58,-19,5,33,9,91,-8,-46,29,-34,-53,-9,36,19,8,-26,-5,4,-21,68,5,75,-43,35,-45,-4,-32,1,-1,-11,-23,57,-8,-72,-55,10,-1,-62,-12,-91,-29,45,13,46,-18,-18,0,-33,9,-47,57,-10,14,-28,-18,36,-1,15,14,-37,-36,-7,-54,-14,0,45,9,1,5,5,9,-45,27,-25,30,-43,-62,43,-19,15,11,5,3,15,25,4,20,30,31,-78,-9,-26,-25,-23,11,-12,23,11,-14,46,7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.92","t":"Behavioral interventions are particularly powerful for depressed mood. Activation for depression generally serves to get the patient moving. Integrating pleasant activities can be effective in improving depressed mood. However, getting the patient to complete activities is key. Almost all behaviors that include physical activity, planning, or accomplishing tasks are appropriate here. 92","e":[-2,49,-152,-32,45,-13,67,3,37,-54,5,26,64,-1,14,-5,-11,-44,-44,46,-36,-29,-22,-47,28,80,45,-14,-28,41,20,-9,32,-35,-37,5,49,71,33,5,2,18,21,-68,3,-50,95,-14,17,-38,12,-68,-6,-79,122,5,10,9,15,-43,102,48,-30,13,74,-15,-39,42,-34,-16,75,8,43,34,-40,33,-12,-22,14,-21,48,-47,69,-80,80,-2,17,7,-27,31,32,17,10,67,-120,11,9,3,-2,-44,-51,4,20,5,24,27,19,2,-21,33,-46,60,3,-55,-20,-3,38,-29,-14,24,-1,17,10,2,20,-3,-24,-10,30,-34,-16,-16,-33,-6,17,31,-20,-30,-22,7,41,38,-35,20,-47,-14,15,-1,-34,25,-8,-5,70,-16,47,-65,-17,8,51,8,80,4,-41,15,19,-38,41,49,21,41,-45,-43,-31,-19,69,18,61,-36,4,-72,29,-46,18,10,-18,-26,45,-37,-93,-44,2,25,14,-6,-99,-24,41,-13,31,-21,-10,11,28,-7,-25,71,19,0,-8,-35,49,-18,30,7,-47,9,-24,-35,-31,-23,22,7,-20,13,38,36,-37,27,-23,22,-28,-59,37,-8,48,16,-26,-5,-1,54,-1,38,61,20,-62,37,-58,-1,-13,15,17,12,-20,-6,69,19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.93","t":"STEP #1: PROVIDE PATIENT WITH RATIONALE FOR BEHAVIORAL ACTIVATION. It is important to educate the patient as to what behavioral activation is and how it can be useful for improving depression and anxiety. Let patients know that feeling a little down or having a bad day and not feeling well physically can make it more likely that they will stop doing many activities that used to be pleasurable. When this happens, patients can get into the habit of avoiding pleasant activities that might actually help them feel better. It is also important for patients to understand the connection between what they do and how they feel, both mentally and physically. You are encouraged to explain to patients that increasing activity and/or taking action, even when we do not feel like it, help us to feel better physically, as well as decrease depression.","e":[14,43,-153,-32,70,-4,87,14,73,-44,-1,66,65,39,16,-40,-10,-54,-40,10,-18,7,-31,-29,4,45,8,12,-36,21,26,-12,20,-26,-51,-14,47,80,-16,-15,32,-11,40,-73,-1,-41,100,-12,32,-26,16,-76,-10,-51,121,3,22,23,10,-53,118,62,-30,16,86,-8,-38,55,-37,23,56,10,27,24,-51,40,-16,-27,15,5,59,-32,93,-83,62,-1,2,-18,-16,68,24,7,20,56,-102,14,6,-6,-14,-47,-70,6,-10,-8,-15,42,11,-3,-11,36,-43,54,-5,-65,6,21,49,-16,-25,17,-6,31,10,6,47,22,-16,11,40,-14,-18,-30,-32,-12,-7,46,-11,-3,2,-6,46,31,-37,1,-47,-10,9,-10,-30,15,-14,14,47,-3,82,-80,-21,-6,53,-8,80,6,-55,46,9,-53,16,36,24,19,-33,-34,-14,-31,54,39,61,-45,9,-57,14,-29,21,21,8,-15,25,-13,-73,-69,-14,0,-60,-32,-94,-25,28,-10,47,-4,-25,-18,11,-12,-35,49,5,-19,-13,-50,25,-29,25,-4,-29,2,2,-48,-15,-13,19,-10,-22,8,32,13,-37,10,-30,1,-23,-66,36,-17,22,15,-45,16,10,34,15,44,64,39,-55,25,-45,-3,-14,1,13,17,-5,-4,58,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.93","t":"Provider: I would like to talk a little about what your day looked like yesterday. Walk me through your day (e.g., what did you do in the morning, afternoon, evening) Patient: Well, in the morning I woke up at 10 am and ate breakfast. I watched TV until noon. Then I ate lunch. Around 2:30 I took a shower. At 3:00 I went for a walk with my dog. Provider: Okay, thanks. How did you feel in the morning? Patient: Tired. I just couldn’t get motivated and did not want to do anything. I guess I was feeling sorry for myself – depressed, I guess.","e":[-1,3,-175,-67,10,66,12,-44,48,-87,-18,23,30,65,-15,-18,63,-81,-61,23,-23,-13,-21,-35,25,44,-36,25,-85,50,64,-19,19,-41,-42,-17,18,62,14,-5,60,-16,27,-53,27,-34,60,24,3,-60,-27,-38,-48,-10,100,10,58,-9,35,3,159,-7,-1,57,50,-52,-16,46,-55,-7,68,-11,12,2,-18,12,-31,-25,34,0,37,-4,43,-21,27,-20,5,3,22,82,-8,-33,5,35,-75,-2,-4,18,-10,-38,-36,-20,-4,-7,72,44,-9,-10,-42,-30,-45,6,-18,-24,4,26,65,-81,30,17,-44,29,-7,50,66,33,-38,4,3,36,24,-15,-43,36,-54,30,4,-28,9,-6,47,3,-10,-24,-15,-16,2,-77,-30,52,1,8,9,46,76,-98,-44,20,31,9,53,18,-43,16,58,-70,-22,44,22,45,14,-40,-21,-49,63,34,28,-35,5,-43,56,8,7,1,6,-42,23,-54,-69,-69,-12,12,-23,-18,-64,-9,42,-6,46,-10,22,19,-15,39,-17,68,-15,18,-6,-30,54,-12,-18,20,-45,-5,-19,1,-10,55,5,-59,-11,-38,34,7,-32,16,-28,-4,-6,-67,21,10,51,33,-26,22,15,-15,15,26,44,10,-81,29,20,-24,6,37,17,35,64,8,64,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.93","t":"Provider: You say you were feeling depressed. If you had to rate that feeling on a scale of 0 to 100 (100 is worst depression) what would you say your depression was? Patient: 65. Provider: What about in the afternoon after your shower and walk? How would you rate your depression? Patient: 20. Provider: To what do you attribute this change in your depression? Patient: I guess I just got off my couch and started moving, which helped me feel better. Provider: That would be my guess as well. (Subsequently, explain the connections between mood and behavior and encourage use of behavioral activation). 93","e":[19,18,-169,-85,40,45,20,-10,38,-89,-42,37,49,13,4,-26,32,-92,-38,26,-53,-56,-64,-56,20,71,-31,17,-57,44,31,7,14,-39,-81,0,17,75,51,-3,63,-22,35,-66,17,-23,89,24,10,-22,-26,-48,-21,-20,88,34,-16,5,40,-31,82,19,-19,47,75,-15,-28,49,-45,-47,51,2,-5,39,-56,36,-28,-46,36,-8,57,-20,71,-45,53,9,2,10,14,102,-2,-33,12,60,-93,9,-31,3,-3,-59,-42,-17,-32,-18,41,57,4,-24,-7,-12,-34,24,-22,-63,12,0,57,-58,-16,53,-22,56,10,59,67,6,-15,28,9,15,-8,-19,-45,14,-29,50,-2,-19,-22,12,80,-2,-2,-8,-43,-27,33,-34,-24,28,10,-17,46,7,47,-81,-31,43,20,-15,66,36,-22,22,54,-70,-10,38,12,36,-50,-58,-7,-46,58,14,28,-33,5,-34,72,6,31,8,22,-68,38,-62,-56,-61,0,-1,-33,-23,-75,-23,39,-21,15,-29,11,37,11,-20,-66,69,0,-12,-18,-54,37,-20,-9,28,-59,5,-13,2,-23,19,4,-16,15,15,51,31,-60,44,-13,5,6,-72,39,12,13,42,-55,-5,22,17,20,25,38,20,-65,23,-21,-6,36,44,7,25,9,22,70,-13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.94","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 13 The figure below visually describes the connection between mood and behavior and can be an effective aid in communicating with patients. To maximize the utility of Figures 13.2 and 13.3, you are encouraged to use the patient's own examples. For example, you and the patient can work together to complete a daily activity log (see handout). From this activity log, you might highlight activities that appeared to raise or lower the patient's mood. Figure 13.2 Lowered Mood and Behavior Lowered mood Decreased Pleasant Activities Decreased Overall Activity Level","e":[-10,1,-173,-52,64,-15,74,-24,25,-49,-18,21,43,45,31,2,11,-29,-27,27,-32,4,-6,-11,25,61,8,38,-50,1,26,-28,8,-45,-90,-26,49,35,-45,29,49,-7,9,-54,-10,5,101,15,12,3,15,-52,35,-45,133,20,2,11,-8,-21,104,38,-58,73,26,-38,-50,34,-38,5,46,-1,31,38,-31,20,-29,-35,12,33,67,-22,72,-34,77,-32,-8,-21,-20,56,3,-9,29,35,-96,35,-21,-26,22,-47,-73,-32,7,0,-17,46,-13,-22,5,6,-57,9,-25,-6,24,-5,53,-28,-8,55,-1,-6,9,32,36,38,-35,9,17,-30,-2,-16,-36,-11,-9,38,-8,4,10,6,27,-3,-14,15,-32,-4,4,-12,-35,0,-18,-25,31,28,43,-64,-19,-13,35,22,45,-10,-26,26,-17,-62,42,49,22,49,-66,-45,-27,7,67,29,24,-21,10,-66,32,-6,19,54,7,-29,10,-48,-63,-37,-23,35,-44,-35,-65,-44,-9,-25,23,-14,-36,13,-22,28,-63,25,-8,9,-7,-86,61,-36,-16,7,-28,8,5,-6,-42,23,4,11,1,-14,15,-1,-7,7,-26,22,-22,-56,14,-2,-12,22,-7,43,-3,46,26,70,49,15,-74,52,-25,-15,7,70,-2,18,7,-18,63,13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.95","t":"STEP #2: IDENTIFY BEHAVIORS – DISCUSS ACTIVITIES. Identification of potential activities begins by exploring with the patient activities that would be most meaningful. This may begin by having a general discussion about values that are important to the patient as well as goals that they may want to accomplish. Values clarification (i.e., identifying the most important things to patients) can help patients feel heard and convey the collaborative process of the therapeutic relationship. Explicitly identifying values may enhance a patient’s motivation to change and guide the identification of behaviors that the patient would be willing to engage in related to his/her values. Additionally, a patient’s values can help identify therapeutic goals to incorporate into the treatment plan.","e":[32,46,-154,-29,55,-19,39,-42,31,13,-10,28,89,49,19,-51,3,-86,-22,38,-34,-12,-16,7,15,31,-1,17,-41,28,19,-9,33,-9,-59,-58,83,46,-3,-6,6,8,17,-74,34,-30,69,-21,41,-4,23,-27,8,8,96,40,24,43,12,-69,137,66,-71,42,74,-22,-40,15,-39,-11,50,-7,32,42,-59,18,0,-11,25,15,23,-14,75,-46,61,44,4,-9,0,59,6,36,48,-2,-111,9,-4,16,-27,-42,-35,4,21,-38,37,37,25,17,-9,39,-35,58,-32,-5,-2,4,69,-34,8,49,4,7,10,49,31,35,-48,-14,26,1,-22,-20,-14,4,8,37,23,-14,-31,21,33,28,1,-7,-11,-16,6,-31,6,-7,27,44,1,-3,12,-73,-21,-24,26,-1,48,1,-27,37,-16,-50,32,10,35,21,-40,-53,31,4,77,27,42,-8,-2,-13,11,-59,44,29,-31,-14,50,-15,-61,-44,-24,11,-35,-42,-33,-29,15,-25,15,-45,-43,7,-82,53,-43,75,-12,-12,-42,-6,46,-32,-21,16,-55,-37,-21,7,-28,26,48,-26,-2,-2,-9,14,-47,13,-22,30,-26,-31,48,13,32,5,-32,29,14,63,0,27,50,21,-57,39,4,-30,-15,44,-5,26,7,-6,41,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.95","t":"Exploring targets for behavioral activation may begin with asking patients about 1) the types of things they would like to do but have not been able to do, or 2) activities they already do but would like to do more often. It may be important to anchor these behaviors within the context of values or goals that are important to them. You might want to ask if there is something that they need to do that they have been unable to do or have been avoiding. Although you want patients to do activities that are purely pleasurable to elicit positive mood, some patients may want to accomplish something rather than focus on doing something pleasant.","e":[-31,56,-156,-15,72,-8,83,-15,68,-16,-1,58,81,54,-2,-42,26,-71,-30,30,-10,-25,3,-29,-16,10,0,6,-47,20,-2,-8,15,-43,-32,-40,31,57,-46,-17,20,9,29,-81,30,-40,112,15,49,-43,24,-59,-16,-52,117,18,18,13,35,-47,107,26,-34,30,58,-17,-42,46,-52,-19,48,16,26,32,-49,29,-31,-30,19,14,71,-36,93,-61,95,21,3,7,-6,50,27,32,24,15,-124,12,5,-10,-13,-6,-50,-7,10,-11,19,30,4,20,0,10,-33,57,-10,-28,-38,42,59,-13,10,61,-11,12,5,40,4,4,-49,-8,16,-4,-23,-26,-13,-10,-3,38,22,-16,17,-13,42,33,-12,16,-18,-31,6,-10,-15,34,5,9,55,-10,68,-87,-20,3,30,15,85,2,-55,43,7,-44,24,40,30,25,-33,-34,8,-23,57,30,60,-30,22,-55,6,-65,12,28,-25,-38,32,2,-62,-40,-11,-4,-40,-48,-72,-21,31,-18,45,-48,-30,-15,-45,45,-71,48,-9,10,-23,-46,43,-33,-11,1,-48,2,-12,-14,-27,14,32,-2,-28,-5,20,6,-22,7,-25,28,-11,-65,42,-11,19,10,-24,5,-9,16,7,30,71,45,-72,-6,-32,-2,0,23,-12,32,-5,-11,46,-19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.95","t":"Possible questions might include: • “Can you think of any activities or hobbies that you used to enjoy doing but have now stopped doing?” • “Can you think of any activities or hobbies that you would like to do but have never done? • “Are there things in your life that you would like to change? If so, what would you like to do about these issues that you have previously not done?” For patients who have difficulty identifying activities, you can introduce a behavioral activity checklist (see Appendix).","e":[12,20,-139,-29,58,38,51,-31,70,-45,-39,40,45,57,-24,-34,-1,-96,-26,28,1,-8,-29,2,9,26,7,-7,-58,40,12,-20,32,-6,-27,-33,66,61,-2,6,56,9,26,-108,74,-29,113,-5,46,-50,42,-42,-14,20,67,16,29,24,32,-29,72,22,-17,74,46,-39,-37,49,-32,-11,50,11,31,59,-74,46,-14,-1,33,22,24,-7,112,-38,67,16,12,-13,18,96,-18,13,44,14,-72,-4,-18,9,-21,-45,-62,-39,11,-16,49,22,-9,-6,-15,10,-51,47,-18,-10,-3,15,51,-31,51,59,-35,11,19,57,20,30,-38,7,28,-11,-6,-29,0,40,15,15,9,-32,2,-25,98,-9,-18,15,13,-38,7,-39,-8,8,-9,24,40,0,45,-83,-45,23,42,-28,63,11,-32,76,-7,-22,-1,67,23,17,-32,-61,27,-7,72,3,47,-36,-9,-39,27,-51,37,35,-18,-38,34,-5,-52,-41,-15,9,-13,-70,-62,-46,24,-31,4,-41,-22,29,-53,37,-57,42,-5,-13,-14,-43,86,-31,-22,4,-36,22,18,-9,-16,35,3,-34,-13,-30,62,8,-22,-3,-43,37,-33,-111,46,2,16,-6,-23,23,9,56,-1,40,37,11,-47,7,-22,-11,14,43,21,28,3,18,27,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.95","t":"Before completing the next steps (e.g., setting a plan), it is important to discuss the potential importance of the behavior with the patient. If he/she reports low importance, encourage the patient to find another, more meaningful activity. STEP #3: SET AN ACTION PLAN. Once the patient has identified a meaningful activity to engage in, help shape this work into a meaningful therapeutic goal. Action plans are one mechanism for creating meaningful behavioral goals for therapy. Action plans in their most basic form stipulate the specific goal to be accomplished, defined in terms of observable and measurable characteristics and a timeframe for monitoring progress. 95","e":[15,56,-126,-23,58,-9,47,-21,48,-16,-49,16,85,16,22,-37,7,-65,-48,46,-3,-29,-6,-22,-1,45,40,7,-52,25,56,2,2,-47,-47,-88,78,65,-25,-43,-7,-6,-3,-78,31,-43,90,-27,22,-20,46,-47,-38,-17,101,50,37,23,6,-62,104,78,-54,32,52,0,-65,37,-65,-28,18,-12,20,0,-40,13,-33,22,11,25,7,-50,91,-30,46,10,-1,15,8,67,-7,66,19,22,-120,-11,-32,20,-41,-42,-71,-32,-1,-39,1,40,2,20,6,36,-14,30,-30,11,-9,33,85,-1,58,61,46,-25,59,23,20,5,-32,-13,14,12,-5,-16,-51,3,-11,47,-6,-30,20,10,34,-20,-2,-9,-40,-12,24,-14,7,2,-2,-4,13,25,39,-63,-16,10,37,-11,75,-8,-25,32,-35,-20,17,19,15,15,-19,-46,23,4,88,28,43,-21,15,-47,0,-25,22,19,-45,-26,50,-42,-51,-36,-1,56,-9,-11,-38,-7,21,-48,30,-33,-8,18,-75,34,-30,70,1,26,-23,-18,51,-3,-13,-8,-63,-31,6,-13,-60,17,22,-11,-18,-19,27,11,-53,3,-19,16,-31,-40,23,1,39,-12,-12,24,35,54,-12,33,76,62,-41,52,7,-56,-30,73,24,3,8,-51,12,5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.96","t":"An expanded action plan might also include: a. Additional details of the plan – e.g., how the goal will be obtained b. Possible barriers to reaching the goal and ways to address barriers if they arise c. Possible facilitators of obtaining the goal, e.g., important people or situations that might aid the patient d. Patient’s confidence in reaching the goal in the timeline established; if confidence is low, you might wish to alter the plan to increase chances of success. e. Skills that the patient might want to enlist to help reach the goal (e.g., relaxation skills, problem-solving skills, etc.)","e":[14,63,-142,-2,24,26,5,16,87,-31,-27,-10,74,43,29,-39,-9,-83,-27,38,-13,-34,-18,-16,-2,17,28,-11,-98,-18,59,-24,23,-70,-8,-87,77,41,-7,-2,-14,11,6,-54,34,-28,78,18,59,-48,-4,-29,-51,5,79,48,-2,19,54,-50,84,57,-18,25,49,-4,-16,46,-22,-23,37,-17,-10,-16,-43,32,-64,12,3,31,18,-7,88,-43,56,10,12,1,-11,61,1,26,45,38,-104,17,-1,-17,-45,-43,-69,-39,57,-13,37,50,2,6,-5,75,-48,13,-38,1,-15,6,59,17,53,29,40,-21,35,12,-21,-12,-14,-37,37,-1,30,1,-17,36,-1,20,-9,4,-1,39,36,3,20,-7,-2,-53,24,8,-49,17,-10,27,17,47,41,-54,-24,-3,19,33,93,-3,-80,75,-13,-16,37,35,13,32,2,-28,5,-8,51,27,88,-39,19,-47,7,-33,17,65,-13,-40,50,-31,-39,-31,41,22,2,-33,-23,-45,49,-21,4,-36,-11,35,-33,13,21,68,-27,25,0,5,60,-17,7,3,-13,-21,11,0,-42,16,35,-33,-43,-8,21,12,-40,-16,-26,45,-19,-76,38,-1,30,-40,-11,33,23,37,16,-2,68,1,-35,25,-5,-19,-3,84,8,33,31,-11,22,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.96","t":"STEP #4: MONITOR PROGRESS IN MOOD, MASTERY, AND CONFIDENCE. It is important to monitor the patient’s mood and feelings of mastery and confidence. Outcomes such as improvement in mood, mastery, or confidence can be best identified through homework assignments that ask the patient to document the frequency and use of the behavioral activity and any corresponding emotions or feelings of mastery or confidence.","e":[31,-7,-194,-23,40,-20,46,-11,46,-47,-9,22,54,43,37,6,43,-71,-9,16,-23,-39,-59,1,29,93,-11,-39,-2,1,6,-7,11,-32,-37,-49,43,62,12,7,28,-1,16,-57,35,-3,19,-29,71,-9,-10,-61,20,-17,121,61,18,-6,19,-61,125,16,-63,49,29,-14,-45,41,-55,-2,35,12,62,52,-51,0,2,-2,21,-3,53,-8,97,-32,65,8,10,18,-38,86,33,17,5,45,-106,19,-3,33,-16,-47,-60,-19,-15,-13,35,44,-9,-7,-20,19,-51,16,-13,-9,19,17,78,-9,-12,46,19,10,31,57,22,58,-28,1,24,15,15,-32,-35,22,6,70,-26,29,-15,-19,27,19,1,5,-38,-54,34,-25,-26,-1,15,0,20,-6,12,-55,-48,-5,58,35,53,9,-49,28,2,-82,42,49,-2,33,-16,-47,6,-28,44,4,35,-47,50,-51,43,-34,64,16,-5,-27,48,-60,-67,-8,25,21,-40,-49,-70,-18,37,-23,6,-31,-38,-11,-12,2,-34,57,25,-9,-7,-26,33,7,-30,11,-11,-8,-9,-9,6,-1,8,-40,-6,-16,3,26,-38,-7,-27,31,-33,-83,42,23,32,-11,-45,50,50,84,8,26,49,28,-61,35,-1,-31,-11,47,40,31,14,1,22,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.96","t":"On the basis of this monitoring of outcomes, evaluate the action plan and the patient’s ability to work towards achieving goals. If problems arise, make changes accordingly (e.g., breaking down goals into smaller steps, determining patient perceptions of importance and changing goals accordingly). Monitoring shows the patient that you continue to believe in the importance of the technique/exercise and also serves to further motivate many patients by increasing the effectiveness of the intervention.","e":[19,48,-162,-5,68,-5,57,-5,82,-15,7,17,91,39,31,-42,8,-99,-48,29,15,-25,-33,15,21,43,27,-19,-47,31,38,23,11,-64,-53,-73,59,51,11,-17,-18,-17,-2,-79,54,-27,35,-4,26,-2,-4,-43,-32,26,127,57,25,9,43,-76,103,57,-61,16,63,-15,-43,15,-49,5,30,-20,31,29,-39,23,-30,27,-13,21,27,-39,77,-32,54,-2,17,18,-45,85,16,44,55,38,-142,15,-8,15,-2,-32,-69,1,11,-53,31,41,31,29,8,2,-13,-7,-20,23,-17,1,81,3,-11,42,35,-15,9,29,3,20,-36,-20,25,31,10,-20,-52,-8,12,61,-1,-9,16,-14,16,-18,21,6,-28,-30,41,-19,-17,27,-7,24,-2,22,56,-51,-63,28,39,15,100,-17,-42,38,-51,-34,26,13,39,13,-29,-43,5,-31,81,22,30,-12,25,-59,7,-37,29,-2,-11,-40,40,-51,-71,-33,32,20,-18,-33,-32,-24,23,-20,42,-34,-20,6,-49,25,-24,52,1,5,-33,-22,46,-4,0,24,-60,-16,24,-16,-34,22,35,-21,-22,-21,13,-19,-66,-9,2,16,-14,-59,36,26,42,7,-19,39,48,63,-4,16,25,8,-38,43,37,-30,-16,18,41,27,21,-10,27,-32]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.96","t":"TIPS FOR MANAGING BARRIERS TO DOING ACTIVITIES 1. Help the patient break down more difficult activities into smaller steps. Look for alternative behaviors to accomplish a goal prohibited by a chronic illness, environmental stressors, or depressed mood. For example, a structural/mechanical engineer who was forced to retire because of a physical limitation may feel that life is no longer productive. Although the patient is physically unable to fulfill prior job duties, you can work with them to identify meaningful activities related to the prior occupation. In this case, the patient might benefit from volunteering at a university; providing consultation (e.g., over email or telephone calls); or volunteering for a local school, youth or church organization (e.g., talking about engineering).","e":[3,60,-181,-25,42,45,48,-16,77,-25,-11,3,37,20,29,18,27,-80,-59,23,4,-28,0,-11,11,42,29,-24,-39,25,21,-34,33,-39,-34,-34,50,53,14,-13,34,-36,-6,-95,40,-36,77,-29,41,-39,56,-73,-41,-1,88,-39,-3,54,56,-53,93,69,-64,47,29,-8,-16,52,-10,6,40,25,59,34,-54,48,-21,5,14,26,15,-2,76,-29,70,25,-1,-5,-19,86,-13,33,37,28,-84,13,-15,14,-43,-36,-29,-27,10,-15,15,24,22,1,17,46,-18,29,-53,-7,12,4,73,-43,6,25,-41,14,-2,18,18,78,-42,-18,60,0,19,-12,-54,16,-1,38,-40,-18,24,-3,48,-12,2,-22,-9,-27,-4,-25,-62,13,-6,42,30,30,64,-83,-27,19,29,8,54,4,-39,51,1,-35,5,41,30,35,-40,-57,8,31,59,11,37,-53,-22,-45,28,-76,48,39,-45,-39,48,-14,-77,-65,-5,35,-11,-52,-75,-42,52,12,33,-55,-18,21,-22,18,-17,43,-15,-8,-20,-38,79,-17,-22,-19,-20,-21,-8,-42,-24,28,-15,-66,6,-10,47,5,-53,1,-22,28,-9,-75,43,10,16,5,-18,41,2,12,21,47,23,-1,-28,28,-6,2,-9,24,44,27,2,-5,20,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.97","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 13 2. It is also helpful and supportive to look for ways to help with behavioral activation. Family or other social networks that the patient has not yet fully engaged might exist, which might assist the patient in moving forward on goals. The patient can also download smartphone applications that help with planning activities and that send reminders.","e":[-18,25,-164,-29,91,-19,48,-17,65,-30,-40,-9,57,32,6,-32,1,-43,-22,20,-35,-4,-19,3,31,48,21,46,-48,-2,50,-25,5,-46,-51,-18,32,7,-62,-6,31,-16,7,-72,45,7,110,25,30,-7,7,-32,11,-14,132,4,5,15,-24,-33,112,67,-53,53,30,-25,-53,56,-46,7,55,-22,65,44,-42,7,-51,-15,-10,38,72,-19,86,-51,63,-8,-23,-14,-19,65,9,38,-1,36,-89,47,-11,-42,1,-58,-66,-2,38,3,8,32,-1,-26,5,-7,-43,10,-27,0,-9,4,45,-30,12,52,-9,-1,-1,33,31,60,-48,-24,12,-34,5,-5,-14,-44,-3,34,-23,1,21,9,33,-3,-8,3,-18,-14,-9,-3,-37,-17,-33,-2,15,22,59,-66,6,-14,63,25,55,-1,-42,29,-27,-58,7,18,48,45,-38,-45,5,-1,71,16,27,-26,21,-52,13,-24,18,77,-19,-23,15,3,-48,-45,-10,37,-45,-11,-60,-38,20,-20,37,-34,-23,4,-26,24,-53,25,-11,6,-1,-64,60,-32,-18,6,-40,3,-19,-22,-47,21,17,6,-20,-13,5,-8,-19,12,-21,50,-24,-74,40,18,23,16,-17,41,-7,48,35,65,63,19,-73,27,-13,-28,-2,39,3,9,4,-12,24,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.97","t":"3. Pleasant activities are the best first step. Pleasant activities are doubly beneficial to the patient, as they increase activity and feelings of pleasure. Activities designed to overcome avoidance or increase a sense of accomplishment should be entertained as the first goals only if highly important to the patient or apparently salient to the attainment of future goals. Highlight 13.1 Summary of Steps Step 1. Introduce behavioral activation and its potential influence to the patient. Step 2. Use patient examples to show relationship between mood and behavior. Step 3. Identify pleasant activities/active-coping behaviors. Step 4. Set an action plan. Step 5. Monitor progress.","e":[17,41,-185,-32,30,-10,92,-39,54,-26,-36,33,62,58,18,-17,4,-77,-63,7,-16,-7,-1,-20,11,75,-3,3,-33,20,7,-20,25,-14,-21,-9,45,75,5,-27,4,-4,44,-64,42,-59,80,-26,53,24,19,-40,-44,-22,124,36,29,6,21,-43,96,19,-30,20,46,10,-41,61,-46,25,46,1,33,8,-44,41,-13,-18,3,-6,33,-45,104,-63,88,-39,-4,-5,-36,40,3,39,42,41,-111,3,-33,-2,-12,-45,-23,-11,26,-3,11,32,10,15,-4,-3,-31,47,3,-46,-8,35,72,-6,11,56,-20,11,14,41,39,19,-83,-19,26,-1,24,-19,-17,10,3,44,18,-16,7,-17,49,6,-12,20,-45,-34,19,-6,10,20,-9,8,47,14,21,-102,-15,19,26,2,84,-7,-38,39,16,-31,22,24,12,11,-19,-77,3,-10,39,-13,48,-28,5,-52,12,-68,16,47,-19,-45,21,19,-55,-27,12,2,-72,-50,-69,-22,29,-22,37,-30,-18,-9,-42,5,-49,84,10,-14,-11,-18,43,-24,-14,-7,-36,-21,-13,-21,-21,-14,32,-30,-22,-40,40,19,-24,13,-67,25,-58,-45,27,15,43,-2,-10,24,10,38,-5,42,51,31,-80,34,-36,-19,-24,21,31,3,12,-31,53,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.97","t":"4. It is important to monitor anxiety and avoid behavioral activation procedures that further aid in the patient’s avoidance of fearful situations (e.g., presenting problem is avoiding interpersonal difficulties with spouse, and patient chooses to shop or be on the internet for pleasure but specifically when spouse is in the house to avoid confrontation/talking about issues). The goal is to introduce behaviors that will facilitate improvements in the patient’s life, while not reinforcing avoidance of uncomfortable situations and emotions. For example, patients with anxiety symptoms often avoid situations out of fear of negative consequence occurring in response to engaging in a particular activity. Although behavioral activation can aid these patients, you must also understand that the activity itself is not reinforcing (pleasant) but rather feared. It is only the resulting completion of the task that may generate positive affect (e.g., I faced my fear, and nothing terrible happened). This response differs from depression in that depressed patients will often look at behavioral activation as a positive outcome in and of itself (e.g., \"exercising is enjoyable,\" or \"I love talking with my granddaughter\"). Please reference Module 14 for more information about anxiety, avoidance, and exposure treatments.","e":[35,56,-150,-20,73,6,99,20,84,-25,-21,39,72,40,15,-39,4,-28,-65,-12,-27,-1,-12,-2,3,40,18,-12,-25,25,44,1,7,-40,-44,-22,40,91,-24,-23,46,-12,23,-69,22,0,91,8,65,-7,58,-59,-10,-39,138,-4,21,23,15,-55,97,49,-42,3,76,5,-58,47,-25,33,27,-3,3,40,-44,27,2,-18,3,32,43,-61,46,-74,94,13,21,-11,-40,56,38,32,19,43,-115,48,2,-39,-25,-10,-51,33,34,8,-7,-15,18,-3,-3,21,-48,96,12,-31,-3,-1,75,-44,1,20,1,26,-2,19,13,17,-46,8,43,-24,-9,-35,-15,-1,14,45,1,8,22,18,44,45,-31,-9,-37,-26,1,-18,-15,9,-19,18,3,49,64,-54,-35,8,56,21,106,-1,-19,40,-22,-46,18,7,21,16,-32,-49,14,-17,62,4,68,-38,38,-57,10,-50,37,8,-6,-24,40,10,-55,-60,20,-15,-65,-36,-88,-46,22,26,68,-21,-21,-7,-29,-7,-43,57,5,-23,-23,-64,28,-24,-7,3,-15,-29,-10,-37,-15,-3,17,-26,-27,-19,19,3,-32,-9,-34,28,-19,-84,54,1,2,35,-3,29,1,-1,10,27,29,33,-37,11,-41,-14,-24,-23,-15,20,14,-15,54,-16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.98","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 13 EXAMPLES OF HOMEWORK ASSIGNMENTS 1. What activities did you previously enjoy that you would like to start participating in again? 2. List activities that you need to do to better your current situation (enroll in school, get your inspection sticker, etc.). 3. Create a schedule of the new activities you will perform. Which ones did you accomplish? Were there any barriers? Why? How did you handle them?","e":[26,-3,-140,-26,66,-2,54,-31,24,-18,-33,0,58,65,-19,-27,14,-52,-12,6,17,-14,-15,7,24,23,-18,7,-50,-14,-5,-49,-19,-57,-50,-42,76,26,-57,-19,42,-22,-10,-53,63,-17,104,-13,53,-2,37,-50,19,5,91,27,15,-13,32,-6,82,63,-50,70,-18,-26,-36,85,-50,28,35,11,56,17,-63,-19,-30,-7,1,53,29,0,69,-13,69,-8,-26,-13,-28,76,-6,24,8,34,-62,27,-3,17,-17,-40,-55,-31,39,-12,22,26,3,-30,-10,-4,-75,29,-30,21,20,48,56,-30,26,66,-46,-24,-9,22,23,61,-48,-16,20,-33,21,-28,-32,16,-3,20,-28,-13,25,-8,62,-28,-23,44,-19,-3,-1,-30,-54,3,-17,-4,52,-6,42,-21,-25,-30,46,27,39,-16,-40,55,-27,-14,2,44,52,53,-55,-66,-13,20,33,23,33,-12,9,-30,37,-6,32,45,-14,-36,20,-10,-53,3,-12,29,-13,-35,-91,-56,19,-41,4,-33,-18,12,-17,34,-58,57,-40,2,7,-41,83,-5,-32,14,-31,19,-17,4,-44,-9,-20,-27,38,-27,37,40,1,-10,-21,58,-7,-75,24,4,9,35,13,33,11,49,23,45,65,-28,-66,21,16,-38,5,42,13,-3,29,33,-3,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.100","t":"Exposure therapy is an approach commonly used to treat anxiety conditions (namely, panic, agoraphobia, social phobia, and specific phobias – such as animals, heights, flying, choking, and blood-injury-injection). Exposure therapy is defined by its systematic approach to confronting feared stimuli in the presence of a safe environment. Feared stimuli can be external (e.g., objects, activities, situations) or internal (e.g., feared thoughts, physical sensations). The aim of exposure therapy is to reduce the patient’s anxiety response to feared stimuli and increase the patient’s ability to experience and tolerate anxiety. The process includes creating a thoughtfully constructed hierarchy of feared stimuli organized by the patient’s reported degree of fear. The patient and provider systematically work their way up the hierarchy by exposing the patient to the feared stimuli with a variety of exposure exercises, allowing the patient to habituate to their anxiety over time.","e":[49,48,-187,-59,51,10,40,42,41,13,1,23,90,19,25,3,20,-30,-51,-23,-39,-52,-4,15,-31,26,-6,-2,7,1,28,-21,-44,-37,12,-58,65,84,-8,19,27,-39,21,-68,-30,24,52,17,17,-2,49,-81,-7,-13,137,-2,8,11,0,-48,62,71,-63,-13,53,10,-79,43,-6,-6,53,-9,14,16,-38,-35,-23,-56,-4,47,38,-30,26,-38,70,21,-12,6,-30,33,33,10,15,21,-99,0,-15,1,-40,-31,-63,-15,49,-27,-10,5,7,-10,16,28,-51,76,-21,-24,22,-20,63,-46,20,-12,15,35,-5,28,10,37,-75,-4,-6,-20,24,-30,-28,10,49,65,-5,-12,-32,22,22,7,0,-16,6,12,25,-33,-26,-29,5,51,-1,37,47,-54,-28,20,31,54,51,36,6,21,-41,-27,20,39,12,19,-50,-37,17,12,47,8,95,-51,-27,-48,42,-50,39,-10,10,19,39,-18,-22,-58,35,3,-33,-1,-88,-54,18,-26,48,-38,-20,19,-34,12,-40,99,-28,-28,-11,-34,47,-52,17,55,-4,-38,-2,-49,-49,10,38,-17,-17,-11,4,25,-50,5,22,37,-19,-44,14,-2,-20,4,11,32,-28,3,-11,21,-3,6,-59,19,4,-30,-9,30,-59,14,13,-26,56,24]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.100","t":"Exposure therapy is rooted in classical conditioning theory, which posits that fear, an emotion, becomes linked with previously neutral or unfeared stimuli through cognitive and emotional processes that result in associated symptoms of anxiety. Subsequently, anxiety becomes a conditioned behavioral response to these stimuli through the activation of fear and engagement in avoidance/escape behaviors. It is important to note that these previously neutral stimuli may be animate (e.g., spiders, clowns, people), inanimate (e.g., toilets, knives, numbers, places), situational (e.g., driving, darkness, feeling uncertain), cognitive (e.g., “impure” thoughts, memories of traumatic events, premonitions), or physiological (e.g., racing heart, feeling out of breath, flushed skin) and would not otherwise elicit a strong or intense fear response. Exposure therapy seeks to “undo” this prior associative learning by reducing the conditioned anxiety/fear response through repeated confrontation with the feared stimuli. Most importantly, the individual undergoing exposure therapy must learn to tolerate the fear while building self-efficacy within the context of processing emotional reactions (see Figure 14.1).","e":[57,44,-191,-51,78,24,68,49,50,-5,-31,50,98,49,16,-1,20,-26,-11,19,-51,-29,3,-10,-35,29,-9,13,-12,13,59,-23,-29,-56,-33,-48,58,74,14,5,44,-17,19,-60,-36,-2,46,18,35,8,39,-72,-9,-30,116,20,21,22,20,-58,67,90,-54,-2,62,22,-52,79,-3,3,43,-26,-24,24,-27,0,-4,-57,-14,33,37,-30,27,-39,90,1,-28,-6,-18,69,38,12,26,17,-85,24,-21,1,-56,-32,-72,-21,42,-45,1,-3,4,-13,12,25,-76,90,-40,-16,9,-23,57,-50,17,1,-3,33,4,21,3,39,-55,1,-5,-30,10,-36,-22,15,39,67,-9,-7,-20,30,23,18,9,-16,-10,-3,35,-28,-35,-12,4,52,-19,47,56,-47,-6,-3,23,39,78,18,21,34,-26,-48,17,30,26,9,-59,-36,4,11,32,26,95,-49,-1,-60,33,-27,47,1,33,-11,14,19,-44,-70,5,12,-46,1,-84,-79,-14,-36,67,-27,-19,16,-17,22,-49,86,-28,-24,-9,-34,39,-15,1,46,-11,-31,-17,-39,-48,1,18,-12,-20,-3,0,24,-50,-13,21,33,-19,-61,45,8,9,37,-3,23,-12,4,-11,31,6,21,-52,-1,7,-54,-12,27,-57,37,13,-15,49,11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.101","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 Figure 14.1. Breaking the cycle of anxiety The vicious cycle of anxiety Reversing the vicious cycle of anxiety Confront feared situations without Anxiety aid of safety behaviours situation Long Term: Increase in the physical symptoms Increased scanning for Greater belief in ability to Short term slight increase of anxiety, more worry, danger, physical symptoms control own responses in anxiety, then a decrease loss of confidence about intensify, attention narrows in physical symptoms and coping, increased use of and shifts to self attention scanning safety behaviours","e":[26,8,-172,-42,99,-7,52,10,45,-19,-46,9,75,11,40,-17,-15,-48,-15,-9,-31,-3,-3,-26,-10,49,21,24,-11,10,64,-42,-16,-50,-35,-55,72,32,-18,-4,77,-13,32,-42,-6,2,91,49,12,7,49,-54,18,-33,120,59,9,16,6,-51,77,37,-49,82,52,-25,-57,47,-28,3,47,-35,19,36,-42,-4,-37,-7,-4,68,22,-36,73,-26,54,2,9,-17,-42,60,32,2,-20,30,-91,44,17,-8,-70,-44,-56,-28,15,-31,-28,7,-14,-57,18,6,-68,46,-28,9,23,-10,81,8,-7,25,-3,10,-18,52,35,57,-18,19,40,-46,27,9,-21,-1,8,72,-8,4,9,32,50,-10,-7,-16,-19,-32,9,-32,-37,-41,-15,16,-11,17,54,-5,-26,16,63,27,24,-9,-39,45,-88,-31,18,34,42,49,-64,-36,3,-7,39,44,78,-12,16,-77,9,5,51,62,18,-11,21,-22,-38,-59,-1,26,-54,-29,-66,-68,18,-38,21,-40,-19,9,-3,5,-45,47,-10,0,-9,-51,58,-50,-19,-1,-18,-11,8,-20,-20,12,17,30,-35,-9,19,21,-8,-34,2,15,-18,-89,55,7,-5,18,23,52,6,24,30,42,35,3,-52,48,-7,-33,5,45,-8,-5,13,33,23,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.101","t":"Escape or avoidance Use of coping skills, anxiety reduces to Short term: Relief manageable level ELEMENTS OF EXPOSURE Exposure therapy, typically delivered in 8 to 12 sessions in specialty mental health settings, is efficacious for anxiety disorders as well as other conditions such as obsessive- compulsive disorder (OCD) and posttraumatic stress disorder (PTSD; Hofmann & Smits, 2008; Rauch, et al. 2012). Although exposure therapy requires adequate time for extinction, recent advances in treatment have shown that briefer formats of exposure therapy (e.g., four to six sessions) are effective for patients with anxiety and PTSD (Cigrang, et al. 2017).","e":[26,37,-188,-41,35,-15,34,20,63,10,-20,4,54,33,31,-22,4,-62,-50,-5,-23,-32,6,-22,-15,71,0,-3,-42,6,51,-23,-25,-42,-8,-56,40,62,6,-22,54,-50,49,-68,-14,-3,88,37,38,-13,60,-59,-22,11,100,3,-40,9,25,-44,76,32,-66,11,74,23,-47,86,12,-35,60,-2,26,5,-35,-9,-17,-67,-9,64,45,-10,33,-58,76,29,-11,18,-26,32,24,24,11,37,-68,7,-4,10,-42,-15,-47,-5,26,-41,13,-4,0,-2,19,47,-72,90,-49,-8,8,-20,62,-58,27,-30,-13,-5,22,38,40,17,-61,3,9,-2,-4,-20,-23,21,30,59,7,-7,-40,30,38,16,-15,-23,0,-1,13,-24,-29,-14,30,41,11,63,22,-62,-37,-28,37,38,34,4,-28,53,-48,-54,5,60,4,22,-44,-66,8,-15,29,17,95,-51,-9,-48,53,-49,-1,13,5,-11,47,-33,-42,-42,27,-6,-49,-16,-77,-59,33,-39,20,-40,4,23,-43,5,-24,88,-27,-17,-8,-58,50,-16,-23,48,-16,-15,-22,-24,-29,34,48,1,-12,-61,19,32,-65,-2,8,32,-17,-60,7,-34,-25,7,9,28,-35,18,8,23,12,7,-57,16,-25,-34,7,24,-40,6,18,-8,21,3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.101","t":"Exposure therapy is generally conducted using one or a combination of different types of exposure exercises: • Imaginal exposure, or exposure to one’s own thoughts and mental images, may be used to help patients experience their most feared thoughts more fully. Sometimes, imaginal exposure may be used as a first step toward a strongly feared in vivo exercise. An example of an imaginal exposure is to have patients write a short story in which the things they fear the most eventually come true. • Interoceptive exposure, or exposure to physiologic sensations associated with anxiety and panic symptoms, should be used to systematically “expose” patients to the most common somatic symptoms associated with their fear responses. This should be done in a controlled way to ensure the health and safety of the patient. Interoceptive exercises may include simulation exercises and naturalistic activities to help patients increase their tolerance of physiologic bodily sensations without using safety behaviors. • In vivo exposure, or real-life exposure to feared objects or situations, may be used to help patients overcome anxiety and panic insomuch as they negatively impact their quality of life. In-vivo exposure is associated with reduced symptoms of anxiety and panic, PTSD, and OCD over the long term. 101","e":[42,52,-192,-59,26,3,52,30,48,-1,-18,23,67,59,9,-5,29,-66,-32,-2,-69,-55,-22,29,-25,27,-1,-25,-19,-16,36,-52,-10,-26,-2,-49,59,64,1,6,38,-28,31,-56,-13,26,72,2,26,3,59,-73,-1,-27,130,-12,0,7,25,-60,66,57,-49,-13,55,13,-88,73,-7,-16,68,-8,29,33,-53,-4,-5,-46,-11,40,0,-11,61,-46,90,32,-8,13,-22,31,51,11,26,35,-88,-5,-16,30,-46,-30,-67,-2,35,-41,-13,7,28,-6,5,28,-33,55,-32,-10,10,-19,56,-60,35,14,4,28,6,45,3,18,-76,-20,-16,-44,14,-37,-45,4,26,71,-2,1,-31,9,17,-25,-17,-6,-6,-24,9,-30,-39,14,6,35,32,33,58,-49,-48,-1,33,27,37,30,-11,44,-28,-33,25,68,36,-9,-49,-60,10,16,49,-6,87,-80,-13,-45,49,-26,12,-17,26,-2,24,-8,-45,-38,21,26,-29,-12,-89,-49,29,-26,36,-19,5,22,-30,19,-49,91,-43,-34,-14,-41,57,-34,10,35,-3,-13,-7,-44,-69,-4,46,9,1,-50,2,6,-72,8,31,44,-35,-63,38,-13,-17,17,-6,34,-15,22,8,11,15,12,-69,10,-13,-36,12,15,-37,30,13,-28,28,38]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.102","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 Table 14.1 lists common terms and elements often associated with exposure therapy. Table 14.1. Common Terms in Exposure Therapy Emotional The use of reflection to assist in the development of new, more realistic beliefs Processing about feared objects, activities, or situations. Believed to be one of the critical active ingredients of exposure therapy. Extinction Weakening or removing previously learned associations between feared objects, activities or situations, and bad outcomes.","e":[36,2,-166,-74,76,5,61,13,27,1,-30,7,87,20,13,-17,18,-33,-32,16,-45,-53,14,-4,-5,46,-11,5,-45,-52,30,-39,-23,-46,-51,-65,53,84,-29,-11,56,-21,22,-46,-8,10,74,14,9,-22,59,-66,41,-31,129,17,3,20,-2,-48,77,74,-76,42,47,5,-62,74,-33,-16,56,3,10,65,-56,-36,-45,-51,12,49,20,2,63,-10,66,13,-24,18,-16,23,34,-3,-2,32,-108,30,12,-18,-26,-23,-65,-41,27,-31,4,42,-20,-10,7,33,-85,46,-51,-3,11,-29,55,-36,14,34,21,10,18,44,10,39,-57,-21,16,-59,6,-29,-13,-21,29,40,6,-10,-3,36,25,12,-11,-22,-3,-13,24,-38,-23,-31,25,21,-10,14,53,-32,-32,-21,34,38,31,33,-30,8,-29,-41,14,45,41,55,-60,-49,7,7,37,24,82,-31,-17,-71,20,-27,34,41,10,-3,17,-33,-18,-29,-2,33,-32,-24,-80,-56,-3,-19,34,-26,-6,31,-40,33,-47,84,-36,13,-20,-33,72,-32,-19,35,-17,-7,-29,-9,-59,11,19,6,-3,-28,-7,38,-20,13,16,39,-27,-71,19,15,-12,4,8,30,-19,41,24,26,20,-2,-82,34,22,-18,27,55,-47,11,-5,2,17,13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.102","t":"Fear vs. Anxiety Fear -- the emotional and cognitive response to an object or situation of concern. Anxiety -- the constellation of symptoms that manifest when a feared response occurs. Flooding Starting exposure with the most difficult tasks of the fear hierarchy. Graded The use of a fear hierarchy to systematically and gradually expose an individual exposure to increasingly distressing objects, situations, or activities. Habituation Decreasing the intensity of anxiety reactions to feared objects or situations over time through repeated exposure.","e":[56,27,-179,-32,79,28,51,17,29,-9,-8,50,85,63,42,-15,12,-24,-29,-20,-50,-9,-11,4,-37,38,-21,-54,0,22,35,27,9,-47,-34,-36,18,47,37,2,73,-5,23,-67,14,0,0,35,78,-14,55,-47,-7,-36,103,55,44,30,23,-29,69,28,-37,18,60,30,-67,50,10,-26,55,-27,-5,27,-59,-10,4,-23,17,33,54,-39,46,-20,81,21,-27,4,-10,75,19,5,27,27,-80,33,-18,-22,-38,-32,-35,-25,55,-14,8,-53,-25,-6,-17,6,-61,87,-18,-11,26,-20,91,-25,8,23,5,12,17,49,-8,35,-35,35,37,-19,23,-58,-8,5,6,75,-43,20,-13,44,66,-30,5,-33,-11,-17,57,-41,-27,-45,28,31,-39,27,29,-3,-30,53,48,33,37,4,26,50,-21,-54,34,15,-7,1,-26,-36,12,14,57,0,101,-28,19,-36,32,-38,70,12,25,-27,65,-6,-32,-62,11,-34,-42,-20,-48,-55,-3,5,50,-34,2,-15,7,4,-25,96,-13,-20,15,-44,38,-24,-9,6,24,-33,16,-22,-28,-17,-25,-25,-31,-36,11,15,-24,-35,1,38,3,-81,62,14,2,52,28,17,29,-11,-38,23,45,5,-32,-5,-22,-24,-17,2,-52,11,8,-16,65,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.102","t":"Panic Sudden uncontrollable fear or anxiety that often involves psychological and biological (bodily sensations) reactions. Within exposure therapy, fear associated with bodily sensations decreased by building tolerance to the sensation during exposure exercises. Safety Behaviors used by patients to tolerate or reduce fear and, thus, avoid exposure Behaviors to the feared object or situation. During exposure work, important to monitor and avoid safety behaviors during exposure exercises. Ultimate goal of exposure therapy: to translate skills into real-world situations; important to help patients minimize use of safety behaviors in their daily lives.","e":[62,47,-185,-2,64,24,80,29,56,-25,-24,37,84,45,31,-4,30,-51,-56,-26,-58,-18,-26,-14,-22,50,13,-6,13,-22,42,-2,-29,-48,-7,-67,52,70,-9,2,40,-22,15,-77,-12,19,60,-7,45,17,82,-71,-25,-29,129,-13,41,-3,7,-39,49,57,-56,-11,57,12,-69,53,-10,-3,38,-1,3,42,-60,-15,-7,-29,-22,63,4,-6,41,-35,78,17,-25,5,-29,72,47,8,38,24,-96,23,3,13,-25,-44,-40,-25,32,-34,-13,-1,24,-1,13,31,-38,92,-25,-26,21,-35,84,-41,11,18,12,7,-8,40,-10,39,-44,26,11,-23,-6,-19,-31,13,27,78,-11,19,-16,24,38,13,2,-19,-8,-32,30,-25,-34,-29,4,25,-25,18,53,-46,-41,31,52,5,55,16,9,23,-45,-49,16,22,12,26,-71,-53,-3,8,51,18,100,-61,0,-60,37,-26,52,5,30,-4,36,-14,-66,-55,17,0,-31,-33,-98,-52,6,-18,33,-31,-18,16,-50,5,-35,77,-20,-29,-7,-37,46,-47,1,22,-11,-35,14,-29,-33,5,4,-16,-23,-30,-2,3,-50,-22,36,27,-21,-53,40,17,-8,5,11,36,3,-29,-17,17,15,9,-55,10,-10,-46,13,24,-48,30,20,-5,50,27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.102","t":"Stress Stress -- the way in which the body responds to any demand or challenge. Experienced daily by everyone. Importantly, not all stress bad but long-term stress harmful to health. SUDs Subjective units of distress. Commonly used to “quantify” levels of perceived stress. Typically used on a 0-100 scale.","e":[16,41,-187,-45,60,3,3,-24,27,-62,-22,50,55,3,45,-52,15,-23,-7,27,-42,-12,-33,-4,-34,90,-15,-29,11,-3,24,10,42,-33,-63,-28,3,55,63,-6,9,-59,20,-48,34,-20,-15,24,66,-25,14,-90,-39,-43,97,-18,16,-5,-15,-1,73,39,-94,36,74,-24,-56,65,13,16,73,-15,4,8,-53,0,-16,-2,42,26,42,-28,81,-13,95,-4,-14,14,-14,71,18,25,31,38,-123,15,27,11,-25,-41,-30,-39,-18,-40,33,-2,-16,2,18,-18,-56,78,-16,6,-30,-4,59,-16,-30,27,-4,7,-14,66,-22,8,-28,26,47,-29,-6,-31,-50,-22,7,102,-47,-33,-4,19,75,-19,-22,-16,-17,-34,41,-59,-35,-22,20,32,-23,18,18,-26,-25,49,24,39,31,-3,-40,23,-34,-36,-31,52,33,49,-52,-74,2,10,70,12,81,-7,13,-58,-10,-49,47,-8,-11,-42,56,-53,-27,-18,20,13,-8,-28,-52,-49,25,12,39,-15,-3,-20,-42,-14,-47,44,-21,12,7,-16,68,-17,-12,25,-40,-41,5,-6,-26,19,13,7,40,9,50,-9,-50,-25,-13,19,-39,-61,63,34,-19,25,24,25,13,9,4,-2,6,19,-53,39,-10,-43,-13,-3,-9,4,40,-12,41,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.102","t":"Systematic Combining exposure with relaxation exercises to make them more manageable. desensitization However, pairing with relaxation may interfere with the exposure experience. Must be monitored accordingly. Relaxation techniques possibly best used after the exposure exercise is completed. Worry A state of anxiety and uncertainty over actual or potential problems. Usually related to something impending or anticipated. 102","e":[52,23,-188,8,19,-15,54,-23,52,-43,-20,38,60,36,25,2,16,-44,-18,-23,-57,-57,-30,-32,-18,53,27,-16,-17,-20,38,-20,-5,-12,-26,-86,56,42,-25,0,48,-16,44,-69,6,22,40,6,53,3,63,-50,-44,-32,111,33,30,12,31,-54,80,15,-56,34,65,-23,-54,44,46,1,67,-27,42,28,-51,-9,11,-11,-3,22,0,-20,79,-31,86,33,-11,-22,-23,70,50,-16,39,56,-82,26,8,44,-56,-64,-44,-20,26,-33,-37,-2,-13,0,19,29,-45,64,-18,5,29,3,41,-53,23,8,-5,17,30,30,3,20,-40,-27,57,-37,1,-31,-26,40,-16,51,-32,20,-38,-22,29,-12,4,-54,-16,-20,17,-67,-35,-26,6,-30,7,-1,61,-29,-50,19,62,24,53,-12,0,52,-11,-15,18,47,32,26,-40,-59,-8,-30,73,30,86,-72,13,-57,16,-16,19,13,-2,-3,60,-45,-67,-40,-10,23,-24,-43,-69,-35,22,-14,21,-8,4,-11,-35,1,-50,95,-37,-7,-7,-57,37,-42,-3,8,6,-61,11,-29,-33,15,-12,-11,-22,-8,14,10,-34,-9,-18,36,-33,-80,51,37,11,22,41,24,-8,3,5,16,24,14,-46,62,22,-15,11,19,-39,-11,-15,7,35,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.103","t":"SUMMARY OF CRITICAL ELEMENTS IN EXPOSURE THERAPY • Identification and articulation of the specific feared objects, activities, and situations, as well as the associated anxiety symptoms (for monitoring and fear hierarchy construction). • Development of comprehensive fear hierarchy. • Selecting feasible and clear exposure exercises. Ideally, should occur through in-vivo exercises and include attention to interoceptive experiences. • The goal of exposure to increase tolerance of panic/anxiety during exposure exercises. • Emotional processing of the exposure exercise to develop more accurate thoughts about the relationship between the feared object/activity and negative outcomes.","e":[50,14,-181,-16,64,14,75,33,44,-12,-8,47,88,43,61,-19,28,-46,-21,-6,-39,-80,-7,-4,-23,60,5,-23,-22,-16,55,-21,-33,-55,-12,-59,55,94,-33,2,37,-31,-1,-57,-15,21,46,3,39,7,58,-46,-4,-23,121,46,9,2,59,-61,76,54,-84,-18,62,18,-65,58,-47,25,42,-4,14,48,-56,-18,-8,-49,6,35,21,-3,80,-48,49,19,-7,9,-25,43,41,36,17,47,-95,9,-13,37,-39,-26,-47,-4,40,-46,-9,-3,11,10,-13,19,-70,67,-51,-13,14,-17,100,-55,31,-1,-3,5,20,41,-8,-3,-46,-8,-7,-39,14,-50,-36,5,35,62,-16,-3,-2,20,13,32,-13,-28,-2,-18,21,-30,-30,-12,34,46,-12,6,44,-51,-37,-30,40,8,46,23,-9,40,-24,-48,12,34,63,34,-35,-54,10,28,25,23,90,-53,5,-61,43,-42,44,24,19,-17,48,-23,-38,-36,15,19,-34,-15,-59,-64,12,-46,40,-47,-9,25,-32,15,-40,97,-13,-15,-14,-38,49,-29,4,21,1,-16,-29,-42,-44,5,26,-14,-36,-24,-15,22,-55,-15,26,31,-5,-51,19,-4,-14,27,14,28,-4,24,-16,15,48,-9,-63,19,-5,-25,-21,37,-58,22,6,5,5,24]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.103","t":"Ultimately, you should use your clinical judgment and the most current empirical literature to determine the most appropriate course of treatment when considering exposure therapy as an option. The information contained in this module provides an overview and basic strategies for using an exposure-based approach in a brief setting. However, these basic strategies may not be appropriate for specialty mental health settings dealing with more complicated presentations. Because brief approaches to psychotherapy are not appropriate for all clinical presentations, we encourage providers to use specific (and often more intensive) treatment protocols when facing more severe or complicated clinical presentations of anxiety. For patients with less severe symptoms or when full protocols are simply not feasible – providers may consider the techniques in this chapter – while recognizing the potential limitations.","e":[57,29,-160,-39,32,7,47,15,39,-4,40,-17,70,65,-31,-38,18,-61,-22,-6,-60,-42,-26,-15,-13,11,11,-5,-36,15,25,-9,-1,-57,-30,-79,52,58,-13,-6,32,-24,16,-69,-1,5,82,43,18,-2,48,-49,15,-11,121,10,-2,47,45,-74,98,65,-50,18,40,6,-56,30,-19,-30,62,-5,61,1,-43,-6,-21,-59,-9,50,19,-19,72,-56,44,41,-3,2,13,52,25,24,28,57,-108,13,-55,-13,-23,-25,-48,23,5,-7,-13,5,-12,3,-4,-7,-51,75,-23,-37,16,-18,62,-49,21,49,-16,-10,41,50,22,30,-68,-10,30,-28,20,-53,-22,9,31,61,8,-1,-2,53,36,9,-1,-7,-25,-10,4,-13,2,-2,11,48,35,54,35,-60,-9,12,39,16,57,19,-27,28,-32,-33,-1,36,12,8,-47,-29,26,-4,91,4,102,-52,19,-54,22,-32,-2,-10,21,-7,55,-19,-35,-30,22,24,-34,-13,-92,-63,27,-18,35,-37,-12,46,-39,49,-65,114,-30,-15,-25,-71,50,-34,-9,33,-43,-13,-29,-47,-68,59,10,-3,-12,-21,16,11,-64,13,12,31,-13,-75,18,5,10,27,13,15,1,17,-27,0,53,28,-57,12,-6,-20,8,44,-27,6,24,0,46,16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.103","t":"Exposure interventions require appropriate provider technical expertise and adequate time for learning, reflection, and extinction of fear responses. Clinical situations in which these ingredients are not present should be approached carefully or with additional supports/alternatives. For example, most brief exposure-based protocols require four to six sessions, at minimum.","e":[16,57,-194,-35,76,8,49,23,55,0,1,5,31,58,19,-14,42,-81,-52,13,-56,-70,-25,-5,-2,21,23,2,-4,-2,59,-5,-15,-66,-9,-86,40,40,-17,-22,35,-10,39,-30,16,6,37,18,23,-47,57,-46,-16,13,73,27,-27,-5,24,-55,111,23,-93,11,29,31,-56,61,11,-16,28,-7,16,34,-23,-14,-43,-51,-22,54,28,16,76,-55,48,0,-26,-4,17,73,31,22,17,31,-57,5,-17,39,-36,6,-55,-9,19,-53,7,-4,20,50,19,3,-79,64,-49,-19,4,-45,51,-40,9,18,-33,-27,37,49,20,8,-66,1,15,-15,29,-30,-31,16,46,66,-4,-8,-24,64,14,50,12,-41,-16,-11,19,-17,-3,-12,38,44,13,52,68,-44,-34,-31,33,45,70,-5,-48,36,-37,-29,15,51,7,30,-32,-42,22,-13,28,19,54,-57,-18,-59,50,-53,-1,18,15,-29,57,-47,-33,-57,55,-13,-25,-37,-73,-32,43,-33,38,-13,-5,16,-23,40,-35,107,-34,-11,-30,-78,63,-14,-32,9,-30,-36,-23,-6,-58,43,33,-2,-17,-61,0,17,-45,-4,16,14,-12,-46,8,-15,-12,14,43,-8,-2,8,-16,19,18,40,-65,-11,-8,-24,-14,33,-34,-3,25,-19,24,39]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.103","t":"GENERAL CONSIDERATIONS FOR BRIEF COGNITIVE BEHAVIORAL THERAPY: 1. Exposure therapy is an emotionally intense experience for patients and may lead to avoidance of therapy to avoid exposure exercises. Exposure should be graded and based on the patient’s presenting fear and fear hierarchy (explained later in this chapter). 2. Technical expertise on the part of the provider is required. Homework and in- session exposures must be done accurately, effectively, and efficiently (e.g., detailed hierarchies and appropriately targeted interventions) to avoid unnecessary negative patient experiences. 3. If you are unfamiliar with exposure principles, consult with other providers and/or receive supervision for initial or complex cases.","e":[57,53,-164,-45,34,17,100,-19,33,6,6,14,66,61,19,-23,17,-41,-15,16,-55,-35,-22,10,-11,42,-8,4,-18,1,38,7,-31,-56,-42,-67,71,53,-24,5,20,-2,28,-80,1,34,79,31,29,5,33,-71,16,-17,119,-2,-1,28,11,-72,75,57,-66,31,9,15,-62,69,-20,0,48,6,38,34,-41,-25,-25,-59,5,37,34,1,47,-34,74,5,-26,9,13,56,22,13,14,39,-74,12,-18,-9,-19,-18,-43,-9,20,1,-23,5,-1,25,17,14,-87,83,-24,-31,28,13,64,-40,27,30,-8,-5,34,43,-1,37,-83,-25,6,-45,4,-54,-26,8,40,52,1,9,-23,26,11,17,5,11,0,10,7,-17,4,-6,12,38,15,13,78,-47,-29,-26,27,40,44,13,-42,21,-32,-35,1,28,19,15,-67,-42,33,-15,46,30,81,-41,-7,-63,15,-41,21,23,10,-4,34,1,-34,-6,37,-24,-37,-1,-112,-92,26,-11,43,-36,-9,44,-30,48,-46,118,-49,-9,-44,-59,47,-45,-13,25,-34,-36,-24,-30,-66,41,35,-16,19,-28,-12,28,-40,14,14,58,-28,-51,17,23,22,33,-4,13,-7,34,-13,24,44,-13,-86,1,-2,-32,3,9,-35,4,21,-10,49,44]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.104","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 4. Consider medication referral (e.g., antidepressants or benzodiazepine) with an awareness that medications may serve to increase feelings of safety (e.g., safety behaviors) and could compromise exposure-therapy impact if used to reduce anxiety during exposure sessions. How? (Instructions/Handouts)","e":[6,23,-158,-23,96,-7,61,-1,49,-8,-8,33,76,26,39,-14,8,-53,-40,3,-50,-56,-20,-39,-18,38,3,4,-7,4,41,-32,-23,-39,-20,-67,76,102,-50,-2,56,-25,3,-60,8,20,99,45,28,-12,64,-58,18,-27,132,-6,1,44,-10,-39,103,52,-46,31,41,-19,-57,72,-23,13,52,-5,56,74,-40,9,-37,-27,-19,21,32,0,62,-37,51,18,-3,-28,-23,43,8,-28,-11,34,-93,38,-1,-38,-3,-48,-68,-3,20,-6,-9,19,15,-27,17,-5,-69,39,-38,-14,10,-5,54,-24,-8,30,3,-14,27,28,35,45,-46,-1,20,-43,7,-29,-9,-37,17,53,-10,-4,0,46,20,4,9,-16,-24,-2,7,-9,-28,-35,30,17,3,43,45,-34,-12,-9,58,12,19,0,-37,5,-14,-44,34,18,6,65,-65,-49,-7,-19,84,28,64,-27,19,-67,37,-21,-5,38,-5,21,18,-42,-50,-33,13,35,-11,-42,-88,-72,23,-16,18,-27,-36,49,-29,4,-61,93,-26,-14,-20,-75,77,-43,10,4,-10,-16,9,-18,-35,39,4,6,17,-48,8,19,-16,-6,-1,14,-8,-51,36,22,10,15,16,37,1,31,21,56,41,21,-67,29,-27,-9,27,62,-29,13,-9,10,34,16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.104","t":"EXPOSURE PROCESSES The process of conducting exposure-based brief CBT follows a general framework (Barlow and Craske, 2007): 1. Psychoeducation: a) provision of information and education about fear and physiological sensations and b) instruction in how to self-record and track fear responses, using a “scientific approach” 2. Teaching Coping Skills: a) cognitive restructuring or threat forecasting to challenge myths or unhelpful thinking styles associated with fear and b) breathing skills training 3. Exposure Exercises: a) repeated and graded exposure to situations in which fear or physiological sensations are anticipated 4. Planning for the Future: a) discussions about symptom return and relapse prevention.","e":[55,-5,-176,-37,80,6,78,-3,52,-26,15,6,76,55,7,-29,22,-51,-42,-9,-67,-47,5,-18,-10,14,-29,-5,-12,-26,41,-19,-9,-40,-17,-60,56,26,-25,1,52,-29,21,-65,7,31,61,0,13,-4,48,-50,13,-26,107,30,15,7,-3,-81,98,99,-56,25,21,5,-75,81,-4,18,42,0,8,58,-37,-17,-25,-52,-21,70,21,13,76,-32,56,-11,-20,11,-20,61,9,11,36,40,-58,25,-20,-2,-28,-26,-61,-27,28,-29,-9,-20,9,-10,41,12,-87,62,-44,17,-1,14,58,-46,3,72,7,0,34,46,-2,37,-78,-27,1,-42,55,-55,-3,5,39,74,10,12,-2,33,39,-5,5,12,0,-7,11,-26,-31,-34,15,27,-2,29,82,-32,-27,1,54,53,54,4,-17,35,-46,-51,17,12,45,19,-70,-68,5,17,16,22,69,-48,-11,-58,66,-23,51,50,20,-30,28,-10,-28,-45,8,0,-50,-15,-92,-67,18,-39,38,-37,7,28,-49,19,-30,87,-41,-4,-30,-41,60,-23,0,3,-13,-10,-14,-7,-51,11,4,-16,-31,-37,13,20,-33,-33,9,49,-13,-65,22,-6,-1,37,9,22,5,27,12,25,48,5,-48,-29,33,-34,6,29,-19,16,48,10,41,16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.104","t":"INITIAL STEPS: BUILDING THE FOUNDATION Assessment and Psychoeducation Initial steps should focus on gathering information about patients’ symptoms, feelings, thoughts, and behaviors regarding the feared stimulus. Specifically, you need to clearly understand factors associated with the onset and maintenance of symptoms (i.e., precipitating circumstances, symptom duration), as well as alleviating or exacerbating factors. Figure 14.2 is an example of how to assess for this information. 104","e":[47,23,-176,-39,75,17,92,33,37,-42,-7,13,55,72,-23,-20,37,-74,-29,18,-41,-31,-10,-7,9,36,-23,-11,-36,22,17,3,30,-27,-22,-75,52,33,11,-50,13,-29,31,-95,-3,16,38,-2,48,12,19,-22,16,-3,87,72,16,3,24,-65,97,63,-83,48,22,-18,-18,39,9,1,34,-17,12,27,-30,33,-4,-21,37,46,51,-18,100,-67,49,21,-21,22,13,87,8,36,1,29,-79,-2,-40,7,-19,-42,-43,-36,1,-45,29,-4,-12,10,8,-7,-54,61,-24,-34,11,11,44,24,-21,51,-24,-2,41,86,23,36,-53,-22,44,-11,38,-29,-23,-14,17,92,2,29,-5,3,37,20,-9,-14,-35,-15,45,-21,-15,-11,-32,33,-10,19,54,-52,-24,-5,45,7,71,19,-22,56,-11,-56,26,0,38,19,-40,-23,13,9,7,33,93,-52,24,-14,41,-57,32,64,-3,-55,18,-13,-35,-31,-5,1,-73,-27,-57,-44,10,-27,31,-28,-8,4,-64,34,-51,113,-38,-14,-14,-9,54,-36,-21,-9,-15,-15,-22,-12,-30,21,3,-1,-14,-49,0,32,-53,-26,-31,19,-12,-107,55,5,14,6,-15,-19,13,27,-10,50,55,24,-58,-15,17,-14,-42,16,-4,-3,7,32,33,-35]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.105","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 Figure 14.2. Example Anxiety Assessment Handout Physical Signs: How does your body react to worry/stress? [ ] Muscle tension [ ] Shaking/trembling [ ] Rapid pulse [ ] Sweating [ ] Shortness of breath [ ] Other: _____________________ [ ] Butterflies in stomach Thoughts: What is running through your mind (including areas of concern)? [ ] Health (own and others’) [ ] Daily events [ ] Finances [ ] Work/volunteer [ ] Issues related to aging [ ] Other: _____________________ [ ] Family/friends Behaviors: What actions do you take to reduce worry/stress (e.g., such as avoiding feared situations or doing something over and over)?","e":[18,8,-156,-37,85,11,55,31,24,-62,-4,27,67,41,30,-35,7,-47,2,8,-35,2,-38,31,-8,71,13,29,-37,-27,26,-24,9,-54,-60,-45,80,47,-21,32,72,-32,6,-59,-7,4,86,26,42,24,8,-47,23,-30,124,40,28,3,32,-20,82,41,-58,56,76,-45,-47,68,-17,47,71,-29,39,39,-60,-1,-68,-3,4,25,23,-7,74,-20,49,4,1,-16,-21,85,24,17,6,24,-72,53,31,-42,-37,-69,-45,2,-15,-34,-13,-1,-26,-22,6,8,-50,42,-29,8,10,-18,57,-24,-18,56,27,18,8,25,24,32,-28,12,26,-48,32,-18,-32,-10,-1,60,-36,22,15,-18,50,8,-22,-21,-9,-19,22,-30,-35,-52,-12,11,9,-1,43,-2,-30,26,40,45,43,-3,-28,58,-32,-49,39,63,51,41,-44,-58,-17,23,31,16,74,-29,38,-56,18,-9,45,44,-13,-21,22,-14,-51,-49,-3,25,-50,-17,-40,-63,13,-13,14,-28,3,-1,-3,18,-47,49,-13,-19,-4,-87,76,-46,-25,35,-9,11,-26,-28,-11,3,-4,-24,-8,-26,1,24,-23,-28,-3,19,-4,-65,65,22,-25,11,12,36,9,6,20,40,47,20,-43,36,-8,-47,5,55,-32,20,49,23,33,-33]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.105","t":"Psychoeducation is critical to provide an accurate foundation about fear and to help avoid misunderstandings. You should provide the patient with a comprehensive understanding of the fear response, including symptoms related to fear responses, mechanisms that maintain symptoms, and common myths associated with exposure treatment (see Table 14.2). Symptom monitoring, a foundation for symptom management in CBT, should be introduced through structured worksheets and exercises. 105","e":[34,26,-174,-21,95,24,77,54,74,-17,9,-2,63,37,-19,-33,-4,-60,-65,8,-53,-48,17,-4,5,31,-10,9,0,34,48,8,44,-5,-26,-64,53,28,5,-5,52,-19,16,-122,-7,15,37,16,23,23,17,-91,48,-26,141,39,27,9,-11,-92,113,65,-70,28,31,-9,-59,48,-33,18,38,-38,20,56,-28,-6,-17,-43,11,50,22,-12,43,-43,61,8,-6,2,7,83,6,3,21,36,-47,14,-8,-3,-17,-15,-66,-21,9,-32,32,-10,0,2,41,-3,-64,62,-27,4,-5,-15,36,-45,16,50,13,16,30,63,22,17,-35,-30,30,6,21,-37,-13,10,27,92,17,16,3,21,54,15,5,-3,-21,-30,18,-22,-34,-8,11,33,-27,21,69,-43,-19,-8,73,21,56,7,-27,23,-10,-67,17,-4,45,32,-62,-30,21,7,36,21,71,-45,35,-31,54,-21,61,49,25,-7,20,-49,-23,-42,7,7,-63,-14,-79,-47,9,4,31,-43,-20,15,-15,14,-43,79,-39,-12,-28,-51,59,-32,27,15,-8,-14,-15,-24,-39,22,1,11,-23,-25,-8,14,-25,-53,-11,37,11,-104,71,-3,5,43,1,-6,17,16,19,17,30,21,-36,-7,10,-36,-42,-3,-11,-9,30,27,48,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.106","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 Table 14.2. Common Myths Related to Fear and Exposure Myth Fact Anxiety is not very Nearly one in five people experiences some type of anxiety common. People with disorder in any given year. Anxiety and stress happen to us all. anxiety are weak. Anxiety will get better Anxiety and fear lead to avoidance, which maintains the over time if you just response over time. Exposure and facing fears and anxiety leave things alone. are effective at reducing anxiety and fear.","e":[28,36,-190,-13,86,40,37,24,50,-25,-19,31,72,60,19,-4,-15,-37,-25,8,-48,-26,0,-9,-33,70,-36,-12,-11,6,77,-29,-2,-60,-37,-35,42,50,20,-1,107,-26,24,-39,-13,4,69,47,35,5,52,-88,33,-20,104,32,-12,26,12,-50,84,4,-59,27,47,18,-67,97,7,22,43,6,7,37,-74,5,-9,-28,-12,54,68,0,49,-37,62,23,-1,-15,-21,59,48,-7,24,45,-46,47,-26,-30,-54,-16,-46,6,22,-6,-11,-5,-17,-16,1,38,-98,54,-32,-20,-2,-15,71,-36,23,23,-14,38,25,48,20,30,-27,15,39,-51,7,-37,-38,1,27,74,-26,35,-7,45,42,20,16,-35,-23,-12,13,-41,-57,-25,23,21,-10,51,20,-18,-28,9,59,21,33,4,13,20,-49,-53,37,56,27,42,-36,-62,-23,8,38,-15,69,-26,11,-46,59,-24,33,23,18,-21,48,-15,-40,-75,8,-12,-31,-20,-65,-71,30,3,32,-19,-14,3,3,2,-33,80,-21,-34,-6,-91,55,-27,-44,33,1,-15,15,-33,-20,6,-14,-8,-34,-29,18,19,-23,-23,1,20,8,-79,72,5,-16,37,33,26,11,-5,-9,30,45,32,-37,15,-31,-35,23,36,-37,15,30,5,38,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.106","t":"Most anxiety conditions can be treated effectively in 10- Therapy for anxiety will 12 weekly sessions. Anxiety reductions can often be seen take years. within the first weeks of therapy, and some providers offer abbreviated treatment that involve four to six sessions. A panic attack can Fainting usually occurs from a sudden decrease in blood make you lose control pressure and is not associated with panic attacks. or pass out.","e":[59,42,-184,-6,55,-14,20,46,69,-37,-26,15,34,27,13,-24,12,-31,-82,-18,-49,-6,-22,-41,-31,54,-16,23,-18,33,65,2,5,-42,-35,-55,57,52,24,0,70,-36,63,-72,-22,-41,66,14,0,-22,35,-50,-43,-37,51,42,-38,17,39,-12,109,-20,-67,42,80,-10,-65,60,-7,-1,42,-34,33,19,-45,2,-35,-26,19,28,35,-37,88,-33,62,12,-21,6,-8,83,5,40,13,34,-62,18,9,-4,-73,-63,-48,19,-1,-45,-1,-26,0,6,-5,8,-57,69,-28,-6,3,-22,55,-27,32,-11,-24,-16,15,19,44,15,-28,57,17,-24,-11,-29,-40,26,7,41,6,12,-14,15,46,11,-7,-32,-27,-26,17,-43,-25,11,3,12,32,39,10,-46,-36,2,67,19,72,6,-11,79,-60,-43,17,52,0,-6,-18,-10,1,13,45,39,78,-33,22,-29,49,-12,10,2,2,4,29,-42,-50,-75,26,5,-18,-2,-26,-32,46,-33,8,-15,-32,6,-8,3,-1,75,23,-19,-27,-55,56,-50,-4,11,-17,-25,-33,-25,-7,71,5,7,-13,-62,7,9,-35,6,30,-17,-10,-64,20,-22,-23,16,-5,4,-14,39,-1,51,43,35,-69,19,-59,-30,-9,4,-34,16,30,5,9,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.106","t":"Avoiding stress often leads to immediate reductions in Someone with anxiety anxiety but creates a host of additional problems, including should avoid situations avoidance and continued fear responses. Often, what feels that cause stress. natural (e.g., avoiding stress) actually turns out to maintain or make anxiety worse.","e":[55,32,-147,7,89,47,46,17,36,-34,-57,33,58,42,44,-17,6,-25,-15,-18,-26,-23,1,-20,-32,71,-7,-5,-25,19,82,-5,8,-57,-34,1,36,87,23,-15,30,-54,21,-46,2,-44,80,50,57,-28,68,-67,-44,-27,99,6,9,49,49,-21,65,30,-54,63,46,-23,-47,63,8,61,42,14,7,35,-47,7,20,-7,3,35,49,-31,54,-72,89,34,11,-38,-32,70,12,24,49,21,-82,70,8,-2,-55,-40,-25,11,25,-19,13,-44,18,-5,1,30,-68,103,-5,-21,13,3,70,-26,34,22,-32,15,3,48,17,39,-31,26,74,-33,-21,-33,-23,12,14,51,-55,11,14,7,51,31,-13,-29,-35,-43,19,-20,-36,-25,-12,0,-30,60,53,-3,-39,1,70,2,62,-57,0,52,-12,-32,27,41,-8,37,-21,-43,-2,19,53,23,84,-34,40,-48,19,-33,22,4,21,-30,26,7,-75,-65,-3,-13,-18,-10,-55,-71,32,21,32,14,-36,-29,-9,-32,-36,81,15,-51,9,-83,42,-32,-43,2,18,-26,6,-24,-33,46,-12,-19,-15,-25,7,8,-24,-19,-39,-23,-7,-72,64,0,4,31,10,37,-5,1,2,44,47,31,-6,30,-22,-37,1,-18,-18,35,9,-11,30,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.106","t":"Introduction to Exposure Treatment Actively inform your patients about the nature of exposure treatment (e.g., in-vivo, imaginal, or interoceptive exposures) and a rationale behind the approach. It is important to communicate that exposure exercises will be done gradually, in a predictable manner, safely, and under your control as the provider. Exposure therapy yields positive outcomes when done correctly and when the patient understands the rationale. Often, patients may feel that exposure therapy is daunting or overwhelming. Regularly check-in with patients before and during the process to ensure that patients display high levels of self-efficacy to complete the exposure process. You should refer to other modules in this guide outlining other skills to address concerns that may impede success with exposure therapy (i.e., cognitive restructuring, relaxation).","e":[20,29,-176,-47,37,-9,87,8,50,12,-8,25,63,62,23,-19,32,-75,-13,46,-62,-45,-26,8,-5,40,0,-31,-7,-27,46,-36,-11,-32,-37,-52,53,65,-1,-9,23,-24,31,-69,2,30,88,20,16,-13,47,-58,-44,-1,113,-6,-4,26,22,-79,82,58,-54,23,38,2,-56,59,3,-14,52,6,49,32,-29,12,-1,-25,-36,23,14,-4,79,-48,71,13,19,-12,-41,36,46,15,9,28,-127,-16,-39,11,-69,-30,-65,-12,19,-16,-10,49,35,6,6,20,-56,19,-14,-14,10,-23,77,-60,45,19,0,4,25,25,6,10,-97,-50,19,-24,13,-25,-51,2,25,62,17,-5,-11,-10,9,15,6,14,-13,-25,12,-30,-7,3,23,35,24,29,49,-73,-53,-22,16,12,59,19,-42,33,-24,-18,18,44,24,2,-36,-47,6,9,73,-4,101,-57,-20,-62,47,-35,2,7,21,-16,42,-4,-50,-30,13,24,-21,-20,-81,-40,50,-31,48,-21,-9,35,-28,30,-56,88,-18,-35,-28,-25,56,-44,1,39,2,-11,-1,-30,-72,17,43,-13,2,-41,16,-13,-66,24,10,24,-30,-78,11,20,-7,6,2,33,-2,33,-1,29,30,6,-76,-5,15,-34,-5,39,-20,16,14,-13,18,19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.106","t":"Receiving benefits from exposure therapy requires continued practice in-session and between sessions. The more the patient can complete exposure exercises, the more their fear will begin to decrease. Habituating to fear is a learned process that has to be reinforced over time. You and your patient will practice exposure in session, but the patient will have to practice exposure exercises three to four times each week, depending on the activity. 106","e":[22,33,-200,-42,40,-15,73,19,68,-9,-42,24,29,40,34,8,27,-88,-58,-3,-51,-41,-4,-11,-36,34,-2,-24,-12,-3,77,-42,-9,-52,-3,-66,72,52,-4,-28,42,-16,28,-40,10,-19,67,9,13,4,41,-69,-41,17,108,22,-15,-18,17,-75,106,40,-80,27,33,28,-49,77,-8,7,30,-1,0,19,-33,-22,-14,-33,-36,50,14,-4,62,-47,96,15,-30,0,-24,73,49,14,27,59,-90,-28,-3,29,-49,-21,-54,-14,47,-33,2,19,24,12,21,39,-80,43,-23,-17,-14,-8,51,-54,-6,14,-38,9,8,51,-11,27,-56,-19,10,-13,16,-26,-41,34,43,50,10,9,-22,45,12,21,24,4,2,-7,20,-65,-14,17,18,20,5,32,69,-67,-39,-6,65,21,46,-9,-4,19,-26,-54,3,81,9,-5,-12,-65,-6,-31,30,8,50,-54,-19,-50,42,-38,11,18,35,-11,32,-36,-48,-57,21,8,-29,-5,-60,-59,49,-24,28,-37,-7,25,-29,14,-24,73,-33,-38,-18,-52,45,-24,-41,34,11,-34,-6,-13,-49,44,32,-6,-37,-58,-5,14,-38,-15,22,52,-25,-67,13,-14,-14,17,18,21,0,3,9,15,29,4,-40,15,12,-14,4,28,-24,39,6,-16,30,45]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.107","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 Collaboratively Building a Fear Hierarchy Collaboratively building a hierarchy of feared situations and formulating a treatment plan are critical steps for exposure. Leverage your patient’s daily symptom recordings (e.g., panic attack records, daily mood ratings, avoidance of stimuli reports) to facilitate a comprehensive fear hierarchy. The patient can use levels of anxiety, distress, or panic to identify a list of feared situations, animals, objects, or sensations. The patient should account or track distress over a period of time or use historical evidence to begin forming the hierarchy.","e":[17,29,-195,-50,93,6,44,18,-20,-35,-36,15,43,40,41,-10,-10,-14,-49,-19,-43,-32,16,10,3,51,-22,-10,-15,4,40,-3,11,-41,-35,-48,40,15,-25,19,78,-40,31,-105,-11,28,75,11,42,21,44,-58,30,-22,94,46,13,7,25,-55,108,67,-37,39,54,-4,-73,64,-40,-8,46,-14,32,30,-67,24,-40,-17,20,46,80,-33,75,-48,47,-36,-12,25,-18,81,3,9,17,66,-70,40,-26,-17,-37,-60,-76,-17,40,-29,-35,19,-16,-7,5,-3,-55,55,-34,-8,33,2,71,-19,-25,27,10,7,8,31,6,59,-58,19,33,-44,17,-27,-39,-14,29,80,-21,23,19,24,28,3,-23,-11,20,-20,15,-44,-50,-15,-15,25,-15,37,54,-11,-22,11,31,30,44,-3,-15,31,-23,-52,42,49,58,48,-43,-54,18,10,32,12,61,-56,18,-59,63,-20,57,32,3,-3,19,-20,-3,-50,19,0,-49,-25,-63,-53,13,-25,37,-43,8,15,-24,32,-42,89,-5,3,-3,-53,51,-46,6,0,-33,-23,12,-27,-43,20,-4,8,-46,-49,9,1,-21,-14,-13,-9,-9,-78,23,-33,4,46,-2,24,12,44,8,23,37,-18,-69,28,-16,-8,-4,51,-43,-1,29,-31,30,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.107","t":"You and your patient will work together to decide target stimuli for the exposure exercises in treatment, based on the patient’s presenting concerns, reported symptoms and case conceptualization. Once stimuli are chosen, work with the patient to create specific and detailed targets to base exposure exercises on, ranked by SUD (subjective units of distress) levels. These targets should be detailed enough for you to create an exposure exercise tailored to the patient’s fear. You should work to understand why the patient fears certain stimuli. For example, a patient may fear and avoid going to grocery stores. The fear could be because the patient has social anxiety and fears embarrassment. Or, the patient could fear having a panic attack in the middle of the store in front of others and not being able to escape. As part of the construction of the fear hierarchy, you must also attend to patient safety behaviors that contribute to the maintenance of anxiety and may undermine future exposure exercises.","e":[19,43,-200,-37,65,25,59,8,41,-25,-26,44,63,36,33,18,44,-63,-53,-28,-63,-43,-15,-16,-15,46,-8,-16,3,9,51,9,2,-53,-25,-59,57,54,0,26,22,-39,13,-88,17,29,40,-10,84,23,28,-77,-33,-30,84,18,28,29,49,-17,83,47,-66,5,62,24,-66,65,-19,11,42,17,30,21,-73,30,6,-31,-7,52,31,-1,54,-59,78,-17,-2,25,-41,67,37,19,41,66,-109,8,-22,12,-26,-33,-56,-13,38,-30,-11,-4,27,19,11,-10,-33,68,-59,-12,18,-5,66,-55,-4,25,19,14,14,53,13,5,-77,13,35,-47,28,-47,-62,-4,18,59,-3,4,-15,10,8,30,-6,-29,10,-30,28,-39,-58,3,-9,22,4,33,60,-80,-29,29,27,23,86,-9,-14,34,-29,-63,19,37,41,14,-58,-73,18,-2,24,12,59,-41,-2,-32,43,-53,57,9,25,-9,39,-15,-43,-45,33,0,-22,-30,-75,-58,15,-17,41,-9,0,19,-48,16,-51,81,-36,-5,-4,-54,36,-53,-2,19,-7,-34,4,-16,-72,11,20,-28,-18,-39,23,5,-63,14,6,38,-32,-57,49,-2,-8,18,19,36,15,3,-8,12,23,33,-45,44,-3,-27,-13,40,-51,19,20,-14,39,26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.107","t":"Figure 14.3. Example Hierarchy Targeted avoidance behavior: Avoiding grocery stores with too many people MORE DIFFICULT Buying a full list of groceries at the store by myself around 6pm Buying multiple items at the grocery store in the longest line at 6pm Buying one item in the grocery store around 6pm after 10 minutes Walking around the grocery store for 10 minutes by myself around 6pm Walking around the grocery store by myself around 11am EASIER Walking around the grocery store for 10 minutes with a friend around 6pm 107","e":[-16,68,-215,16,44,23,75,-40,17,29,-58,34,35,68,25,-7,7,-19,-18,31,-32,2,-8,-65,-5,21,20,-1,-7,45,-32,-26,8,-62,-46,-76,40,6,20,-29,20,23,49,-66,24,10,91,56,76,-41,16,-17,-51,1,33,-21,45,44,0,-28,111,45,-24,63,75,9,-34,57,-32,-10,47,-26,-19,-20,14,12,-35,-13,23,77,15,0,50,-45,28,-23,32,20,8,52,-4,18,30,35,-88,63,-34,17,-30,-51,-6,-7,6,-25,16,11,45,32,-25,-2,-40,38,-47,-7,0,38,83,-65,41,-25,-28,11,-21,47,-12,28,-95,50,2,-21,21,-22,-27,-10,-10,25,-2,29,28,37,47,23,19,-37,8,-68,26,-56,-37,-3,-37,46,-20,56,33,-36,-9,24,59,10,46,-24,-49,28,-41,-39,31,78,34,18,-48,-25,-3,4,6,-16,47,-33,-16,-27,63,-69,44,40,-4,-37,25,20,-41,-37,20,17,-40,-31,-59,-18,76,-15,20,-44,0,-59,-25,55,-19,59,-10,14,-10,16,31,-22,-7,-17,-10,-24,-16,39,-22,55,6,-45,-1,-12,67,-6,16,4,-40,5,0,-50,26,-32,-10,23,0,8,27,-6,14,41,40,28,-39,2,17,-26,-6,49,-17,54,11,-21,62,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.108","t":"INTERMEDIATE STEPS: EFFICIENT USE OF EXPOSURE An exposure activity is essentially broken into a series of seven steps. Exposure starts with a low-level feared exercise according to the fear hierarchy to prevent inducing a response too high for the patient to cope with and to increase the likelihood of the patient’s habituating to the response. Providers should ensure that safety behaviors are accounted for and monitored during the exposure exercise. Before and after the exposure, collect fear/anxiety symptom ratings as well as the patient’s cognitive and emotional response to the exercise to correct unhelpful thinking or behaviors, and commend the patient for completing the activity. Following successful completion of the exercise, work collaboratively with your patient to move up the fear hierarchy until symptom remission is attained. Repeated practice is critical for symptom remission.","e":[37,40,-214,-34,55,-13,92,16,50,2,-55,48,53,54,40,0,36,-82,-38,-17,-46,-46,-9,-4,-2,54,12,-19,-26,-15,72,-14,10,-61,-18,-53,48,46,-16,-24,34,-36,36,-42,15,0,65,11,42,15,45,-57,-27,8,87,42,9,-13,41,-46,72,37,-41,-6,49,5,-51,64,-6,-1,34,-29,11,17,-64,-2,5,-28,-5,31,19,3,99,-37,57,17,-20,15,-34,34,34,8,36,49,-95,-12,-17,47,-31,-47,-61,-41,34,-31,-20,24,22,8,22,32,-57,71,-32,-30,16,2,69,-25,-3,29,-21,-6,19,33,3,-4,-61,-13,16,-32,26,-36,-24,17,34,62,0,-3,-28,0,-9,4,-6,-41,10,12,33,-48,-20,-13,2,18,0,38,50,-63,-27,-2,36,15,61,-17,-14,42,-42,-45,27,42,41,10,-42,-73,-2,-12,16,-5,78,-69,-25,-44,57,-29,56,40,18,-35,42,-20,-51,-66,27,16,-55,-40,-82,-15,24,-26,26,-29,30,8,-31,17,-36,107,-27,-17,-7,-42,60,-17,2,10,-13,-13,-5,-29,-35,9,15,-17,-31,-52,32,27,-45,-35,-6,10,-21,-60,33,-16,-8,-10,17,20,13,19,-19,21,33,0,-60,32,-5,-24,1,42,-32,-12,11,2,47,18]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.108","t":"Treatment Duration and Frequency Exposure sessions may vary in terms of duration and temporal spacing as well as the level of involvement of the provider and/or significant others. Duration of treatment may be short or longer term. Shorter durations may include single sessions or abbreviated/ weekend treatments, but such work often uses longer sessions and may be facilitated through delivery in group settings where interpersonal learning is possible between patients. Temporal spacing of sessions may include the traditional one session per week over a period of four to six weeks (or more) but may also be spaced such that exposure is heavily weighted at the beginning—with high levels of provider involvement—and then tapered into less frequent sessions (greater spacing between sessions) and/or less involvement of the provider.","e":[32,49,-190,-71,-9,-28,50,-7,52,-31,-4,5,49,43,13,-62,3,-66,-58,37,-42,-22,-31,-46,-13,40,19,-4,-13,9,39,4,2,-29,-9,-101,34,24,14,-37,47,-31,48,-51,33,-57,49,62,-1,-18,5,-27,-51,0,96,8,-29,33,23,-6,119,31,-64,53,51,4,-19,50,11,-51,35,8,27,28,-5,-14,-23,1,-18,29,11,10,68,-62,60,20,-4,11,-5,83,6,-19,31,34,-113,-22,10,18,-41,2,-35,-8,54,-16,18,31,12,4,-1,13,-73,42,-29,8,8,-14,51,-75,40,5,-8,-38,-3,60,15,16,-49,4,-2,-2,-18,-1,-40,42,19,64,41,-29,-41,39,24,-5,4,-13,-16,-19,18,-74,-17,30,28,17,8,45,23,-58,-53,-9,39,34,33,-13,-31,29,-36,-35,5,42,-13,-25,-29,-65,-14,2,52,42,74,-58,-7,-27,23,-45,-19,-3,9,-8,46,-55,-54,-23,23,-7,-14,-26,-81,-63,48,-22,4,-56,-23,0,-40,53,2,82,-17,10,-48,-31,47,-21,-27,39,-7,-25,-35,-12,-46,56,50,-14,15,-64,53,-2,-44,25,-16,32,-42,-51,-8,-17,-31,12,22,-10,-3,26,0,22,10,0,-54,-8,-18,-35,8,44,-35,26,22,-13,20,4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.108","t":"An exposure exercise is typically completed in session, and then the patient is instructed to complete more exercises at home. The exercise consists of a series of trials. Each trial consists of the same level of exposure to the fear stimuli, over a period of time, within the same time frame. For example, the patient may complete 10 trials of sitting in a dark room for 20-second intervals within 15 minutes total. Or, the patient may read an imaginal exposure script you both created three times during 15 minutes. Ultimately, by you in collaboration with patients in terms of their needs and preferences of the patient.","e":[38,61,-213,-46,53,-15,77,0,43,0,-32,50,32,68,25,-27,23,-71,-45,-23,-38,-41,-63,12,-4,27,11,-26,-18,11,34,-20,8,-48,-6,-58,42,48,-8,-11,12,-40,16,-16,44,9,49,20,-23,-7,11,-62,-35,9,87,12,-23,-24,58,-38,97,16,-50,18,69,29,-49,70,20,15,42,-22,23,7,-49,-17,3,-32,-12,59,-5,9,65,-42,93,12,-22,-3,-22,45,74,14,32,48,-111,-27,-2,79,-40,4,-68,-22,42,-39,14,19,22,26,20,27,-47,49,-43,-3,-4,-6,81,-59,-6,1,7,14,26,43,4,-17,-68,-15,3,-29,18,-13,-42,21,32,43,23,-10,-71,16,-24,-5,-7,-8,15,-16,21,-53,-22,39,21,17,21,11,66,-78,-31,-14,23,35,61,15,-38,35,-43,-35,10,78,44,-14,-41,-86,2,-11,33,-2,69,-54,-25,-32,56,-44,9,-5,27,-18,37,-39,-49,-57,29,-25,-13,-6,-81,-36,37,-20,35,-13,19,11,-6,40,-18,94,-43,-34,-20,-36,55,-8,-16,33,16,-14,-14,-17,-39,10,51,-23,-18,-70,21,-6,-50,-15,-7,41,-31,-36,22,-23,-7,8,20,43,-10,7,0,-3,18,6,-78,1,18,-27,10,33,-25,16,20,-23,45,50]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.108","t":"Attention to Safety Behaviors Critical processes for exposure therapy require interoceptive and in vivo exposure as well as careful attention to the restriction of safety behaviors that undermine the exposure activity. Exposure requires that a patient tolerate and accept anxiety and fear rather than avoid it through compensatory strategies. For example, the goal of an exposure exercise is to learn to tolerate the distress associated with the feared stimulus. Other CBT skills such as cognitive restructuring and relaxation skills should not be used during an exposure exercise, as they can serve as “distractions” and may reduce the experience of the exposure itself, serving only to prolong or solidify the fear. Additionally, the use of anti-anxiety medications (e.g., benzodiazepines) has been found to complicate and even negatively impact treatment outcomes both immediately and over time.","e":[56,37,-165,1,71,10,106,20,66,-2,-13,29,62,45,50,-8,9,-67,-43,-13,-40,-37,-5,-15,-9,50,8,-16,-7,12,60,-2,-32,-65,-4,-59,66,89,-25,6,50,-22,14,-59,13,21,79,22,45,-4,89,-48,-23,-41,128,13,11,17,0,-68,95,36,-79,-22,44,-14,-64,69,-27,16,49,19,17,62,-37,-16,-1,-28,-9,41,11,-6,70,-36,70,13,2,-16,-26,51,35,4,31,26,-86,30,-11,-7,-43,-12,-45,-8,25,-13,-24,0,28,7,21,2,-73,70,-26,-14,5,10,78,-51,26,14,2,-18,17,30,-8,28,-82,-12,17,-34,-6,-27,-3,-2,-1,48,-18,-5,-14,30,26,26,22,-8,-17,-31,5,-32,-22,-10,1,28,1,48,73,-55,-27,7,48,23,54,10,-37,43,-38,-36,38,21,30,32,-85,-58,2,-6,67,30,79,-45,-9,-62,15,-26,15,30,11,-18,26,-13,-64,-33,32,24,-38,-26,-90,-79,41,-15,32,-18,-32,26,-34,9,-55,76,-31,-30,-19,-56,37,-33,-8,22,-17,-31,10,-13,-39,32,13,-12,-22,-44,7,1,-49,-16,18,30,-22,-58,33,15,-8,22,-2,40,13,3,-13,51,29,15,-42,19,-11,-20,-12,20,-48,16,20,-18,47,14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.109","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 More examples of safety behaviors: • A patient who goes to the grocery store only with a friend so the friend can stand in the long lines. • A patient who sits closest to the exit during meetings in case of a panic attack and they need to get out quickly. • A patient who carries paper towels in case they start sweating in front of others.","e":[15,38,-171,-19,83,18,72,-35,55,-30,-34,-6,20,39,25,-27,13,-74,-29,-20,-47,18,-6,-20,23,41,5,56,-40,-22,18,-8,-3,-77,-54,-71,53,45,-16,14,59,29,23,-81,14,-2,119,7,19,13,40,-47,15,-15,132,-1,51,48,-19,-21,71,48,-62,20,48,-6,-50,84,-27,11,46,11,26,41,-29,8,-35,22,0,72,11,3,56,-44,60,0,0,-21,-15,50,26,-5,13,28,-81,50,4,-25,-22,-52,-21,-56,24,5,-19,7,30,-11,11,5,-25,58,-22,6,29,38,58,-11,19,37,-15,3,-24,15,-1,44,-38,26,21,-23,-6,-9,-18,-27,-16,47,16,27,17,24,41,12,-4,-11,12,-55,14,-19,-39,-9,-38,22,0,80,36,-13,-22,28,63,21,45,-12,-68,20,-35,-43,22,40,40,58,-80,-78,-3,10,32,-1,41,-33,-6,-68,19,-21,30,50,17,-18,4,1,-59,-60,5,19,-42,-43,-73,-65,16,-13,33,-50,-18,-4,-28,53,-57,43,-43,9,-2,-53,55,-21,-27,1,-46,-20,-14,22,-45,24,8,-23,17,-22,37,19,4,-14,-17,24,-61,-41,30,-2,-5,1,-14,41,27,-9,28,70,34,5,-31,18,-23,-46,45,37,-21,15,36,-13,16,-3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.109","t":"Steps of Exposure Exercise: 1. Choose exposure activity (e.g., interoceptive exposure, in-vivo exposure, imaginal exposure) a. Imaginal exposure i. Goal: Indirectly increase tolerance of a feared object or situation to allow a corrective learning experience through vivid imagination. ii. You choose this exercise when real-life exposure to that feared stimuli is not feasible or would be too intense for the patient to do at that time. iii. Imaginal exposure consists of you and your patient writing a detailed scenario of the feared stimuli, in first person. The scenario should include vivid details that tap into the patient’s specific fears and include the worst possible outcome of the feared situation. The patient reads the script completely as one trial of the exposure. iv. Examples: Imagining standing on top of a skyscraper, imagining talking to a friend, imagining a traumatic experience from the past, imagining taking a plane ride, or imagining not locking the house door b. Interoceptive exposure i. Goal: Increase tolerance of a feared bodily sensation or physical response to allow a corrective learning experience. ii. You would choose interoceptive exposures when the feared stimulus is experiencing a bodily sensation. The patient will build tolerance to a specific sensation with repeated exposure over time.","e":[38,47,-195,-53,24,6,72,23,27,-1,-17,40,73,91,21,7,22,-100,-29,-10,-58,-42,-26,51,-17,22,10,-43,-38,-3,37,-37,9,-24,-6,-59,38,77,3,-19,12,-24,31,-22,32,24,78,-6,34,-9,44,-54,-16,-18,115,18,7,-21,23,-55,88,44,-31,2,43,20,-85,81,-18,-11,46,-13,22,38,-58,8,-10,-32,1,50,-8,21,108,-40,77,29,12,-11,-45,37,42,19,37,26,-90,-25,-22,76,-26,-16,-64,-30,38,-56,-11,34,41,4,19,4,-40,24,-33,-20,20,7,50,-49,27,42,-16,2,30,59,-4,5,-75,-54,-1,-53,31,-25,-28,6,20,61,10,-9,-32,2,-7,-29,-8,-20,-27,-32,13,-34,-21,19,11,47,35,4,57,-57,-40,-10,24,12,49,15,-37,48,-19,-23,25,55,48,-14,-50,-66,2,19,32,-20,48,-63,-31,-30,59,-48,24,22,11,-35,11,15,-43,-26,0,0,-27,-37,-82,-27,46,-24,21,-12,19,23,-32,16,-52,82,-28,-52,-25,-15,58,-3,-18,4,7,-4,4,-19,-67,-17,54,-8,-11,-52,19,-3,-50,-14,4,30,-30,-64,41,-10,-2,9,-10,42,-8,0,2,8,20,0,-72,9,22,-41,2,53,-14,18,7,-9,24,48]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.109","t":"In Session Example 14.1 Feared Sensation Exposure Activity Racing heart Jumping jacks, running in place, push-ups Dizziness Shaking head, chair spinning, twirling in place Shortness of Straw breathing, voluntary hyperventilation, breath stair climbing Derealization/ Staring at self in a mirror, voluntary hyperventilation, dissociation staring at a fixed point on the wall 109","e":[49,59,-201,-7,59,-15,76,17,38,-42,-34,35,25,76,29,-29,-9,-77,-52,-15,-61,-20,-34,10,13,59,-1,-24,2,-2,36,-35,30,-13,-41,-52,48,28,12,24,34,-67,25,-48,-15,1,82,7,38,6,57,-42,-17,-49,112,29,63,-12,27,-14,55,1,-14,14,54,-4,-51,85,-21,13,61,-6,3,38,-80,30,-37,-20,3,41,-13,16,61,-48,111,9,-29,48,4,43,8,9,20,34,-97,6,30,46,-18,-37,-56,-14,-5,-46,28,20,-13,-4,-2,-12,-46,59,-33,-2,15,-17,57,-12,3,35,4,17,-34,63,0,18,-69,-29,1,-40,25,-31,-44,1,32,45,-1,-11,-6,-8,64,-6,1,0,-25,-60,42,-52,-37,-26,9,1,13,6,65,-54,-44,32,17,20,37,-8,-26,37,-33,-73,30,85,50,43,-58,-47,-17,17,12,25,52,-60,-28,-10,78,-30,8,14,19,-43,25,-4,-63,-18,-29,14,-26,-66,-44,-54,32,-27,27,-6,6,15,-21,13,-42,60,-28,15,-11,-30,70,-29,-4,-9,-20,-18,10,-22,-33,12,31,-36,-8,-58,37,1,-34,-24,11,21,-21,-64,53,-18,-11,-15,-3,46,7,-5,5,30,2,-23,-72,14,-15,-32,10,42,-49,31,46,-22,27,31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.110","t":"c. In vivo exposure i. Goal: Directly increase tolerance of a feared object or situation to allow a corrective learning experience in real life. ii. Choose this type of exposure when the patient is ready to build tolerance in situations that are accessible in real life. These exposures can be conducted during the session but often will be planned for the patient to complete in between sessions. iii. Examples: Staying on an elevator, remaining in dark environments, being surrounded in crowds, purposely standing in long lines, holding a snake, touching a spider, giving a speech in front of an audience, or talking to a stranger 2. Monitor safety behaviors. a. It is important to help patients understand safety behaviors (i.e., overt behavioral or covert internal thoughts and beliefs) and signals (i.e., internal or external cues of safety) as an unhelpful part of their fear response that maintains their symptoms. 2. Assess for anticipatory anxiety subjective units of distress (SUDs). a. It is important to help patients understand their levels of anxiety and distress as they complete exposure exercises in-session as well as homework assignments. SUDS range from 0 to 100 and function as an emotional thermometer, where 0 is perfectly relaxed, and 100 is the worst anxiety and distress ever experienced. b. It is useful to rate SUDs before beginning an exposure exercise. 4. Conduct exposure with specified duration or trial number. a. It is important to agree upon the number of exposure trials as well as the duration of such beforehand. b. It may be best to think of duration in terms of the cumulative length of time of an exposure exercise as well as the amount of time it may take for SUDs to decrease to a sufficient level. 5. Assess for SUDs/intensity of sensations. a. The general goal is for the SUDs to reduce across the repeated trials. b. The amount of reduction will depend on the patient’s first exposure exercise. 6. Process patient’s feelings, thoughts, and associated SUDs over time 7. Complete exposure process repeatedly, until SUDs reduce to the agreed level.","e":[50,28,-202,-41,55,0,85,14,24,-19,-7,42,66,58,52,-31,40,-66,-34,-24,-61,-39,-17,22,-9,58,-6,-8,6,-11,44,-18,-4,-24,-30,-68,41,89,-3,1,23,-43,26,-54,4,39,51,-6,73,-23,43,-63,-16,-7,134,5,3,21,14,-33,88,32,-73,-1,53,22,-62,60,-21,12,46,11,-8,30,-44,8,-8,-29,-13,55,9,19,58,-38,95,6,-10,5,-52,72,48,37,23,30,-88,12,-16,24,-19,7,-52,-13,38,-22,0,6,21,-11,12,-8,-49,51,-60,-11,27,0,76,-31,1,43,7,12,20,60,22,40,-71,-12,34,-9,15,-15,-46,6,36,85,-7,-22,-19,23,25,13,-13,-31,-13,-28,37,-40,-29,15,10,49,1,8,43,-53,-39,-3,37,32,56,22,-51,36,-44,-49,12,21,28,6,-66,-56,19,18,12,17,74,-37,-27,-39,42,-44,30,11,1,-13,52,-30,-53,-37,19,0,-38,-31,-104,-65,40,-18,32,-31,-15,14,-55,2,-47,56,-26,-34,-24,-44,65,-30,-2,8,-23,-25,2,-15,-36,-5,32,-30,6,-21,9,10,-44,-15,23,33,-46,-63,30,4,-13,16,9,43,1,-9,2,21,-3,29,-71,24,4,-49,-15,64,-53,24,42,0,34,26]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.110","t":"You may find it difficult to develop an effective hierarchy and might struggle to identify an exposure exercise that leads to an appropriate level of intensity. As with other treatment types, trial and error (with reflection) and clinical consultation are critical to modifying and refining exposure-based treatments.","e":[33,27,-181,-28,70,19,72,0,51,4,12,5,78,50,24,-28,23,-71,-18,26,-65,-64,-31,-33,-8,16,-6,-43,-27,-15,29,-15,28,-51,-12,-51,53,62,9,-13,32,-32,8,-64,6,3,46,43,33,-8,58,-63,-20,-2,85,24,10,35,42,-61,86,67,-66,26,42,3,-71,51,-28,-40,51,-12,50,32,-41,-23,9,-55,6,40,5,-7,107,-38,39,16,6,12,6,44,45,35,24,47,-146,-9,3,24,-37,-17,-63,-14,47,-6,24,17,41,27,-22,-2,-59,44,-43,-32,2,-22,89,-36,6,22,2,-26,22,63,-3,2,-68,-18,8,-59,2,-34,-12,14,39,64,-2,-35,-25,-15,15,17,18,4,30,-7,31,-22,-6,12,28,17,-6,12,15,-67,-42,17,39,8,61,-14,-51,6,2,-46,10,50,32,27,-33,-40,30,-3,66,21,74,-69,11,-60,18,-39,-17,-12,13,-24,56,-55,-44,-44,6,30,13,-32,-72,-35,53,-30,31,-27,23,16,-23,46,-43,115,-21,2,-48,-40,58,-25,24,36,0,-34,-28,-38,-73,45,26,-20,-20,-35,9,3,-47,9,1,17,0,-79,25,9,3,-7,25,11,19,52,-10,37,42,-26,-42,25,17,-13,-12,40,-13,19,21,-19,8,52]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.110","t":"Exposure may require modifications depending on the feared stimulus. For example, it is common for patients with blood-injury-injection phobias to experience a fainting response (a physiological reaction that is associated with increased heart rate and blood pressure) during exposure exercises. Prior to exposure exercises, counter measures or techniques such as applied tension strategies (tensing the large muscle groups) may be required to reduce heart rate and blood pressure spikes and, therefore, avoid a fainting response. 110","e":[80,70,-208,-9,83,9,40,36,57,-37,-13,51,38,50,15,-16,19,-98,-16,-19,-69,-33,-31,34,14,29,4,-9,-28,11,46,0,7,-60,-24,-13,38,50,21,53,16,-42,41,-43,-16,-6,63,4,29,3,59,-56,-25,-51,86,3,31,-26,16,-64,64,21,-28,-7,57,-8,-59,75,4,22,12,-4,2,27,-25,27,-37,-39,-2,27,0,20,82,-25,113,2,-12,-25,-30,84,42,9,66,21,-79,47,31,37,-16,-33,-70,-8,13,-36,-29,-13,12,-5,16,-7,-54,54,-21,-41,14,-11,57,-46,-22,28,-34,-19,10,64,-6,14,-67,-17,12,-64,13,-44,-40,-9,41,20,-3,23,-11,1,26,18,41,-38,-25,-11,30,-32,-6,-8,19,44,-4,27,20,-57,-55,24,28,6,75,-2,-15,45,-19,-49,49,68,29,30,-48,-44,12,7,11,9,57,-70,0,-41,55,-58,25,10,-4,-25,32,15,-68,-59,-10,22,-2,-55,-55,-62,16,-15,30,-24,-18,7,-24,-17,-25,76,-21,-23,-17,-32,57,-26,-6,11,4,-17,-4,-25,-31,40,11,-16,-24,-31,16,-4,-29,-18,26,-16,26,-60,51,-8,-42,0,25,32,-9,-37,-8,21,32,19,-48,40,-7,-30,-5,-7,-29,15,4,16,30,27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.111","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 14 TERMINATING STEPS: ADVANCED PRACTICE CONSIDERATIONS Dealing with Setbacks Setbacks are also learning experiences if handled accordingly. You should prepare your patients for setbacks, as they are a normal and an expected part of growth and development. Building a foundation that includes setbacks helps to ensure open communication between the provider and patient about both positive and negative therapy experiences. If patients accept that setbacks will occur, you will be in a strong position to use any setbacks as growth and development for building skills and maintaining future changes.","e":[22,40,-161,-48,60,25,47,24,55,-33,-34,-12,50,-1,29,-37,29,-39,-4,18,-25,1,-7,-2,-20,57,-12,47,-45,-3,73,-26,31,-26,-38,-21,75,10,-55,-63,72,-20,1,-89,22,-5,106,40,8,5,41,-80,1,-41,126,29,22,54,-4,-50,72,55,-58,59,17,-34,-26,43,-5,-1,49,-11,30,24,-47,4,-37,2,-18,57,5,-15,99,-24,40,19,7,3,-41,89,10,-9,-2,1,-90,12,-4,-2,-22,-43,-55,-20,9,-34,0,48,10,-27,28,2,-57,34,-41,-8,-14,17,32,-41,-1,27,-1,10,10,23,39,64,-58,-19,40,-38,0,-7,-50,-17,37,48,16,-31,21,15,34,25,-20,-17,5,9,29,-27,-42,14,-5,12,-17,34,76,-40,-14,-12,65,8,62,-10,-95,12,-24,-40,-1,36,43,40,-33,-46,17,14,61,32,64,-29,-19,-65,12,-19,34,68,-5,-8,0,-57,-41,-38,25,18,-16,0,-40,-50,44,24,24,-7,3,54,-50,23,-60,45,-18,18,-40,-41,69,-13,3,24,-14,-11,-3,-6,-29,18,7,14,-29,-26,24,6,-2,-16,-18,15,-43,-79,35,-7,29,6,8,0,11,38,26,56,40,9,-88,14,25,-36,-9,39,36,3,32,9,0,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.111","t":"Involving Others Significant others can have a positive or negative impact on the maintenance of fear and anxiety. Although others may provide invaluable support for a specific treatment plan, they may also serve to unknowingly maintain anxiety by providing safety and support during critical exposure work. Providers who directly involve significant others in anxiety management treatments must ensure that communication is effective. Others involved in the care plan must have appropriate psychoeducation about anxiety and fear and ways anxiety is maintained.","e":[26,26,-156,-21,62,58,-4,-14,58,-4,-43,21,40,56,42,24,34,-20,-72,15,-74,-71,-2,-3,2,23,34,-27,-28,19,72,31,-25,-73,-28,-32,45,54,6,-3,97,-1,5,-80,1,-13,63,-3,69,27,72,-49,-6,12,88,10,16,33,17,-46,98,46,-79,20,51,-22,-69,35,3,17,28,1,52,15,-64,23,0,-15,10,12,73,-34,80,-56,41,22,45,-42,-31,69,58,28,5,59,-77,28,-23,-39,-68,-31,-27,5,35,15,-18,28,4,28,18,46,-62,27,-18,3,23,-46,71,-75,23,21,10,29,5,22,6,34,-34,25,50,-26,-3,-42,-14,-14,13,53,-30,13,-6,25,35,49,-13,-51,-4,-20,15,-20,-44,-27,17,30,-29,50,26,-15,-53,12,59,22,54,-3,15,27,-21,-12,75,21,14,28,-22,-32,-10,-19,69,-11,50,-45,29,-26,10,-53,29,-36,8,-8,53,-9,-55,-74,15,3,-18,-21,-48,-62,18,3,51,-27,-34,-7,-31,39,-9,76,-8,-14,-15,-101,32,-55,-1,-7,7,-58,-2,-21,-55,37,1,-8,-24,-37,27,5,-42,4,-39,11,-27,-74,24,19,-10,26,-1,37,-19,39,-2,24,43,32,-36,59,-38,-19,-30,37,-6,-10,16,-13,20,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.111","t":"REFERENCES AND SUPPLEMENTAL READINGS Barlow, D. H. & Craske, M. C. (2007). Mastery of Your Anxiety and Panic, Therapist Guide. (4th edition). New York: Oxford University Press. Cigrang, J. A., Rauch, S. A., Mintz, J., Brundige, A. R., Mitchell, J A , et al. (2017). Moving effective treatment for posttraumatic stress disorder to primary care: A randomized controlled trial with active duty military. Family Systems & Health, 35 (4), 450-462. Hofmann, S.G. & Smits J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621-632. Rauch, S. A., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: A gold standard for PTSD treatment. Journal of Rehabilitation Research Development, 49(5), 679-88.","e":[37,-10,-179,-28,27,41,19,34,45,-1,3,-25,46,-9,26,-31,0,-26,-33,-21,-44,-79,-8,-22,4,80,-22,-1,-44,6,48,-20,-27,2,-19,-28,69,38,-24,-3,66,-8,30,-108,-39,-27,51,39,27,17,44,-19,10,-44,97,-19,-18,40,33,-70,84,50,-80,-4,64,-40,-58,64,-7,-45,31,11,42,38,-64,-43,-29,-46,-18,19,73,-2,73,-57,59,-16,-26,18,-29,54,11,59,-9,59,-49,38,-22,-35,-54,-57,-52,5,57,0,40,4,3,-15,-48,1,-71,67,-20,-12,1,-33,57,-49,27,27,8,-4,19,67,10,14,-46,9,11,0,7,-19,-25,12,17,76,-2,7,-8,-6,38,-11,-13,-23,25,-6,0,-3,-55,-18,27,49,-20,56,17,-18,-22,7,54,45,27,-7,-42,91,20,-58,14,26,40,31,-24,-47,43,-34,66,4,78,-39,27,-53,89,-49,74,41,-3,-24,5,-6,-49,-34,-24,35,-70,-1,-88,-33,43,-37,48,-26,-2,21,-22,10,-23,81,-21,-8,-7,-59,29,-22,25,35,-18,-24,-13,-48,-35,17,-20,18,-7,-17,9,11,-12,40,49,4,-4,-89,-2,-4,16,25,-10,79,-4,58,2,63,36,34,-31,33,-30,-22,5,16,-4,22,27,31,33,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.112","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 15 Module 15: Problem Solving OBJECTIVES • To introduce problem solving and its potential use in psychotherapy • To learn how to apply problem-solving skills during brief CBT What is problem solving, and why is it important in therapy? Problem-solving techniques generally involve a process by which individuals attempt to identify effective means of coping with problems of everyday living. This often involves a set of steps for analyzing a problem, identifying options for coping, evaluating the options, deciding upon a plan, and developing strategies for implementing the plan.","e":[21,43,-122,-48,60,-24,60,-38,23,-22,-18,-23,62,10,-19,-40,-10,-62,-51,1,-27,-32,37,7,21,50,-18,-1,-36,1,15,-57,-13,-65,-81,-51,95,30,-34,-9,27,-36,20,-86,24,-22,94,8,1,-21,50,-82,47,-37,103,45,4,1,11,-15,95,74,-52,64,16,-55,-35,39,-54,3,47,-34,37,18,-45,-19,-28,4,10,42,38,-37,64,-7,29,-6,-22,-1,-28,54,-13,16,13,15,-111,45,-3,-16,0,-10,-44,-26,2,-9,-4,70,11,3,-10,9,-66,50,-25,-25,-24,16,56,-10,22,44,-16,-16,2,22,42,75,-27,-10,27,-23,-1,3,-40,-14,35,62,-4,-1,44,37,28,6,-11,32,-12,-20,-12,-20,-60,-17,-42,15,6,0,51,-14,-27,-2,70,-14,28,7,-60,22,-45,-20,0,11,30,52,-38,-42,14,18,93,47,76,3,9,-58,24,-18,29,55,1,7,21,-38,-25,-14,9,37,-47,-30,-64,-50,19,-5,28,-36,-18,53,-32,44,-40,55,-25,44,-1,-23,68,-35,-7,5,-41,-26,-10,2,-49,6,6,4,-38,1,17,25,-27,3,-23,24,-30,-73,29,34,32,18,21,22,4,79,13,35,43,39,-46,46,15,-47,-31,20,3,-24,24,7,12,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.112","t":"Problem-solving strategies can be used with a wide range of problems, including depression, anxiety, anger and aggression, stress management, coping with medical illness, addiction, and relationship/family difficulties. Problem-solving techniques teach skills that aid the patient in feeling increased control over life issues that previously felt overwhelming or unmanageable. In this manner, problem solving can help with practical problem resolution as well as emotion-focused coping (e.g., increasing control, decreasing stress, and increasing hopefulness). When? (Indications/Contraindications)","e":[42,64,-151,-12,63,-23,38,-29,50,-14,-3,-37,81,39,-5,-1,6,-48,-76,21,-21,-40,20,-13,-13,71,-39,-20,-26,17,0,-39,-1,-69,-61,-21,60,30,53,8,16,-34,27,-85,15,-48,49,10,59,-15,70,-105,13,-29,94,40,3,17,26,-54,102,67,-39,19,39,-39,-27,47,-23,17,88,-30,42,-3,-52,-4,12,27,17,21,62,-46,52,-47,55,28,-13,-23,-28,55,-3,39,29,19,-100,36,14,-5,-20,-23,-35,-26,12,-4,11,47,13,4,-32,43,-60,38,-8,-31,8,33,57,-29,19,42,-16,-5,-2,-4,28,48,-29,-19,39,13,-39,-21,-47,13,12,63,-22,-12,34,20,69,7,-21,20,-31,-19,-20,-21,-73,-22,-44,31,-5,32,45,-13,-57,46,66,-27,50,0,-63,28,-23,-25,2,36,8,63,-51,-37,-4,8,120,-9,107,-35,9,-56,37,-36,23,7,5,6,46,-42,-50,-42,4,46,-15,-12,-62,-63,22,2,13,-15,-31,23,-19,-5,-24,65,-22,9,6,-19,49,-20,10,10,-32,-17,5,-6,-43,16,-1,-29,-63,-4,49,12,-57,17,-35,2,-19,-88,57,21,45,-7,1,12,18,70,-2,33,35,35,-13,39,-6,-35,-30,39,16,13,-2,-5,16,-34]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.112","t":"Thoughts and beliefs are challenged when a thought or belief is not true or a situation is unchangeable. Alternatively, problem solving may be used when the root of an issue is a changeable situation; and the thoughts associated with the noxious situation might be accurate. Problem solving can be especially effective when a specific problem is able to be addressed and operationalized. A specific operationalized problem is one that is easily explained, identified, and/or measured. Problem solving works best when a practical solution is available. For example, a patient complaining of social isolation likely has potential solutions to this difficulty (e.g., calling a friend, joining a group, engaging in a socially driven hobby).","e":[35,59,-151,-34,91,-7,23,-2,44,-3,19,-19,46,61,-29,3,14,-79,-40,41,-18,-21,34,-24,16,27,-37,-46,-33,22,9,-51,24,-54,-59,-71,57,13,70,-44,20,3,16,-117,44,-33,42,-6,52,-59,44,-85,20,-13,95,86,-1,45,-7,-25,86,61,-39,19,8,-18,-48,54,-25,-23,65,-39,20,0,-67,14,-7,2,-4,34,42,-59,58,-32,72,26,3,-10,-24,66,16,2,29,1,-99,19,-2,-10,-17,0,-38,-66,-17,2,-2,54,17,46,-25,43,-45,23,-52,-13,2,12,79,-30,15,13,-19,25,18,56,33,43,-4,-13,36,-11,-16,-20,-41,4,-7,53,-3,-13,11,15,80,5,-8,20,2,-59,-8,-27,-53,21,-35,44,-8,15,23,-29,-20,36,67,-31,49,-3,-74,14,-35,-18,3,43,15,16,-62,-41,0,40,108,10,96,-24,-1,-13,11,-57,30,14,-5,6,64,-39,-57,-40,-7,41,-11,-7,-66,-63,34,0,28,-41,-3,21,-51,32,-7,48,-15,18,-8,-15,85,-5,15,16,-34,-27,12,19,-48,3,-1,-36,-46,7,32,6,-86,-2,-42,32,-20,-82,62,11,38,7,-3,4,51,75,-5,18,-7,30,-34,24,20,-29,-44,32,-2,0,14,-31,23,-24]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.112","t":"Examples of problems appropriate for problem solving include: 1. How to communicate with a partner about a difficult issue 2. How best to cope with the functional limitations of a medical condition 3. How to reduce financial distress Note that you, as the provider, are not responsible for finding answers to these questions but rather should aid patients in finding their own answers. In this manner you are a facilitator who possesses problem-solving skills. 112","e":[56,80,-117,-27,54,-13,35,-38,61,-19,-2,-29,42,59,-21,4,5,-99,-57,24,-34,-33,-4,17,22,38,-10,-24,-71,-1,-18,-6,18,-96,-64,-58,69,42,40,-1,29,-38,9,-73,28,-44,67,-16,58,-6,75,-67,22,-13,62,39,15,16,34,-31,80,51,-55,12,27,-26,-3,78,-8,29,48,-11,34,19,-41,-31,-12,39,13,18,37,-14,69,-39,55,19,-34,-19,10,61,0,33,32,13,-71,45,-26,-9,-25,-30,-16,-24,41,6,18,45,32,37,-37,23,-47,40,-23,-48,7,-5,84,-10,25,63,-63,-3,5,13,-1,40,-27,-1,53,24,-2,-24,-39,5,13,64,-1,-5,50,-3,79,2,0,-8,5,-37,-5,-17,-53,12,-49,19,5,15,49,-15,-52,15,56,-35,73,-14,-94,40,4,-15,3,36,16,68,-46,-45,8,33,110,6,84,-14,-3,-21,32,-60,35,15,11,-17,33,-20,-69,-12,-8,66,-22,-25,-56,-47,33,-4,8,-7,7,21,-22,38,-11,59,-32,17,5,-24,46,-38,1,11,-46,-15,-4,30,-43,29,6,-56,-37,-25,43,14,-46,10,-20,23,-15,-99,48,5,35,-11,-29,23,15,45,10,39,23,29,-18,29,-3,-43,-22,34,12,10,44,5,13,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.113","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 15 PROBLEM SOLVING MAY BE DIFFICULT FOR THE FOLLOWING INDIVIDUALS: 1. Patients with serious mental illness (psychotic disorders, bipolar disorder) 2. Patients with severe depression, who might require more focused cognitive work or medications 3. Patients who have difficulty thinking about long-term effects (e.g., persons with cognitive impairment) 4. Patients with problems that are largely emotional; for example, a person who feels incompetent at work and often feels that others are overly critical may be reacting to emotions (e.g., depression). This problem may be better served using another skill (e.g., Unhelpful Thoughts modules).","e":[10,38,-146,-42,66,23,34,-21,25,-32,-17,-17,27,3,-1,-16,2,-41,-31,23,-45,-3,10,-8,22,48,-17,11,-48,34,10,-38,-23,-92,-62,-36,86,32,0,46,58,-36,26,-116,5,1,117,40,11,-29,32,-73,62,-40,92,49,-30,38,1,-34,89,62,-53,41,5,-57,-44,73,-31,-17,79,-10,40,45,-56,-2,-44,-5,12,36,54,-21,65,-29,55,-14,-6,1,-3,63,-1,-2,12,28,-94,35,-17,-24,-19,-34,-39,-28,3,-10,-21,43,-6,-12,-1,-5,-73,27,-35,-34,20,18,37,-16,-3,47,-14,-16,5,26,25,72,-1,9,61,-45,-10,6,-18,-33,9,54,-23,17,23,41,37,17,-1,19,1,-42,-18,-20,-61,-24,-12,22,23,7,50,-18,-22,27,45,-18,8,10,-67,40,-10,-35,13,49,44,63,-54,-66,11,15,92,41,58,-12,18,-59,14,-25,11,38,6,14,19,-17,-18,-35,20,44,-35,-31,-53,-57,22,-3,21,-54,-16,45,-13,29,-46,46,-26,4,-8,-44,56,-25,-16,14,-17,-29,-11,-15,-44,22,20,-9,-7,-16,22,-9,-31,2,-21,16,3,-69,75,6,7,7,2,8,11,60,-6,46,49,18,-36,26,-4,-31,-14,46,-24,-15,8,0,9,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.113","t":"How? (Instructions/Handouts) PROBLEM-SOLVING THERAPY (PST) In problem-solving therapy, it is important that you first educate the patient about the problem-solving strategies that will be used during sessions. To enable patients to use the strategies after therapy ends, teach them to carefully examine a problem, create a list of solutions, and make decisions about which strategies are appropriate for a variety of problems.","e":[33,42,-171,-36,52,-19,18,-27,28,-29,-27,-9,61,1,-26,-26,32,-65,-67,22,-28,-56,-12,-23,-5,43,-38,2,-18,9,20,-23,4,-45,-61,-46,84,3,-2,1,32,-28,10,-96,10,-84,38,4,-8,-22,44,-52,5,-32,85,46,23,19,39,-17,117,66,-64,28,47,-67,-21,54,-40,4,50,-19,77,8,-30,-17,-23,-12,13,27,29,-19,75,-37,43,27,-8,10,-39,88,-13,8,23,7,-115,19,5,4,-5,-25,-47,-38,15,-26,15,66,23,-2,-15,19,-50,45,-31,-9,-27,-11,70,-36,28,15,-13,-4,18,52,39,77,-54,-28,14,7,-25,-7,-43,22,26,77,8,-29,42,12,10,5,0,6,-8,-15,-25,-43,-51,12,-17,32,0,39,53,-65,-24,4,85,-4,62,5,-86,24,-14,-21,9,59,3,18,-16,-63,15,9,93,35,77,-7,-3,-23,41,-43,12,29,-22,10,3,-39,-53,-33,21,68,-44,5,-73,-46,32,4,23,-27,-22,24,-27,17,-39,73,-43,24,-11,-8,57,-32,0,26,-57,-28,-12,-7,-65,43,13,-2,-38,-30,-5,19,-35,22,-13,21,-35,-77,-2,45,37,-24,-11,26,18,59,13,50,29,49,-31,52,27,-45,-24,23,14,10,16,4,35,-50]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.113","t":"General guidelines for using problem-solving strategies are as follows: • Training should be tailored and specific to each patient. • Obtain a thorough assessment of the problem before proceeding with problem- solving therapy. • Encourage the patient to try as many solutions as possible. • Decide whether the patient requires more problem-solving work or more emotional work to experience growth through the therapeutic process. STRATEGIES FOR EFFECTIVE PROBLEM SOLVING The SOLVED technique helps guide you through the steps to most effectively identify and solve problems in your life.","e":[21,66,-142,-17,53,-32,53,-16,30,3,-19,-41,83,28,-35,-11,18,-90,-52,33,-35,-54,10,-19,1,29,-36,3,-39,-5,5,-36,21,-65,-71,-34,70,24,26,-11,31,-26,16,-86,11,-46,62,-18,29,-15,58,-52,7,-48,91,41,-7,24,23,-66,115,57,-89,7,30,-27,-38,53,-28,11,59,-28,53,-2,-50,-25,-4,19,21,43,38,-29,75,-51,54,23,-23,-20,-17,69,-2,45,52,30,-95,22,4,-2,-18,-20,-34,-33,11,-12,-2,62,40,16,-27,28,-64,38,-4,-29,-12,30,73,-22,29,35,-33,-8,4,12,27,51,-54,-35,35,23,-9,-40,-65,21,-1,72,16,-9,47,17,26,-13,-11,27,-8,-21,-16,-14,-50,19,-37,40,17,33,46,-47,-37,32,50,-14,58,-18,-53,33,-21,-16,6,35,32,49,-37,-43,-4,21,120,2,109,-28,-8,-29,30,-46,20,23,-1,7,52,-42,-49,-15,28,54,-34,-8,-60,-42,55,-20,28,-24,-31,42,-35,25,-48,56,-26,31,-1,-21,32,-21,-2,28,-59,-28,-7,-3,-65,37,8,-15,-76,10,22,14,-57,8,-6,15,-19,-60,32,-5,35,-9,-32,6,20,67,1,30,33,34,-40,41,13,-32,-12,44,26,35,9,-24,32,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.113","t":"S (Selecting a Problem) ... the patient would like to solve. Ask the patient to think about situations when they feel distress or difficulty problem solving. If planning does not seem to be possible, suggest a different therapeutic technique (e.g., changing unhelpful thoughts). The decision to remain with problem solving or move to a different skill is largely dependent on you to direct. 113","e":[29,58,-131,-32,62,5,26,-29,53,-10,-8,3,86,25,-21,-1,43,-98,-40,10,-28,-37,-7,-2,13,32,-15,-43,-49,37,1,-5,27,-50,-62,-72,77,27,5,-25,17,-34,13,-126,61,-40,77,13,58,-60,27,-39,-9,-18,90,43,25,19,10,-31,91,50,-45,27,33,-48,-60,30,-26,-16,53,-20,54,20,-67,3,-12,1,15,38,43,-50,79,-38,44,42,-5,-17,-11,63,-44,33,36,21,-113,13,-12,0,-20,-53,-42,-51,-4,-37,4,57,4,38,0,-9,-32,28,-46,-35,10,-7,63,-16,40,37,-4,-11,14,45,21,68,-25,13,52,2,-6,-13,-19,13,-10,59,-12,-20,15,23,85,24,-3,-5,-18,-21,11,-1,-45,-12,-26,19,-3,17,44,-47,-30,47,61,-46,81,16,-92,37,-24,-37,21,34,12,27,-28,-36,44,24,121,-5,59,-14,8,-29,20,-41,37,14,8,-11,34,-41,-29,-52,14,33,-18,-31,-49,-49,29,-24,23,-9,2,49,-55,12,-47,50,-23,17,-7,-18,42,-25,-7,0,-32,-56,23,18,-54,39,18,-47,-39,16,6,4,-42,-7,-22,28,-26,-94,59,34,53,18,-17,9,14,56,-10,24,26,34,-59,25,32,-36,-23,49,4,8,6,-18,23,-9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.114","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 15 O (Opening Your Mind to All Solutions) Here, it is important to be as broad as possible. You are encouraged to work with patients to “brainstorm” all possible solutions. Writing may be particularly helpful for some patients. Even ideas that seem ridiculous at first may generate realistic solutions. In-Session Example 15.1","e":[-3,32,-155,-66,63,5,33,-11,31,-42,-21,2,58,20,-6,-10,-19,-91,-11,11,-8,-29,-6,15,29,24,-10,27,-52,14,44,-52,8,-51,-67,-41,50,21,-44,4,54,-13,21,-83,40,0,105,23,2,-28,4,-57,31,-12,138,42,2,36,4,-9,100,60,-57,60,11,-18,-45,80,-42,-5,58,-19,32,6,-59,24,-47,-1,4,40,39,-38,88,-22,28,-20,-1,-27,-22,74,8,-11,-1,38,-82,31,2,-27,-15,-48,-51,-17,12,-22,-5,62,6,2,9,-3,-60,26,-46,-31,-28,9,53,-30,3,49,-32,-14,11,28,41,72,-18,-23,27,-50,25,-2,-30,-14,28,55,-15,-7,39,30,14,11,-3,12,-8,-44,1,-18,-47,2,-30,21,24,23,30,-43,-10,-7,46,16,19,3,-55,28,-37,-40,17,44,29,60,-50,-45,12,-8,78,35,68,-17,17,-63,28,-17,7,71,-17,-3,28,-15,-27,-17,11,19,-35,-24,-56,-56,29,-8,10,-35,-25,44,-40,38,-53,68,-23,17,4,-50,80,-15,-8,14,-37,0,-15,-22,-73,20,27,23,-9,-23,8,-4,-27,-7,-2,32,-19,-64,49,13,17,-15,16,41,-5,45,29,48,39,-12,-80,36,-4,-41,-6,34,-21,-10,38,-9,3,3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.114","t":"For example, Allison’s family would often drop by several times a week without calling beforehand and expect her to care for their children. She enjoyed this but felt tired many times and was beginning to get concerned about her ability to continue child sitting at such a frequent pace. Her first idea was to tell them she could no longer baby-sit. Although she did not like this idea, it led her to consider related ideas, such as telling them they had to call beforehand to make sure she felt up to the task. Highlight 15.1","e":[33,18,-190,-46,18,68,-7,-47,26,-24,-65,-29,68,99,-6,-21,-2,-66,-21,31,-11,-5,-56,19,-14,28,5,52,-3,57,33,-49,28,-66,-81,-43,56,38,12,-21,34,7,28,-73,14,-82,86,36,44,-57,45,-77,-82,-6,84,13,26,50,17,13,123,13,-13,77,33,-24,-36,36,-13,-23,16,-17,16,-1,-12,43,-22,19,0,43,46,-7,66,3,18,49,28,1,-17,85,-1,-35,20,-3,-62,12,6,12,-33,-51,-37,-30,-29,-36,-18,-10,-16,22,30,5,-22,13,23,-35,-2,7,45,-48,44,-18,-46,7,-9,23,16,67,-50,37,-18,-29,-7,-30,-19,10,16,34,26,-34,15,9,45,17,5,-40,1,19,23,-41,-12,53,-16,-19,0,14,51,-42,-26,20,47,-11,53,13,-46,20,-23,2,-17,75,24,21,-37,-50,12,-19,49,-21,68,-24,-30,-88,6,-53,5,23,11,-7,19,-16,-58,-57,-24,21,-24,-46,-76,-25,36,-4,28,-14,-9,-26,-19,26,-59,83,-4,-14,-11,-61,67,9,-18,34,-72,-4,-7,-16,-55,37,0,2,17,-13,51,-14,-14,-5,-34,-9,-26,-90,34,52,-3,-6,-20,43,-9,39,-11,-7,50,10,-68,5,6,-29,-8,23,-19,-19,-6,-18,28,27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.114","t":"Tips for generating possible solutions: • Ask the patient to think about advice they would give someone else with this problem. • Ask the patient to examine the ways they have handled similar situations. • Instruct the patient to consult with a close friend or relative for additional solutions.","e":[11,31,-134,-50,86,1,-8,-3,40,-4,-14,-15,63,59,4,9,40,-99,-29,36,-23,-55,-15,5,-14,6,-26,64,-43,-6,9,11,17,-49,-66,-34,25,10,14,2,28,-12,20,-102,35,-35,99,8,44,-28,28,-17,-8,-37,91,51,20,42,77,-21,93,39,-39,30,21,-22,-32,93,-10,21,47,8,74,-5,-76,29,-11,29,9,31,52,-19,82,-76,29,22,14,-4,-7,65,-10,15,56,16,-98,-3,-31,16,-41,-79,-26,-15,19,-27,9,45,43,39,-5,5,-47,8,-20,-5,19,5,64,-1,50,45,-27,11,-6,22,39,58,-39,-32,65,0,0,-36,-44,15,6,69,-5,-7,15,-10,37,-21,8,16,3,-28,1,-21,-43,38,-28,36,13,36,81,-44,-38,21,30,-30,80,-36,-75,43,-9,-27,43,47,18,31,-30,-45,15,19,113,20,64,-44,-8,-19,35,-59,33,52,19,-14,20,-38,-48,-41,14,26,-4,-33,-25,-19,59,-38,36,-9,-31,24,-49,44,-34,71,5,-11,9,-23,20,-44,-13,-11,-74,13,-12,-1,-67,39,32,-17,-35,3,22,9,-81,30,-2,16,-25,-84,30,-14,32,-27,-47,29,-31,65,2,29,42,14,-65,61,19,-42,-7,49,30,30,8,-2,9,-36]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.114","t":"L (Listing the Potential Pros and Cons of Each Potential Solution) Often, writing options, along with listing pros and cons, can be helpful in considering potential options. Writing allows additional thought, as well as a visual image of options. Recommend that patients consider solutions in a logical manner, thus reducing the time spent ruminating. It may also help to identify additional thoughts that might benefit from changes using the techniques, such as changing thoughts. In some cases, identification of pros/cons may require obtaining information from other people, such as lawyers or financial advisors.","e":[29,63,-113,-82,62,-18,-2,3,19,-5,27,6,91,77,-16,-39,17,-94,28,-9,-14,-43,-64,7,18,29,-11,-13,-57,7,29,-7,6,-37,-57,-49,63,5,-3,-40,19,8,52,-73,45,-46,83,-12,52,-28,57,-30,16,1,132,34,20,35,33,-21,115,56,-68,61,73,-51,-15,41,-29,1,46,5,15,-12,-68,33,6,2,25,61,38,-59,82,-21,43,52,35,-43,-21,47,-33,5,29,40,-88,44,-9,-19,-18,-26,-43,-18,11,-9,20,19,0,7,3,15,-55,25,-17,-53,33,-23,84,-45,21,68,-30,52,-10,33,12,61,-31,-26,51,-32,19,-34,-32,25,23,65,-12,-33,-4,-5,77,12,-23,-10,-32,-30,-11,-16,-42,7,2,34,17,35,20,-50,-1,21,24,21,52,39,-39,26,-49,-23,13,44,2,46,-13,-23,37,6,103,-16,66,-40,15,-33,9,-42,8,45,17,-13,48,4,-51,-65,12,20,-13,-30,-56,-66,35,2,4,-22,-31,12,-66,4,-57,52,-3,3,-12,-27,70,-10,12,-5,-10,-6,-19,14,-24,33,22,-32,-10,14,9,11,-52,-3,-39,14,-52,-71,89,2,7,-27,15,23,-4,35,17,28,25,26,-42,15,49,-38,-9,70,11,39,6,-1,15,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.114","t":"V (Verifying the Best Solution) Examine the pros and cons of the solutions listed. Patients may wish to “rank order” the solutions based on which solutions are most practical and/or desirable. E (Enacting the Plan) Identify the steps needed to carry out the solution selected. Patients may need to break actions down into steps small enough to facilitate achievement of goals. Once you and the patient finish formulating a specific plan, encourage the patient to carry it out. 114","e":[19,55,-153,-23,78,-23,12,-6,39,7,-2,12,94,35,-8,-31,19,-106,-38,-5,-17,-49,-57,-16,46,36,20,-37,-53,-19,28,9,83,-57,-70,-52,45,48,-2,-43,5,-13,8,-70,50,-39,39,-6,60,-37,1,-10,-17,-7,99,61,21,41,34,-14,98,38,-54,47,57,-35,-58,47,-17,-15,15,-39,56,-10,-53,-1,-26,-26,1,24,35,-35,99,-17,62,22,3,-32,-13,73,-28,24,9,59,-143,-1,-12,7,-3,-51,-44,-39,-1,-49,32,40,45,32,1,-1,-48,9,-58,17,22,12,83,-15,-1,60,32,6,31,50,-4,53,-17,-8,29,10,30,-13,-21,6,3,62,-9,-9,9,-9,26,12,17,-36,-49,-39,48,-12,-37,17,4,24,-9,3,31,-48,-3,29,34,-16,63,19,-76,45,-26,-62,25,19,0,28,-52,-35,20,16,79,25,49,-19,17,-23,40,-37,40,59,-22,-32,22,-25,-60,-48,35,23,-9,-47,-44,-23,5,-19,2,-16,-9,23,-45,36,-43,62,-40,-11,-11,16,56,-26,-9,4,-28,-32,18,-7,-49,41,12,-42,-12,-14,18,21,-40,-22,-18,10,-30,-68,35,8,32,-16,-23,37,15,45,-1,17,13,14,-50,46,43,-52,-31,71,14,2,11,-7,32,-17]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.115","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 15 D (Deciding if the Plan Worked) Follow-up with the patient to see how well the chosen solution worked. If the solution was effective, give positive reinforcement. If the solution was not effective, return to the first step in the SOLVED technique to specify a new problem or move to “O” or “L” to identify other goals or potential solutions for the same problem. The decision to move back and to which step is largely up to you, who might now have additional information about pros and cons and possible solutions.","e":[16,9,-159,-51,79,3,55,-26,26,-44,-33,2,70,18,-2,-20,25,-101,-17,7,-5,-19,-21,11,41,24,2,28,-52,-21,37,-31,37,-77,-79,-35,78,32,-34,-47,20,-6,16,-89,67,-7,107,32,21,-21,17,-17,23,-13,108,45,2,-5,8,-23,98,58,-45,35,31,-38,-51,62,-43,-12,41,-23,34,12,-57,15,-35,-12,-11,36,35,-62,98,-26,12,-10,2,-25,-36,62,-20,0,15,49,-102,21,-6,-32,-16,-70,-45,-36,4,-25,-17,77,20,-8,3,-2,-64,16,-28,-21,-11,12,64,-23,5,34,-10,-9,20,18,36,72,-55,-24,37,-20,38,13,-41,0,12,54,9,-15,31,30,33,-1,-12,17,5,-28,23,-6,-33,-3,-8,11,23,25,45,-53,-28,1,55,1,56,-17,-52,13,-20,-33,21,41,44,60,-41,-41,34,-29,76,33,43,-20,20,-56,17,19,35,72,-4,-10,29,-27,-35,-38,8,33,-34,-38,-55,-40,30,-26,34,-36,-18,43,-18,27,-65,44,-21,29,-5,-33,68,-12,-9,17,-42,-29,3,14,-64,16,-5,17,-18,-8,10,32,-41,-13,-32,29,-1,-88,13,22,44,1,9,17,9,46,17,44,29,6,-65,44,21,-21,10,48,3,0,41,-10,-3,18]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.115","t":"**To effectively use the SOLVED technique, problems may need to be more specific than those listed above. Table 15.2 Opening Your Mind Through Brainstorming to Solve Problems through SOLVED SELECT A SPECIFIC PROBLEM: Minimizing Effect of Symptom OPEN your MIND to ALL possible SOLUTIONS 1. Talk to your doctor. 2. Change or modify medications. 3. Engage in healthy life choices, including proper diet and exercise. 4. Educate yourself by talking to others and by reading about your illness 5. Explore alternative treatments. 115","e":[44,44,-138,-48,66,-48,46,23,82,-31,-13,-3,78,65,-28,2,-2,-106,-27,24,-25,-43,5,-16,-30,30,-30,28,-43,21,34,-48,13,-39,-59,-49,51,40,23,23,36,-37,48,-111,42,-18,93,-13,42,-36,36,-55,7,-36,69,42,10,-4,46,-41,115,68,-42,43,41,-41,-46,77,-30,-5,66,-30,42,-9,-55,17,-12,10,-3,22,24,-53,87,-54,60,17,-7,-23,-6,61,-17,7,29,33,-62,11,17,0,-21,-45,-41,-30,-4,-29,14,48,56,11,17,25,-68,3,-22,-34,4,-5,59,-22,31,32,-57,17,11,28,41,36,-25,-39,52,-25,0,-26,-29,53,21,67,-14,6,25,-11,58,-30,-14,15,-18,-27,-16,-21,-52,3,-10,34,-10,36,44,-73,-11,1,47,-34,57,-1,-49,55,-22,-23,17,44,28,43,-62,-39,1,39,96,17,71,-46,10,-33,46,-51,16,41,-25,-6,37,-33,-31,-16,21,25,-37,-27,-44,-37,39,3,25,-20,-24,37,-59,16,-28,58,-20,5,-4,-11,38,-28,5,-11,-55,-4,9,-13,-60,55,23,-16,-23,-11,34,10,-49,-14,-19,-14,-12,-83,67,-5,31,-24,-7,6,16,51,-2,42,28,18,-40,46,11,-34,-22,36,-2,24,36,10,25,-16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.116","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 15 SELECT A SPECIFIC PROBLEM: Forgetting to Take Medications OPEN your MIND to ALL possible SOLUTIONS 1. Turn several alarm clocks on to remind you. 2. Put your medication in a place you will notice it at the time you are supposed to take it. 3. Have a friend or family member remind you. 4. Buy a medication dispenser to help you remember whether you have taken the medication. 5. Take it at the same time every day. Other examples of problem-solving worksheets are listed at the end of this module. These worksheets expand the common pros and cons lists to help a patient consider multiple perspectives and outcomes before making a decision.","e":[13,-8,-156,-54,69,-9,38,-49,40,-7,-26,15,58,44,12,18,-4,-57,-38,19,-8,-21,-19,-16,-8,44,-2,19,-38,26,50,-47,1,-70,-61,-61,66,40,-54,33,72,-11,28,-61,54,37,90,40,2,-8,37,-78,23,-39,71,4,32,1,27,-22,166,25,-30,69,7,-15,-56,93,-34,14,49,-1,57,49,-43,12,-54,14,10,24,28,-13,102,-38,25,5,18,-17,-31,76,-10,-23,-18,34,-66,46,-5,-19,-39,-42,-48,-28,-24,-13,6,38,9,0,-19,-16,-61,-6,-20,-15,3,10,52,-33,8,3,-43,-1,12,27,48,44,-18,-11,46,-37,21,12,-36,-8,8,45,21,4,15,19,23,-7,27,1,-13,-14,-5,-32,-49,-43,15,3,7,16,55,-42,-6,-5,72,13,17,-8,-48,42,-21,-48,23,61,32,69,-66,-37,-14,-32,78,48,24,-21,27,-73,48,-2,3,75,-5,5,10,13,-44,-13,18,27,-17,-49,-36,-34,23,-20,29,-35,-29,23,-20,28,-44,59,-15,-6,-10,-72,95,-7,-25,-21,-28,-3,-9,-16,-29,17,3,-6,18,-25,21,15,-21,8,-28,-5,-4,-87,25,7,58,8,-12,37,-13,42,6,70,63,16,-81,38,6,-33,-9,66,-9,-10,11,-21,32,9]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.119","t":"Relaxation techniques consist of a collection of psychotherapeutic techniques designed to reduce tension, stress, worry, and/or anxiety. Relaxation techniques vary in their focus (e.g., physical sensations or changes in cognition/thoughts) and can be selected based on presenting difficulties, as well as patient preferences. Some patients respond to physical procedures (e.g., muscle relaxation and/or deep breathing), while others respond favorably to guided imagery.","e":[34,54,-169,-30,31,-38,30,-28,30,-27,-16,-16,31,9,-12,-49,4,-55,-15,-1,-45,0,-1,-37,-22,83,18,24,-15,-26,24,-10,29,15,-8,-56,68,51,-10,22,9,-39,58,-74,18,-24,27,-28,5,9,65,-62,-36,-59,116,-1,15,60,14,-63,81,19,-36,67,57,-30,-68,40,48,-11,65,-33,32,23,-38,-3,-13,-4,26,-16,37,-73,37,-30,68,27,-13,1,-13,87,8,-22,55,29,-78,26,45,-6,-26,-54,-65,-2,44,-28,7,20,5,4,-15,26,-22,32,-5,5,9,-15,50,-26,46,27,0,4,13,-14,5,36,-53,-13,30,-7,20,-2,-59,30,-21,50,-27,-30,16,-11,36,-40,-20,-12,-8,-35,12,-33,-34,-1,35,-20,37,13,49,-38,-25,24,61,40,45,13,12,52,7,-45,8,23,32,-5,-46,-38,-40,20,93,36,127,-59,29,-66,4,3,8,9,-6,18,30,-66,-63,-45,-7,-14,-28,-20,-59,-43,15,-13,27,12,-36,-18,-12,-9,-43,86,-34,-9,-9,-31,42,-26,31,4,-5,-37,-22,-49,-43,8,21,11,-38,4,9,-20,-51,8,-2,2,-50,-82,28,39,28,14,28,2,4,12,14,37,14,24,-59,36,-2,-18,-5,3,4,-2,4,22,51,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.119","t":"Relaxation techniques are important for brief therapy for several reasons. First, they focus on skills that alleviate stress, anxiety, worry, and tension that are often debilitating and interfere with patient functioning. Second, stress, anxiety, worry, and tension are often very uncomfortable for patients; and providing help to alleviate distress can go a long way towards increasing positive treatment expectations and rapport. Relaxation techniques are easily conveyed as a method of increasing control and often do not include a direct discussion of mental health difficulties, which can be important for some patients who are concerned about mental health stigma. Finally, relaxation techniques are generally easy to teach and learn. For these reasons, it is often advantageous to teach these techniques early in treatment to give patients an easy-to- learn, yet highly effective, skill set.","e":[34,73,-170,-36,16,-31,40,-12,39,-34,-28,-11,35,14,-13,-25,12,-55,-28,10,-54,-8,6,-36,-28,79,27,20,-24,2,36,-25,6,-9,-15,-65,77,54,-3,4,32,-32,50,-76,25,-18,38,-17,9,-18,44,-97,-25,-51,115,13,5,49,20,-61,62,36,-48,58,24,-16,-43,19,44,10,49,-24,29,15,-48,10,2,-4,1,3,38,-60,21,-54,61,20,-15,-7,5,82,33,-1,42,59,-81,31,26,-9,-10,-25,-55,-8,40,-14,1,12,-3,20,-9,19,-28,54,0,-7,11,4,39,-29,48,14,-25,0,11,-6,28,43,-30,7,56,-8,-25,-12,-69,23,11,61,-30,-7,11,-2,25,-5,-26,-15,-31,-8,-12,-22,-41,-3,14,-18,38,38,44,-30,-5,-6,71,36,53,16,-1,54,5,-34,15,4,18,4,-39,-19,-2,-10,76,30,117,-60,44,-86,7,-22,18,-2,-19,28,38,-70,-74,-44,-5,3,-60,-11,-67,-43,34,-4,22,27,-45,-13,-23,-11,-41,93,-31,-23,-31,-45,55,-25,20,8,-6,-39,-31,-49,-45,19,31,1,-7,-5,7,-16,-63,8,-19,22,-64,-84,28,53,28,5,48,-1,-5,33,18,28,26,13,-59,31,-7,-48,-10,-11,0,-9,25,-4,39,-16]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.119","t":"When? (Indications/Contraindications) As indicated, relaxation techniques are quite effective early in treatment to reduce tension and increase early treatment successes. They generate increased self-efficacy, perceived control over stress, and improved coping. Examples of applications might include daily relaxation exercises to reduce an overall sense of tension or stress not affiliated with any specific situation (e.g., general worry or apprehension) or the use of relaxation techniques to manage work-related stress in preparation for an upcoming social or family event.","e":[34,35,-188,-13,13,-42,55,-17,51,-14,-28,4,39,36,4,-39,25,-50,-10,2,-32,-16,-17,-20,-7,87,13,14,-1,-24,45,-17,35,-16,-15,-50,77,40,-4,-26,11,-46,58,-52,33,-29,49,2,11,-13,61,-80,-36,-37,125,31,15,48,7,-54,79,42,-42,45,76,-19,-40,17,43,3,71,-42,19,12,-28,2,-4,-5,0,10,35,-55,51,-62,64,28,-3,-9,-11,64,49,-6,31,32,-83,16,38,-13,-29,-57,-41,-9,37,-18,-13,18,24,-10,-22,12,-16,55,13,-23,15,13,62,-39,28,27,-23,2,-1,5,20,45,-54,-17,55,-15,4,-1,-53,28,-12,68,-31,-33,3,-12,44,-19,-14,8,-19,-45,15,-42,-45,29,6,-10,29,27,42,-37,-35,5,61,20,62,-7,-7,65,-19,-34,11,45,24,17,-45,-29,-43,-9,77,35,117,-51,23,-64,15,-7,16,-5,-19,6,46,-50,-87,-47,-8,8,-40,-17,-82,-52,36,-4,14,15,-39,-11,-14,-19,-50,87,-22,-10,2,-30,47,-23,22,5,-4,-35,-8,-31,-26,14,26,-3,-29,-7,6,-15,-53,13,-21,14,-60,-73,24,30,35,-5,44,-1,12,38,14,31,11,28,-69,47,6,-44,-10,0,0,1,9,14,51,-8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.119","t":"Relaxation procedures can also be appropriate for persons with depressive symptoms to increase their perceptions of control. However, it might not be appropriate for depressive symptoms occurring outside comorbid anxiety/worry. For example, teaching a severely depressed person, who is experiencing fatigue and lack of motivation, to relax would not be useful unless the patient has a specific need for relaxation. Additionally, relaxation techniques might not be appropriate for patients with anxiety and panic symptoms as they may use them as avoidance behaviors. Use of relaxation when faced with feared stimuli can reinforce anxiety and further exacerbate fear. 119","e":[22,66,-162,-38,32,-7,27,-8,58,-42,-6,-9,39,36,5,-17,21,-61,-45,-4,-50,-9,-25,-29,-10,87,27,12,-21,14,49,-5,28,-13,-5,-59,60,72,20,20,33,-33,58,-68,3,-7,72,4,37,-25,62,-94,-43,-75,104,37,9,42,19,-69,86,14,-14,41,54,-10,-55,29,30,-13,83,-12,25,25,-43,15,-7,8,2,5,44,-43,48,-48,81,3,11,-12,17,77,40,-32,56,70,-47,25,18,2,-34,-50,-51,10,31,2,-21,-5,-4,5,-1,-19,-25,73,-7,-21,48,10,52,-26,31,48,-12,5,8,5,29,43,-28,-6,67,-12,-12,-11,-48,32,-3,35,-42,4,-7,-11,39,-12,-18,-19,-62,-41,3,-25,-55,10,-6,-11,54,28,53,-32,-43,18,83,36,83,14,-2,53,0,-36,8,61,30,2,-56,-41,-29,-24,91,15,100,-46,32,-67,11,-2,25,-15,3,13,36,-41,-60,-42,-6,23,-49,-24,-85,-46,30,-8,28,-8,-41,-12,20,-47,-52,47,-22,-19,5,-53,48,-33,26,5,-7,-27,-25,-23,-29,17,6,-27,-38,-10,18,-23,-69,-2,0,-8,-25,-113,54,25,29,16,-4,-8,9,19,18,17,31,43,-26,26,-29,-9,9,-16,-9,12,23,10,44,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.120","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 Relaxation techniques are appropriate for persons with chronic pain, migraines, and insomnia, as well as in smoking cessation treatment and weight management programs. These techniques can aid in symptom reduction and underlying issues that make it difficult for patients to cope with physical ailments. However, it is important to consider how various relaxation techniques are impacted by any physical limitations. How? (Instructions/Handouts)","e":[30,23,-173,-46,46,-35,13,-2,29,-33,-14,-20,36,-1,-16,-37,-32,-60,-22,2,-48,-21,-2,-20,8,62,36,51,-24,-10,58,-46,24,-47,-17,-46,91,32,-29,-7,45,-61,68,-80,34,8,102,29,-16,17,28,-86,18,-50,113,-12,9,23,-15,-47,95,46,-41,66,32,-46,-56,35,3,-12,75,-35,39,34,-52,-2,-30,-14,-15,22,8,-46,75,-33,43,-4,-10,-13,5,67,26,-28,40,48,-70,29,50,-18,-14,-44,-70,-18,26,-15,-2,29,4,-4,0,16,-48,16,6,-7,4,22,50,-38,19,52,-11,-37,27,7,12,71,-61,-32,55,-29,8,7,-21,1,-6,39,-9,-10,28,15,29,-32,-11,-4,-10,-18,-13,-40,-57,-11,8,-14,49,13,67,-50,-30,13,68,48,27,-3,-23,32,-9,-38,-1,65,59,33,-75,-23,-27,0,106,52,69,-16,27,-86,18,30,7,49,-2,12,12,-48,-38,-34,-1,18,-49,-13,-82,-28,57,-10,24,-50,-9,20,8,-12,-59,49,-40,4,-12,-50,62,-13,18,21,-24,-30,-3,-49,-56,31,38,-2,-24,-11,8,-34,-31,-13,3,17,-25,-88,41,34,9,22,29,23,17,20,38,38,26,-2,-78,42,-2,-40,7,32,-11,-6,16,-6,25,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.120","t":"Regardless of the actual relaxation technique, it is imperative that the physical environment be attended to so as to maximize results. Before beginning relaxation techniques, it is suggested that you create a safe, quiet, and comfortable environment. You are encouraged to work with patients to create such an environment. Patients may be comfortable with certain recommendations (e.g., unfolding arms) but may be uncertain or uncomfortable with others (e.g., closing their eyes). The following list of options can be used to create an effective atmosphere for relaxation-based interventions.","e":[24,59,-164,-28,24,16,37,-1,45,-18,12,-10,29,47,-7,-27,6,-98,-17,-17,-79,-20,0,-23,-21,61,36,47,-29,-21,48,11,23,-15,3,-80,59,89,4,-8,7,-31,43,-90,35,-26,48,-34,25,9,54,-56,-59,-46,101,29,30,43,42,-59,97,33,-45,54,50,-8,-64,32,22,-21,39,-15,36,27,-36,31,-5,-23,29,16,37,-51,62,-78,64,1,-3,-38,-6,87,26,-32,33,29,-85,17,11,36,-36,-42,-37,-19,30,-5,-17,6,4,32,-13,-1,-25,28,-12,-16,21,1,88,-37,57,62,-22,20,-11,-35,12,34,-51,-30,53,-17,1,-14,-67,20,-8,54,-17,-26,25,-22,25,-1,-8,-22,-21,-28,15,-11,-26,40,-9,-4,41,32,27,-67,-26,29,83,38,97,7,-3,33,15,-35,13,27,47,12,-79,-44,-23,22,64,27,89,-56,12,-68,31,-21,14,-14,-8,-1,22,-51,-72,-49,20,4,-47,-31,-44,-16,52,-25,28,-10,-15,12,-24,13,-70,90,-35,-9,-13,-48,53,-28,8,-5,-15,-21,-17,-41,-57,52,31,-19,-25,-7,20,-28,-83,15,-2,13,-43,-77,37,22,8,14,26,15,-15,10,25,44,15,1,-50,32,-1,-45,-5,-9,10,7,14,-17,13,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.120","t":"Other tips to increase stress-management effectiveness include: • Having the patient loosen tight clothing (collars, belts, shoes, etc.) or remove glasses • Having the patient sit in a comfortable fashion (e.g., uncrossing arms and legs, placing feet flat on the floor) • Dimming the lights or removing bright sunshine from the room • Having patients close their eyes • Asking patients whether they need a bathroom break before starting • Asking patients to clear their mind and focus on your voice and instructions","e":[-15,44,-178,-21,65,-43,25,-3,96,-1,5,-3,57,59,41,5,49,-85,4,-3,-24,-69,-3,-12,-31,59,14,43,7,62,97,-9,8,-71,-12,-29,51,41,-1,-1,42,-52,5,-84,27,-29,50,-12,-1,4,42,-48,-26,-20,121,-23,-8,36,65,-23,98,8,-34,42,6,0,-21,62,-9,38,58,6,33,6,-66,26,-45,-3,28,8,25,-35,76,-99,70,7,25,-27,-24,36,19,24,27,99,-110,24,67,-16,-8,-91,-49,-20,27,-33,-8,19,18,38,-15,12,-43,64,-4,-17,8,17,67,-6,8,4,-14,6,1,-5,27,19,-28,-29,58,-3,-21,-24,-57,-10,5,58,1,5,33,-27,-1,12,-4,-8,-14,-52,15,12,-43,39,5,-4,10,44,18,-31,-27,-19,34,35,59,-72,-39,37,28,-46,52,58,30,36,-35,-29,-5,6,46,20,54,-58,9,-44,40,-54,24,40,-34,3,54,-35,-75,-37,16,47,7,-39,-55,-36,30,-32,17,-26,-39,-35,7,-16,-55,53,-7,-46,-8,-23,46,-14,15,-17,-18,18,0,-47,-27,15,17,-6,-13,11,20,7,-34,26,-33,-2,-37,-44,23,-14,8,-35,6,61,-20,55,4,15,49,-21,-52,60,-24,-66,-22,12,38,11,22,-30,28,-43]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.120","t":"The following sections of this module addresses three specific techniques: progressive muscle relaxation, deep breathing, and imagery. You largely determine selection of a specific technique, but you should select it with the patient's expressed interests and learning preferences/abilities in mind. For example, patients who are largely somatically focused may prefer muscle relaxation or deep breathing. Other patients, especially those who appreciate the association between thoughts and mood, might be best served using guided imagery procedures. However, the ultimate decision of which procedure to use may relate to exposure to all three techniques and a trial-and-error approach. 120","e":[10,52,-184,-53,11,-7,36,-19,2,-21,26,1,46,43,-29,-40,23,-73,-13,28,-84,-17,-40,-4,13,34,8,-3,-12,17,51,-16,21,-17,-21,-74,43,51,6,31,17,-48,51,-75,19,-22,21,-7,24,-14,55,-37,-11,-70,88,2,-6,19,37,-75,85,31,-34,25,45,-27,-86,58,8,9,61,-34,51,45,-46,10,-24,-50,27,11,36,-55,82,-36,45,19,30,33,-9,75,-4,12,28,86,-70,29,20,42,-3,-69,-78,12,41,-15,-7,13,28,2,1,10,-27,16,-18,1,-8,-13,63,-39,20,38,-27,-13,30,-2,-8,48,-69,-42,17,-22,1,-34,-43,7,4,60,-36,-21,-9,-3,14,-25,-24,-15,-15,-31,2,-14,-22,6,56,30,41,3,59,-59,-54,13,48,27,53,14,-3,46,4,-62,35,30,58,-15,-41,-29,-17,-4,94,15,88,-71,29,-45,28,-9,-22,39,3,14,15,-27,-63,-34,2,22,-55,-16,-75,-24,36,-7,1,-21,-8,-3,-11,16,-43,77,-11,18,-11,-30,49,0,-9,11,-17,-16,-15,-26,-46,9,38,5,-22,-22,15,-28,-40,-9,-6,7,-33,-93,71,10,36,1,2,4,11,15,-3,14,36,-3,-72,28,16,-30,19,17,-15,25,13,-25,28,13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.121","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 PROGRESSIVE MUSCLE RELAXATION (PMR) PMR consists of learning how to tense and then relax various groups of muscles all through the body in a sequential fashion, while paying close attention to the feelings associated with both tension and relaxation. Although muscle relaxation has been around for many years, it has become more popular recently for dealing with different anxiety and panic disorders. With this procedure, the patient learns how to relax and how to recognize and pinpoint tension and relaxation in the body to identify tension and reduce its influence before each reaches high levels/impairment.","e":[33,15,-197,-6,26,-39,31,-20,31,-57,-23,7,11,-5,30,-36,-4,-78,-37,10,-40,18,3,23,29,83,8,-39,-11,2,43,-29,8,-43,-13,-80,76,35,-33,18,7,-58,54,-57,44,-8,53,5,0,20,57,-63,20,-71,84,15,23,11,35,-40,114,10,-56,73,27,-55,-60,38,18,48,48,-35,26,35,-44,-18,-58,-31,8,-3,45,-22,76,-20,59,-13,12,0,-43,87,46,-7,27,49,-52,22,21,-5,-29,-53,-64,-11,52,8,-2,76,-4,-38,-17,33,-43,32,-7,-2,-1,2,79,-25,4,41,7,-14,10,6,-27,53,-43,-10,39,-11,-13,-9,-31,-14,2,71,-10,-8,15,26,18,-24,-24,-18,-31,-22,12,-37,-47,7,34,1,19,-12,56,-32,-47,10,94,32,35,-8,-43,57,-11,-51,31,68,42,5,-27,-56,0,-22,45,56,89,-42,33,-58,16,-7,5,24,-21,29,-6,-13,-59,-32,-19,40,-78,-14,-57,-58,41,-23,34,-31,-24,-22,6,-3,-24,52,-1,31,18,-13,68,-16,2,-4,-24,-48,-11,-3,-24,12,16,18,-35,14,6,-2,-16,-13,8,24,-47,-55,34,85,22,16,22,37,-23,5,41,40,22,9,-72,49,14,-34,4,8,7,-5,38,-1,42,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.121","t":"In teaching patients muscle relaxation, you should first explain the reason for using muscle relaxation and how it will benefit the patient (rationale). You should also give a full explanation and demonstration of how it is done. Step #1: PMR Increases Control. Introduce PMR principles and procedures. PMR begins by letting patients know that they can create sensations of relaxation and that this process of “inducing” relaxation begins by being able to identify and discriminate between sensations of tension and relaxation.","e":[32,64,-179,-13,42,-42,18,-13,45,-40,-30,28,29,19,14,-25,10,-102,-38,26,-52,5,-17,-20,7,56,1,-19,-7,1,48,-3,56,-30,-6,-82,54,72,-28,18,-6,-57,47,-50,28,-40,39,-20,18,36,69,-85,-19,-40,93,14,12,17,65,-55,94,14,-43,44,34,-8,-44,45,32,52,39,-24,26,5,-33,0,-28,-6,13,-2,59,8,65,-51,50,15,1,-24,-30,80,38,0,60,53,-57,-13,14,23,-15,-47,-71,-1,67,-4,10,81,48,-1,-1,30,-51,16,-16,-3,3,0,85,-37,14,63,-13,4,-7,20,-21,28,-40,-17,46,4,-9,-31,-60,-3,23,71,5,-9,21,-13,14,-18,-34,-23,-55,-22,31,-19,-20,44,33,19,22,8,71,-67,-54,0,71,6,70,-12,-60,55,10,-38,35,34,21,-27,-14,-59,-16,-9,34,45,104,-41,26,-60,39,-41,24,7,-3,3,19,-19,-109,-22,-39,33,-55,-27,-61,-50,44,-27,19,-4,-28,-35,-13,-21,-48,54,-22,8,-2,7,31,-19,-5,-22,-51,-20,8,-7,-33,16,24,-5,-30,5,2,-11,-47,-9,-8,18,-50,-54,29,56,30,-26,1,22,1,4,27,17,53,8,-75,19,18,-41,14,11,19,12,31,15,41,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.121","t":"Step #2: Note the Incongruence of Tension and Relaxation. Inform the patient that sensations of tension and relaxation cannot occur at the same time. No muscles in the body can be tensed and relaxed at the same time. This principle is critical, and you should ensure that patients fully understand how this applies to their current difficulties.","e":[56,38,-187,-17,53,-7,7,-16,31,-32,-33,28,-7,31,8,-13,44,-76,-14,45,-57,17,-8,-34,16,109,7,-32,-49,-11,63,-5,47,-42,-29,-75,36,9,-13,9,50,-38,48,-92,25,-31,36,26,10,8,57,-45,-25,-56,109,27,59,19,50,-54,53,-5,-2,57,56,-18,-52,52,44,15,39,-15,37,13,-56,9,16,-8,-10,4,27,30,104,-32,69,-19,-4,-27,-10,102,42,-12,61,20,-65,-5,33,74,-40,-73,-88,14,12,-17,-26,16,14,13,7,-13,-47,19,-3,3,29,-10,74,-16,9,24,-29,17,13,21,-11,38,-34,9,46,-43,3,-2,-45,13,-5,49,7,-27,7,-16,53,0,-25,0,-47,-56,15,-41,-48,23,23,15,14,11,41,-54,-23,9,35,-4,53,-31,-25,58,38,-39,1,65,48,-9,-73,-48,-9,14,70,58,55,-58,6,-62,2,4,-17,-6,-3,1,11,-18,-94,-28,-24,4,-62,-33,-34,-32,63,-12,23,-4,-25,-14,-10,2,-56,68,-46,-6,23,-13,37,-18,-31,-6,-25,-45,30,-31,-29,4,21,13,-14,-7,0,-19,-59,-4,-31,-7,-19,-66,39,32,17,17,0,19,7,28,-6,12,45,22,-73,47,39,-35,27,38,1,-15,-3,28,33,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.121","t":"Step #3: Identify States of Tension. Explain to the patient that tension often builds gradually without conscious awareness. Learning to detect the initial signs of an increase is an important step towards avoiding a full-blown occurrence of tension. Inform patients that, no matter the level of intensity, they can stop and reverse the tension using knowledge of PMR – in essence, it is never too late to reduce tension. Over time patients become increasingly skilled at identifying stress earlier and earlier (e.g., their awareness increases). Step #4: Tense Muscle Groups. Highlight 16.2","e":[65,6,-191,-9,53,-34,38,-6,30,-33,-39,19,19,20,47,-20,37,-103,10,28,-42,16,15,3,-17,91,-2,-26,-27,-5,72,-15,15,-50,-49,-69,63,44,2,17,22,-55,40,-43,12,-22,12,20,47,10,51,-68,-15,-21,86,45,5,1,74,-60,89,24,-50,64,11,-32,-50,39,32,48,31,1,45,-1,-43,10,-13,-16,14,-6,61,12,89,-68,77,10,6,-29,-13,96,48,20,43,23,-74,-9,20,42,-35,-75,-54,-32,-2,-20,-2,62,14,-36,15,15,-63,42,-21,-43,-9,14,73,-12,-9,41,-10,-1,21,50,8,18,-34,-12,54,-32,-11,-30,-36,-4,-6,105,-13,-21,26,28,42,15,-26,-31,-19,-49,26,-45,-20,15,19,14,-6,31,47,-40,-33,-3,59,10,45,-30,-72,48,9,-64,29,66,21,-9,-39,-52,14,-6,37,36,89,-54,48,-45,26,-33,41,31,1,-25,7,-18,-78,-20,-21,35,-71,-12,-49,-59,39,-18,40,-18,-24,-36,-21,5,-44,75,-6,-18,1,-6,34,-23,-25,-17,-26,-23,12,14,-24,31,21,10,-15,2,-4,1,-31,-4,-6,9,-46,-46,46,50,35,-13,-7,46,-1,45,-3,15,43,3,-63,32,33,-37,-21,20,43,5,33,38,23,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.121","t":"A brief word of caution: If at any point during the technique a patient experiences pain, alter or completely discontinue the technique. If the patient experiences chronic pain in any part of the body, it is best to avoid the tensing component when the patient gets to those muscle groups.","e":[96,41,-172,-21,32,-18,16,-16,15,-35,-23,11,22,-5,23,-25,-13,-82,-11,42,-57,-39,-16,0,-1,61,20,7,-51,11,51,-4,52,-65,-73,-72,56,19,1,3,55,-45,24,-79,42,-36,32,19,23,27,27,-96,-67,-65,97,-40,19,-5,63,-53,52,33,-59,45,28,-22,-76,35,41,19,64,8,31,29,-50,36,3,-42,-41,12,4,-5,67,-41,45,-15,20,-14,-24,90,24,4,60,41,-81,-7,29,49,-18,-63,-27,22,-10,-6,-22,11,36,5,24,-3,-41,46,-6,-21,14,11,62,-49,0,43,-36,1,-6,60,-3,52,-65,-9,55,-40,-32,-15,-32,15,24,58,-10,-33,32,2,48,15,22,-32,-18,-40,5,-24,-1,14,7,16,4,17,61,-34,-26,43,69,16,58,1,-42,40,-4,-67,-25,59,40,4,-86,-46,23,-36,73,23,33,-21,23,-32,-5,-22,29,14,-5,-3,15,-16,-79,-40,-8,11,-57,0,-71,-41,53,31,46,-23,16,2,-49,10,-52,34,-33,9,-38,-39,72,-12,-20,8,-46,-23,26,-25,-36,62,23,2,-17,-20,6,-24,-28,-22,-9,16,-27,-85,43,3,-16,16,-2,48,12,5,27,6,14,-24,-71,31,26,-29,24,-5,16,1,-10,35,31,7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.121","t":"PMR asks the patient to tense and release different muscle groups in sequence, moving from the arms to the face, neck, chest and shoulders, torso, and legs. For each specific muscle group, it’s important to try to tense only that muscle group during the tensing part of the exercise. Throughout the procedure, it is important to concentrate on the sensations produced by the different exercises. Asking the patient to describe bodily sensations is 121","e":[20,39,-197,-7,32,-47,24,-21,9,-38,-30,16,22,41,27,-37,-4,-112,-4,45,-53,0,-17,13,31,73,40,-45,-49,-20,45,14,34,-66,-34,-93,48,25,-33,23,34,-64,24,-42,30,-7,41,-3,13,48,44,-53,-31,-75,68,-12,40,14,80,-34,82,1,-68,52,53,-25,-52,44,14,36,43,-10,52,13,-51,9,-34,-27,14,-2,52,15,78,-24,68,13,0,-16,-32,89,44,17,36,64,-70,-7,35,34,-25,-47,-72,3,19,-5,4,49,41,19,27,14,-20,43,-26,19,-10,1,86,-32,-2,57,4,1,6,10,-40,-4,-39,-27,39,-28,-25,-46,-40,-7,7,57,-3,-15,23,2,17,-4,-37,-43,-37,-45,26,-34,-29,27,27,11,20,11,73,-50,-26,25,50,15,51,-9,-39,43,2,-71,-10,57,51,-15,-33,-57,-11,-9,35,47,82,-47,43,-51,29,-29,10,8,-22,-8,14,-7,-96,-20,-17,33,-61,-27,-65,-37,42,-27,31,-9,12,-26,-28,-13,-31,58,-13,44,-4,-3,59,-31,12,6,-24,-37,4,-17,-6,36,15,6,-21,17,21,4,-38,-24,1,10,-46,-38,48,47,-17,-15,12,39,-11,-3,11,10,27,2,-92,56,20,-27,17,23,-6,1,16,4,38,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.122","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 very important for the learning process. Statements or phrases from you might include: “What are you noticing about your body right now?” These questions help the patient to focus on the way the body “feels” when tense and relaxed.","e":[2,-8,-152,-39,73,19,48,-28,14,-52,-22,8,51,28,13,-41,-14,-92,-3,20,-33,2,-24,11,42,49,-8,31,-36,-7,37,-55,19,-54,-57,-78,69,26,-74,-5,59,-28,-2,-67,48,37,88,21,-8,-6,-5,-57,18,-34,135,26,33,9,0,-31,110,60,-69,49,9,-44,-54,53,-48,30,47,-12,8,43,-54,-24,-32,-9,0,36,20,-14,101,-15,39,-20,-13,-10,-8,81,49,0,0,37,-90,41,10,5,-9,-48,-62,-23,4,-28,10,40,6,-7,0,-22,-52,31,-25,19,-30,16,56,-39,-16,47,-24,-7,37,29,36,61,-38,-3,22,-38,13,3,-35,-31,14,71,-4,12,33,25,22,36,-10,4,-28,-49,9,-23,-29,-34,3,-15,26,7,37,-34,-16,-20,57,38,30,0,-32,46,-34,-49,2,41,53,37,-58,-49,12,-13,49,30,52,-35,36,-55,10,10,9,61,-32,-16,-7,-16,-41,-24,-22,28,-54,-19,-62,-37,32,-24,34,-33,-7,14,-14,25,-44,44,-24,19,-30,-55,96,-23,-15,11,-25,-6,-10,-13,-33,25,21,10,-10,-21,0,2,-19,-23,-29,36,-22,-87,52,47,5,22,5,27,15,29,23,36,59,-28,-70,36,18,-44,6,24,-26,3,25,3,25,8]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.122","t":"TENSING INSTRUCTIONS Model each tension procedure. Ask the patient to practice, and provide feedback. Check to be sure that the patient can identify tension in each group before moving on to the next. a. Dominant arm. Make a fist and tense biceps; pull wrist upward, while pushing elbow down against the arm of chair or bed. b. Nondominant arm. Same as above. c. Forehead, lower cheeks and jaw. Lift eyebrows as high as possible, bite teeth together, and pull corners of mouth tightly. d. Neck and throat. Pull chin down toward chest; at the same time, try to prevent it from actually touching the chest. Counterpose muscles in front part of neck against those in the back part of neck. e. Shoulders, chest, and upper back/abdomen. Take a deep breath and hold it. At the same time, pull the shoulder blades back and together, trying to make them touch. Try to keep your arms as relaxed as possible while tensing this muscle group. At the same time make the stomach hard by pressing it out, as if someone were going to hit you in the stomach. f. Dominant leg. Lift foot off the floor and push down on the chair with thigh. g. Nondominant leg. Same as above.","e":[38,32,-180,-32,29,-48,26,-13,14,-51,-38,-23,33,2,56,16,29,-96,13,11,-44,-26,-9,2,12,58,6,12,-79,-43,5,21,36,-63,-35,-44,51,2,-36,38,52,-46,6,-61,15,-27,30,-6,6,35,5,-59,-30,-125,66,-32,33,33,105,-22,75,17,-62,71,11,-10,-48,81,49,9,37,20,66,-23,-77,-6,-12,-31,-7,-20,36,0,67,-55,59,-33,-25,-13,-16,78,48,43,33,38,-30,-5,36,36,-33,-94,-42,14,-23,-15,-49,40,45,12,-4,-8,-37,34,-3,8,-2,11,69,-13,1,29,-5,-7,-10,-21,-1,3,-71,15,10,-31,7,-22,-45,0,33,69,-31,-62,41,-14,24,23,-33,-51,3,-25,4,-23,-27,29,24,-7,23,14,69,-11,7,6,39,35,51,-36,-50,33,28,-56,9,80,54,23,-72,-54,-13,-37,18,45,50,-66,24,-45,25,-32,29,13,-41,-8,-15,-17,-57,-41,22,61,-37,-28,-31,-40,81,15,43,5,-19,-37,-4,13,-32,62,-32,7,17,-16,21,-13,1,-13,0,-30,8,-36,-34,41,26,-10,-16,1,30,-13,-26,11,13,-7,-30,-50,12,-13,17,7,7,70,-6,23,-5,10,37,-31,-76,48,20,12,18,2,26,29,-4,-17,-9,-29]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.122","t":"Step #5: Debrief After the Exercise. After relaxation training, question the patient about his or her reaction to the muscle- relaxation exercise. It is also important to make any adjustments needed to the training. Monitor any pain the patient experienced to adapt and improve the technique for the individual patient’s needs.","e":[25,42,-174,-9,54,-50,64,-11,36,-82,-75,30,40,5,27,-46,35,-142,-28,-6,-41,-2,-35,-35,31,59,35,20,-22,-7,16,-5,41,-22,-22,-52,38,35,-17,-12,54,-27,27,-60,52,-4,39,-14,12,21,53,-53,-54,-49,85,-8,41,5,52,-87,79,-22,-63,24,33,-53,-63,61,24,7,48,-22,18,62,-39,21,13,12,-32,1,3,23,106,-51,29,2,-20,5,-8,102,35,1,62,54,-61,19,28,37,-25,-39,-37,-21,30,-46,20,42,-4,28,18,-14,-36,16,-13,14,10,16,75,-49,-20,48,-30,-14,-12,2,34,-7,-46,-22,46,-5,0,-13,-55,28,4,63,-2,8,-20,-50,20,-20,-7,2,-20,-36,31,-49,-16,38,-21,-32,21,-20,94,-49,-56,5,73,35,79,-35,-13,69,40,-28,4,43,73,-7,-36,-94,11,-54,60,50,36,-61,-23,-52,8,21,52,31,5,-4,14,-25,-67,-31,-18,43,-57,-37,-58,-4,50,-13,15,-14,-17,-38,-29,8,-19,33,-28,1,-32,-31,48,-4,3,-7,-15,-13,28,-28,-23,10,27,-14,-32,-2,13,-2,-29,-12,-27,13,-34,-90,45,39,27,-16,-8,50,7,18,28,24,51,12,-63,43,31,-17,16,-17,26,6,2,35,9,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.122","t":"Step #6: Continue to Practice Outside Session. It will be important for the patients to practice PMR at least once a day over the first week or two to build skills and confidence. As they become increasingly skilled at PMR, they might find it possible to relax without having to actively tense the muscles. The patients should use regularly scheduled homework to practice in a nondistracting environment. When they have learned to relax in a calm environment, it should be easier to relax in more distracting situations, whenever they notice tension developing. 122","e":[20,28,-201,-10,13,-40,28,-30,47,-54,-33,-17,-25,21,4,3,19,-103,-40,0,-60,-2,-2,-6,-14,71,9,-45,-20,18,19,-25,9,-66,1,-79,70,45,-4,-17,40,-38,43,-43,54,-45,45,-6,35,19,51,-74,-21,-26,67,35,33,-9,63,-57,142,-4,-78,81,-18,-27,-67,47,3,48,41,-9,59,9,-42,7,-21,-24,17,30,60,11,94,-54,97,14,-5,-22,-21,85,46,-5,31,29,-40,-9,9,55,-48,-34,-51,-20,32,-3,8,49,6,-2,-24,19,-34,17,-22,-37,22,43,66,-28,34,62,-27,-16,27,19,6,51,-21,-20,42,-5,-21,-21,-55,13,-2,79,-15,5,0,12,41,8,-23,-17,-22,-19,2,-58,-32,51,-1,4,29,1,62,-38,-49,17,113,18,56,-13,-66,56,6,-42,20,77,9,-7,-22,-72,2,-48,26,20,63,-37,23,-54,42,-30,-16,2,-14,16,6,-19,-67,-19,0,44,-69,-11,-78,-41,68,-27,24,-10,-26,5,-5,-2,-34,65,-9,-24,6,-27,38,-11,-21,15,-2,-56,-5,14,-41,58,26,-20,-36,-12,6,17,-33,24,7,46,-44,-63,14,43,38,-13,-7,29,-4,20,40,39,30,10,-80,23,10,-7,-7,12,50,15,42,6,10,-13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.123","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 DEEP-BREATHING TECHNIQUE Another physiological-based relaxation technique is deep breathing. Deep breathing focuses on reducing rapid and shallow (ineffective) breathing that often occurs during periods of stress, worry, or anxiety. Rapid and shallow breaths can lead the patient to have decreased oxygen in the system, which can cause hyperventilation, dizziness, lightheadedness, or decreased ability to concentrate. Alternatively, taking a deep, full breath can produce a feeling of calmness or slowing by increasing oxygen-rich blood flow. It can also strengthen muscles in the chest and stomach, which can make it easier to breathe on a daily basis.","e":[53,41,-190,-12,25,9,62,3,29,-66,-22,20,56,23,-11,-38,-19,-83,-15,-14,-56,-1,-14,-14,4,58,13,23,-24,3,63,-34,11,1,-18,-52,43,65,6,45,46,-78,76,-66,-6,-6,17,0,-4,-37,53,-87,-61,-73,97,8,-19,30,16,-53,71,31,0,60,48,-28,-52,60,-5,1,40,-47,14,36,-55,40,-38,-20,21,13,19,-24,84,3,90,1,-15,-5,-3,83,11,-14,43,47,-62,26,64,33,-39,-78,-61,-3,13,2,2,6,0,-20,-2,11,-62,24,-14,-8,4,23,53,-18,9,36,-4,-5,25,-10,3,76,-86,-32,37,-24,-15,-9,-51,2,-4,14,-43,-4,-3,9,33,-11,5,-8,-16,-60,5,-38,-36,-1,15,3,53,25,61,-14,-68,28,53,48,33,21,-12,28,-16,-37,3,47,29,47,-45,-42,-26,22,71,28,110,-59,-16,-83,27,6,-18,11,-3,2,4,-30,-54,-65,-6,-9,-13,-19,-78,-30,32,-15,7,-12,-36,-31,10,-17,-17,77,-25,15,-20,-17,54,-7,-3,7,17,3,-30,-14,-28,51,23,-25,-35,-27,17,-44,-46,-32,-8,-19,-1,-84,54,33,32,19,5,22,7,26,14,0,20,-10,-58,7,-17,-55,10,1,-16,5,35,-12,10,13]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.123","t":"STEPS TO DEEP BREATHING: Step #1: Introduce the patient to Deep Breathing. Indicate why Deep Breathing was chosen, and provide an overview of the procedures and potential benefits. Step #2: Ask the patient to put one hand on the abdomen, with the little finger about one inch above the navel, and to place one hand on the chest. Step #3: Ask the patient to pay attention to their breathing (pause for several seconds to allow the patient the opportunity to assess breathing) and then to tell you which hand is doing more of the moving. Ideally, the hand on the abdomen should be moving; while the hand over the chest remains still. This ensures that the breaths are deep.","e":[41,37,-167,-28,30,46,27,19,20,-71,-62,43,54,36,9,-41,11,-95,-14,6,-64,-35,-45,-12,19,-16,13,44,-52,10,32,-12,43,0,4,-91,33,46,-15,13,42,-68,40,-66,11,-5,22,-5,15,-16,8,-58,-73,-42,59,13,4,0,77,-41,61,32,-7,43,30,17,-59,72,25,9,18,-15,73,19,-56,33,-47,-27,38,1,36,-9,115,-16,41,6,-2,-15,-12,73,18,25,36,81,-35,-7,19,82,-22,-116,-67,19,-15,41,-21,61,48,10,-4,-24,-55,-11,6,-24,22,48,44,-8,25,58,-26,35,22,1,19,25,-87,-28,29,-12,4,-3,-37,-5,-9,18,-33,-14,-1,1,15,10,5,-29,-9,-41,17,-40,-34,6,39,16,63,28,85,-25,-19,18,37,51,41,13,-34,44,1,-43,-20,27,21,38,-15,-48,12,-1,41,9,66,-50,-8,-72,68,-22,18,41,-17,-18,-15,-27,-35,-73,-6,4,-10,-8,-58,37,47,-16,4,-4,-5,-33,13,13,-28,88,8,24,-21,0,38,-3,-34,-19,-2,63,-21,-19,-47,37,15,-21,-14,-23,46,-3,-29,-13,13,-25,-6,-67,39,-21,9,-7,-34,44,-7,64,-6,-26,58,-2,-69,29,2,-42,-11,16,-13,14,34,-8,2,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.123","t":"Step #4: Work with the patient to take deeper breaths by getting the hand over the stomach to move while having little movement of the hand over the chest. Inform the patient, ”Your hand on your diaphragm should move out as you inhale and in as you exhale.” Highlight 16.3 NOTE: Patients with a lung or heart condition might have difficulty with deep breathing. If patients report difficulty, slow the process down and help them to maximize the exercise comfortably. Step #5: To pace the patient, you might suggest saying the words in and out slowly, while taking breaths. Inhalations and exhalations should build to approximately three seconds in duration.","e":[68,42,-180,-1,30,24,26,28,2,-88,-52,25,28,41,33,-16,10,-77,-18,1,-36,-37,-18,-35,22,9,12,-1,-51,1,47,-18,29,-8,-26,-72,59,15,-2,30,24,-76,55,-20,62,-18,19,15,-13,-18,-15,-65,-98,-43,20,18,17,-1,69,-58,66,-5,-25,46,48,-4,-57,50,14,4,27,-11,52,6,-52,45,-56,-24,53,20,14,-11,114,-12,76,2,-9,-4,-10,96,22,-13,35,64,-50,8,11,72,-17,-103,-57,-5,-1,11,-12,33,53,14,-19,-10,-65,7,-12,-30,10,60,48,-13,39,52,-2,25,19,-5,27,3,-81,-36,41,-19,5,-6,-35,12,-25,-2,-13,-3,-17,-5,31,7,47,-23,-20,-28,6,-44,-50,-4,18,6,48,69,80,-18,-18,37,44,19,42,3,-48,52,2,-59,5,64,21,46,-37,-48,-6,16,41,28,67,-47,-36,-78,67,-35,-15,35,-16,-3,12,-29,-39,-76,29,15,5,3,-58,-1,67,-17,9,-33,-10,-33,22,10,-20,54,-36,12,-8,-12,53,-10,-51,-18,20,18,-25,-6,-27,36,-4,-47,0,-38,22,-29,-36,7,-10,-6,4,-56,50,-8,43,-14,-28,58,-10,51,19,-17,53,0,-59,44,12,-37,-23,33,-4,34,54,-37,0,-17]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.123","t":"Step #6: Ask patients if they notice any changes in breathing and feelings of relaxation. Ask for general feedback about the technique. Step #7: Repeat the breathing exercise three or more times until the patient reports skill understanding and benefit. Step #8: Ask the patient to identify situations when deep breathing might be appropriate. 123","e":[2,16,-183,-28,40,-7,52,-20,51,-37,-47,42,17,62,-20,-40,16,-141,-11,9,-44,-30,-45,-47,-5,29,-2,40,-53,-9,50,7,50,-6,-19,-63,46,38,-27,14,65,-56,46,-56,45,-13,31,-21,4,-23,21,-51,-64,-29,56,24,-12,17,50,-74,62,4,-18,58,53,-1,-45,75,-9,-13,33,-35,56,24,-61,23,-43,4,23,9,27,-17,123,-23,59,14,-7,1,0,65,-2,9,64,51,-54,-13,17,42,-39,-86,-79,-8,8,-6,-36,37,17,33,0,-12,-56,4,-15,-9,0,26,54,-18,6,67,-39,2,-3,-3,19,9,-80,-36,20,-10,8,-1,-47,4,-35,24,-3,11,-6,-18,28,-11,11,1,2,-41,19,-34,-28,22,37,-8,79,2,65,-68,-78,6,46,47,48,-15,-47,59,-2,-13,9,48,47,18,-32,-56,-12,-2,60,15,70,-50,-14,-59,34,-10,19,27,3,-9,9,-48,-52,-69,2,7,-9,-24,-53,11,37,-44,8,-11,-19,-26,3,5,-36,64,-12,-5,-30,-15,49,-22,-14,18,-38,37,-7,-10,-29,43,20,-26,-47,-28,37,-17,-54,-13,3,6,-14,-92,30,-3,38,-4,-43,33,9,45,8,8,44,21,-76,28,0,-29,19,13,9,22,24,14,13,-11]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.124","t":"Other tips for Deep Breathing: 1. Inhale through nose and out of mouth. 2. Ask patient to purse lips (as if blowing on hot soup) while exhaling. 3. Do not pause between inhales and exhales. 4. Ask patient to close eyes during the exercise. 5. Patient may want to use mantra such as “relax” during each exhale. 6. Pair up deep breathing with imagery once the patient has begun to master breathing skills. 7. Point out that deep breathing is a portable skill that can be used in a variety of situations and relatively without notice of others (PMR is less portable).","e":[29,13,-170,-26,19,-9,21,-12,31,-45,-23,14,13,51,13,-21,-11,-130,-16,25,-74,-44,-3,-25,-5,8,12,6,-27,-13,66,-39,10,-12,10,-48,43,56,-18,33,49,-67,70,-22,45,-6,14,2,0,-13,69,-44,-72,-51,66,4,15,3,76,-50,96,-18,-22,67,44,-10,-74,83,-3,25,52,-27,65,18,-30,32,-39,-30,44,33,15,-5,110,-26,75,19,-8,-8,-19,56,7,4,56,91,-30,22,16,70,-43,-81,-51,26,36,20,6,49,54,19,-12,5,-58,9,-13,-25,-27,52,69,-40,32,47,-13,33,24,-17,-5,32,-56,-75,22,-23,-13,-25,-42,-2,-15,32,-39,0,12,-15,27,-11,7,-23,-27,-53,-30,-55,-36,36,30,9,46,39,91,-12,-61,-1,63,30,28,-4,-64,46,17,-30,-2,75,23,14,-28,-34,-2,-10,50,3,95,-48,-19,-59,73,-23,-25,53,-7,14,11,-12,-57,-45,-8,16,1,-16,-67,-18,54,-27,31,-14,-28,-28,8,29,-10,68,-5,11,-3,6,44,-6,-13,-32,-16,52,-22,-9,-57,46,14,-20,-32,-18,39,-13,-37,7,18,6,-8,-80,46,29,31,-22,-14,68,-23,26,21,-7,49,-23,-81,22,-21,-37,8,12,-3,37,59,-21,22,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.124","t":"IMAGERY Imagery is a cognitive relaxation technique that can be used to ease stress and promote an overall sense of well-being. Imagery focuses on increasing cognitive, emotional, and physical control by changing the focus of an individual’s thoughts. We all have daydreamed about pleasant things that have distracted us and made us feel better. Imagery uses much the same process but encourages positive adaptive “dreaming” that distracts and relaxes the individual. Imagery is highly effective for depression and anxiety, as well as specific situations that require clarity, focus, distraction, or feelings of mastery. The following are examples: Table 16.1 Imagery Examples","e":[-12,62,-172,-74,32,-48,28,-2,15,16,41,5,92,52,30,-1,-26,-33,-33,23,-56,-15,-25,15,2,53,24,-7,-27,32,24,-16,-8,-33,-18,-51,47,64,78,9,-9,-12,39,-14,2,-8,37,2,25,-11,27,-34,15,-55,124,16,-1,3,8,-52,77,67,-32,41,53,-39,-89,28,25,21,78,-54,11,44,-58,-19,-24,-44,14,13,88,-75,31,-22,58,49,28,-18,-8,64,40,-9,-27,66,-57,38,27,16,-22,4,-88,-23,48,-65,4,41,-15,21,-5,36,-13,1,-7,-14,1,-4,69,-14,19,13,16,23,41,24,-5,39,-35,-40,12,-15,-17,-44,-16,10,26,61,-44,-8,-2,15,39,-15,-16,-49,-11,-32,26,-18,-52,3,14,-3,15,-1,41,-14,-22,30,38,-10,74,51,2,35,2,-52,41,20,46,-2,-51,-20,-65,-4,63,-5,111,-33,25,-44,-11,-43,24,9,-13,-8,49,-18,-48,-32,-10,13,-25,-15,-77,-39,7,-15,28,-19,-25,-19,-1,12,-32,62,-26,-13,1,-35,35,12,25,37,4,2,-2,-36,-26,-28,31,9,-15,11,15,-9,-12,2,-22,19,-29,-76,77,14,42,18,9,46,-11,15,-5,33,-7,21,-48,18,8,-47,-10,15,10,-21,8,0,74,-33]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.124","t":"TOPIC FOCUSED TOPIC IMAGE OUTCOME Depression Negative Images of success or past Increased self-confidence, Self-worth situations of success, reduced negative thoughts’ images of a pleasant past distraction from negative experience mood Anxiety/ Public Speaking Image of speech that goes Reduced negative focus, Worry well, image of something distraction, increased positive funny expectations Medical Fear of Procedure Relaxation, peacefulness, Less tension, reduced anxiety, Anxiety (e.g., needles) pain-free environment toleration of procedure with less distress Sports Focused efforts Envisioning the desired shot, Increased focus, increased self- Performance during golf game positive words of advice confidence, positive thinking","e":[27,20,-143,-55,57,10,44,-38,0,-47,5,22,68,40,40,0,-31,-70,-32,62,-73,-29,-73,-25,-15,67,-2,-31,-42,16,18,-48,-29,-45,-33,-8,46,79,57,20,56,-2,2,-74,1,-14,53,29,57,-63,71,-32,6,-39,89,12,13,12,28,1,72,52,-69,33,57,-68,-37,67,-40,15,33,32,-10,39,-37,9,17,-45,-19,14,43,-54,22,-45,43,16,14,13,-27,53,33,40,9,66,-94,84,26,-1,-22,-14,-40,-28,70,-27,26,67,-30,-12,-14,12,-45,37,-29,-33,18,-42,88,7,13,9,13,1,32,33,-13,17,-43,-31,42,-16,3,-38,-18,45,29,54,-16,-19,29,23,65,-7,-32,-6,-10,-94,31,-26,-28,12,6,-18,19,31,47,-54,-47,1,44,-6,51,18,-5,38,-31,-37,37,-4,28,55,-16,-39,-32,-13,70,-17,76,-14,2,-32,-3,-50,33,40,9,-4,54,-2,-35,-19,-20,43,-28,-66,-82,-61,38,5,8,-19,-6,20,-8,34,-29,50,20,-24,-23,-30,16,-12,-2,-5,26,29,-30,3,-31,-6,13,-14,-52,-13,63,28,-24,2,-55,16,-45,-112,38,0,-6,-3,20,14,-13,57,-21,30,25,10,-70,31,-10,-20,8,36,3,43,7,-22,37,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.125","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 How Guided Imagery Works Research has shown that the mind can affect how the body functions. It seems the body may not know the difference between an actual event and a thought. Guided imagery uses the power of the brain—images and the perception that you are either somewhere else or in a different state of mind—to increase pleasant experiences and performance to promote wellness and health. On the flip side, imagery helps to reduce stress tension and anxiety by changing thoughts and emotions or through distraction.","e":[-13,71,-154,-69,74,7,55,26,30,-34,10,17,52,47,16,15,-6,-25,-18,28,-77,4,-21,17,-22,39,-3,-14,-5,27,76,-24,3,-48,-27,-35,63,47,22,39,-12,-22,5,-58,10,-19,82,3,6,-11,7,-21,22,-35,139,-12,15,12,19,-47,104,66,-40,27,36,-58,-110,36,-13,45,65,-38,29,46,-57,-19,-9,-19,-14,47,64,-66,47,-27,32,39,37,-7,-29,72,31,-14,2,68,-55,36,8,-18,1,-2,-85,-8,42,-35,9,39,21,-10,-2,29,-35,-32,-20,-8,-32,-18,98,-38,-5,20,20,12,18,15,15,76,-30,-51,18,-41,-7,-50,-19,-5,43,97,-26,-20,3,21,18,-4,-15,-17,-9,-41,17,-13,-33,-15,27,34,3,3,84,-39,-8,18,40,-4,80,28,11,27,-20,-44,49,17,49,0,-55,-22,-38,8,72,28,70,-16,53,-26,9,-32,-13,26,2,-14,19,-30,-44,-39,-6,17,-55,-9,-87,-43,27,-1,33,-30,-21,-5,-1,12,-26,43,-5,-2,-15,-65,70,3,12,38,-22,5,6,-23,-35,11,7,21,-4,-1,8,2,-31,-30,-21,25,-18,-42,69,22,40,34,21,24,25,38,4,23,20,17,-80,20,22,-37,5,20,4,26,5,-10,44,-4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.125","t":"Imagery is commonly referred to as guided imagery. Guided imagery refers to a process whereby you facilitate or guide the initial images the patient uses. The following section describes how you can guide the patient into the effective use of imagery for relaxation or performance improvement. Step #1: Introduce Imagery. Introduce imagery to the patient, pointing out the power of the brain or thoughts and how images, when accessed correctly, can change physical and emotional states. Step #2: Identify the Desired Outcomes, Such as Decreased Anxiety, Increased Focus, Distraction. Step #3: Develop an Image or Scene.","e":[-16,79,-155,-102,39,-23,58,1,7,5,22,17,72,45,9,5,23,-51,-36,26,-78,2,-27,2,-10,6,17,-27,-9,16,55,2,20,-34,-13,-70,45,53,46,22,4,-4,27,-38,-11,-2,40,10,2,6,23,-2,5,-35,115,16,9,23,23,-44,111,60,-48,9,48,-31,-97,28,45,26,65,-29,70,31,-67,-21,-18,-27,12,47,66,-55,40,-41,34,48,31,-5,-28,60,12,0,-15,61,-59,18,-30,23,-10,-28,-85,-25,61,-57,9,43,29,15,3,24,-5,-6,-20,-27,-20,0,110,-20,19,24,8,20,46,16,15,43,-46,-61,10,4,4,-52,-15,-7,26,93,-3,-24,-14,6,2,-20,-1,-43,20,-34,43,-16,-7,-4,40,40,8,-10,70,-48,-15,20,33,-5,96,41,-20,31,-10,-71,65,-12,48,-23,-12,-14,-26,10,63,36,106,-22,21,-26,16,-56,11,25,-1,-12,39,-25,-37,-29,3,18,-27,-15,-88,-24,34,-26,34,-12,-15,-15,-11,33,-40,68,-15,-16,-11,-27,43,-10,0,37,-16,-7,11,-11,-41,-5,27,-13,-7,-5,29,-5,-18,-2,-19,20,-41,-61,55,-12,49,-1,-16,24,5,20,-22,34,33,14,-87,14,23,-34,5,23,12,10,15,-13,59,7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.125","t":"Work with the patient on the third step to identify a situation, either in the past or a desirable place to be, that both you and the patient feel might benefit or produce the desired outcome. Sample imagery scripts are provided below and can be used if the patient has difficulty creating a personal situation. Selection of a powerful image is critical to the success of this technique. Selection of an image that the patient is able to fully embrace increases the odds of treatment success. Selection of a “weak” image (e.g., not viewed as important by the patient or unable to be fully visualized) will likely lead to treatment failure. Step #4: Increase Vividness of the Image.","e":[2,54,-167,-57,34,-19,10,9,21,14,21,19,88,42,-34,-2,44,-91,5,57,-58,-32,-26,3,7,-5,15,2,-48,12,47,29,23,-64,-36,-74,66,50,13,1,4,-2,33,-67,12,-31,34,24,15,11,12,-38,-5,-18,117,2,-5,3,16,-58,78,50,-35,54,73,-14,-66,24,2,-8,21,-3,51,11,-72,-18,-19,-32,9,52,66,-37,63,-41,43,49,49,-10,-9,66,-6,41,1,54,-111,30,0,47,-26,-21,-67,-35,23,-51,-6,58,24,31,-1,1,-44,-7,-27,-22,8,-5,53,-12,-6,38,2,26,14,52,7,25,-55,-42,37,-16,-15,-14,-24,2,44,76,21,-19,-5,22,29,16,10,-13,-26,-52,31,2,-41,19,-2,34,25,7,31,-50,-7,34,34,-10,94,-5,-43,29,2,-61,42,19,49,13,-17,-46,1,-30,63,-28,67,-23,12,-58,9,-63,3,15,5,-17,37,2,-56,-38,-4,13,-14,-7,-70,-47,28,-10,-4,-37,5,24,-40,73,-58,63,-12,-9,-34,-24,34,-4,-19,11,-15,-5,22,-22,-50,28,33,-1,-8,-7,29,18,-43,11,-19,22,-32,-97,61,32,43,-7,-16,32,-4,44,-42,5,33,6,-57,35,22,-61,-2,40,-4,21,25,-10,10,-2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.125","t":"To ensure that patients find a “strong” image, ask them to explore as many senses as possible to increase vividness of the image. For example, when imagining a glass of lemonade, imagine holding a glass that feels icy and cold; visualize the color of the lemonade; think of the fresh citrus smell; and, finally, think of how the lemonade tastes. This is an example of imagery that uses multiple senses and increases vividness of the image. Increasing vividness is largely a matter of increasing the details the patient experiences. The more details described by the patient, the more powerful the technique.","e":[23,60,-182,-69,40,-28,-2,22,28,8,31,22,83,96,-4,41,-20,-109,-10,23,-61,-10,-21,-9,-33,8,-10,26,-50,27,34,-25,-1,-29,-6,-62,65,74,56,13,20,6,52,-36,36,-1,60,-34,-1,5,6,-29,-2,-26,127,44,7,2,45,3,63,49,-4,51,47,-9,-89,57,-1,-1,41,-31,25,27,-30,19,-30,-7,-5,18,74,-12,59,-22,56,-10,38,-2,15,71,40,3,32,78,-79,-16,17,34,-19,-26,-89,-22,27,-38,-3,50,-4,37,19,19,-37,-4,-28,-22,1,5,31,-47,16,36,13,26,19,50,34,45,5,-64,15,-56,1,-38,-1,-4,22,54,9,-2,6,25,15,-36,-10,-17,-29,-82,4,-5,-21,15,2,20,32,21,27,-50,12,13,34,-8,71,9,-10,23,-6,-72,67,22,31,-8,-61,-20,-5,-25,47,-17,50,-59,19,-21,-3,-54,-18,4,-1,-21,18,-13,-41,-1,-10,9,-25,-33,-62,-25,16,-27,-3,-31,-8,7,-33,54,-46,74,-41,-8,-25,-6,30,16,3,-14,3,27,16,-36,-33,15,27,12,-3,-35,-2,-2,-26,8,-42,17,-24,-77,81,21,36,-8,-20,49,-1,20,-22,10,24,4,-64,20,31,-57,17,55,-1,12,33,9,48,12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.126","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 Step #7: Ask the Patient to Identify Situations When Imagery Might Be Appropriate. Expand upon the patient’s responses by adding other situations (e.g., how the technique can be used). Step #8: Continue Practice Outside Session. Work with the patient to set a homework assignment that encourages application of imagery to situations when the patient feels stress or feels that imagery might be beneficial. Highlight 16.5","e":[0,16,-170,-78,52,-16,26,-23,17,-35,-1,-11,47,39,-1,-17,2,-85,-9,0,-41,-6,-15,22,20,15,7,54,-43,-4,41,-37,10,-70,-45,-53,59,22,-48,1,48,-41,6,-61,36,0,96,29,6,-5,2,-36,29,-34,129,37,3,9,14,-33,99,62,-46,44,9,-25,-78,54,-28,12,62,-21,61,35,-82,-18,-57,-25,7,53,45,-9,93,-29,48,3,3,-18,-17,68,1,-4,12,44,-71,29,-2,15,-1,-50,-69,-29,19,-46,-29,59,-5,7,-4,-10,-56,3,-42,-9,-5,31,51,-14,7,59,-17,-16,29,27,37,47,-44,-32,22,-30,27,-18,-18,-14,19,50,4,-4,17,24,15,9,-4,-6,-5,-26,9,-22,-36,-20,-10,5,32,18,71,-33,-9,-7,44,19,42,-12,-54,46,-6,-46,23,43,65,29,-51,-50,-11,-11,52,33,46,-8,25,-40,19,-6,14,64,-7,-16,3,-16,-38,-25,-17,43,-41,-18,-84,-52,22,-29,14,-37,-19,33,-13,34,-57,49,-30,-2,-9,-62,64,-13,-31,27,-39,4,9,-14,-69,25,17,18,-7,-19,17,23,-1,9,-16,41,-31,-72,56,-3,26,23,-5,52,-3,46,12,41,59,7,-83,37,13,-40,-4,50,5,-13,24,-4,13,6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.126","t":"Other tips for imagery: 1. Pair up imagery with deep-breathing exercises. 2. Ask patient to close eyes during the exercise to increase vividness. 3. Interject during the imagery experience aspects that you feel might benefit the patient. For example, a patient might use a beach image; and you might ask how the sun feels on the skin, whether there are sounds, or what else is visible. 4. Help the patient focus on aspects of the image that will guide them towards the goal. Help the patient to avoid too many unnecessary details that might distract from the goal. 5. Point out that imagery is a portable skill that the patient can use in a variety of situations and completely without notice of others (PMR is less portable). 6. Avoid imagery with psychotic patients, who might confuse reality with images.","e":[8,37,-161,-67,28,-25,30,0,17,-9,34,4,47,63,-2,-2,-14,-110,-40,11,-79,-30,-18,15,-16,-5,16,-7,-43,14,65,-20,4,-44,0,-80,44,68,26,35,36,-37,41,-34,11,-5,51,1,-8,2,49,-17,-11,-29,105,-5,-14,-2,66,-53,93,16,-34,47,49,-24,-101,40,32,55,66,-24,44,45,-42,23,-37,-64,32,41,57,-18,70,-42,48,49,50,-9,-23,58,11,-3,15,93,-36,26,12,55,-22,-27,-83,15,44,-34,-1,47,26,35,5,29,-18,-20,-21,-31,-31,11,65,-52,33,40,2,34,40,20,0,13,-26,-76,21,-17,-13,-35,-27,5,-8,58,2,-6,36,13,8,7,-8,-29,-26,-66,-1,-25,-27,38,20,12,26,33,87,-27,-40,17,53,-9,61,13,-39,41,11,-69,38,44,41,-2,-8,-26,-18,-6,48,12,81,-44,-9,-31,40,-41,-14,28,-1,-3,20,-20,-60,-30,-6,33,-6,-16,-73,-25,34,-14,6,-22,-24,10,-1,43,-27,63,-28,-4,-12,-44,30,-17,-4,10,-20,47,-17,-9,-46,11,34,0,-13,-12,36,6,-21,11,-17,7,-26,-76,82,20,31,6,-27,52,-21,16,2,7,42,-9,-65,26,-11,-32,-12,34,18,17,39,-15,42,1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.126","t":"Script #1: Generic Example Once your whole body feels relaxed, travel to your favorite place to read, it can be any time or any place. This place is calm and safe... there are no worries here... Look around this place. What do you see? Do you hear the sounds around you? What are some of the sounds you hear in this place you are imagining? How does this special place smell? Walk around a little, and take in all the wonderful sights... Feel the air around you and relax.... The air is fresh, and it’s easy to breathe here. Pay attention to how your body feels..... Say to yourself, “I am totally relaxed... without worries... all the tension has drained away from my body.” Take a moment to fully experience your favorite place.... Notice the sounds, the sights, smells, and how it feels to be in this very special place. Remember that you can visit this place as often as you want and that it is wonderful. Say to yourself, “I am relaxed here... this place is special and makes me feel at peace.”","e":[-4,13,-198,-46,19,-27,28,48,22,-65,-4,34,23,41,-20,-9,10,-87,26,2,-67,-24,-5,10,23,56,-7,25,-72,-21,-15,-49,2,6,-1,-89,1,73,-18,35,55,0,9,-23,73,-64,56,-35,30,-27,-1,-59,-46,-21,83,7,39,-8,19,-34,115,5,-17,97,31,-4,-85,50,-11,-32,53,-35,-2,9,-97,15,7,22,8,19,9,-16,85,-38,31,7,42,-53,-39,57,46,-2,17,37,-7,20,33,54,-31,-66,-57,-6,-3,0,3,10,-2,-4,6,-17,7,15,10,-8,4,23,85,-44,28,18,-37,66,-30,-7,7,17,-25,-8,-9,-22,17,-20,-37,54,-3,72,0,-24,-22,-13,32,-33,-33,-27,-48,-84,2,-35,-10,0,16,16,6,5,28,-27,-5,15,70,33,30,-8,-3,39,-10,-31,-12,96,28,-2,-76,-31,-37,-16,18,-33,46,-68,5,-59,57,-22,4,-15,8,17,18,-7,-32,-38,-1,-23,-50,-35,-78,-26,31,-17,11,3,-9,-3,-10,15,-35,76,-14,-19,-24,-3,87,-29,-7,10,8,-19,9,-36,-28,13,29,-22,0,-28,26,-8,-41,-29,-13,-2,-41,-103,52,59,21,-12,-13,57,9,-13,29,28,20,0,-44,18,24,-47,32,7,10,44,38,9,34,-58]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.127","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 When you are done with your visit to this special place, open your eyes and stay in your comfortable position. Continue to breathe smoothly, in a relaxed and rhythmic fashion. Take as long as you want to enjoy and relax. Feel at ease knowing your special place is always available to you; and find that you feel relaxed, even after you leave. In-Session Example 16.2","e":[-2,1,-195,-46,31,8,57,5,35,-55,-31,12,27,6,22,-31,2,-85,7,1,-48,1,-3,12,38,48,18,59,-42,4,52,-44,28,-37,-23,-54,44,28,-56,1,79,-51,7,-63,60,-5,93,-2,8,-14,-1,-39,-11,-20,120,41,28,18,9,-15,113,20,-19,94,24,-29,-60,62,-42,-12,42,-31,10,34,-81,-1,-46,5,-1,40,5,-25,104,-38,33,-23,-4,-39,-17,60,35,-24,9,49,-65,40,10,28,-2,-66,-37,-28,-8,-4,-14,24,-22,3,14,-34,-57,11,-18,10,-14,39,49,-53,13,25,-23,0,6,11,42,69,-44,-20,30,-32,14,-1,-31,18,7,49,-9,-2,17,27,17,-8,0,0,-37,-63,21,-51,-27,-29,25,-6,23,31,47,-48,-10,13,66,46,35,-12,-26,34,-33,-21,8,38,56,20,-63,-57,-26,-6,35,-4,23,-26,29,-88,32,16,-11,40,-14,-12,-3,-36,-25,-46,19,5,-49,-27,-96,-48,33,-21,8,-45,0,18,-15,23,-39,58,-15,10,-10,-35,81,-3,-17,10,-23,-1,3,-38,-29,20,23,11,-17,-17,20,1,-30,-13,-6,30,-17,-99,50,48,23,10,13,55,1,15,53,32,31,-12,-77,52,12,-49,20,21,-13,-10,42,1,10,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.127","t":"Script #2 – The Beach: Imagine yourself walking down a sandy beach. The sand is white and warm between your toes. You are looking out over the calm, blue water. The waves are gently lapping at the shore. You feel the pleasant warmth of the sun on your skin... it’s a perfectly comfortable temperature outside. Breathe in deeply. There is a gentle breeze, and the sun is shining. Big, cotton-like clouds drift by as you hear sea gulls in the distance. You taste traces of salt on your lips. You are completely relaxed... there are no worries on this beach. There is nothing to distract you from feeling tranquil. Worries drift away. Notice the sounds, sights, smells, and how it feels to be in this very special place.","e":[1,7,-185,-62,60,39,44,9,24,-79,23,63,51,69,15,8,31,-87,66,-19,-43,-32,-2,31,33,49,6,53,-31,-40,16,-31,-56,-8,8,-112,-14,17,-3,20,44,-17,34,1,52,-103,73,-2,-21,-59,6,-28,-21,-7,11,-10,37,-24,20,26,114,14,-19,115,45,-18,-51,26,-1,-10,49,-35,-3,3,-57,22,-14,11,19,46,25,16,43,-53,61,-6,16,-17,-50,30,-11,-16,30,35,-41,13,25,67,-49,-72,-33,-4,31,-8,52,9,13,27,6,-17,0,26,-6,-15,3,14,61,-41,63,54,-29,35,-15,8,41,7,-44,-13,2,-23,8,1,-26,15,-6,45,-18,-15,-9,0,26,-20,12,-4,-26,-65,-15,-5,6,24,12,-2,18,57,33,-27,5,17,53,55,61,15,9,20,-22,-38,27,69,-1,35,-34,-34,-25,-18,12,-13,23,-42,-15,-38,41,-13,27,20,18,-51,9,-50,-34,-27,-32,-7,-67,-42,-20,-6,53,-44,13,12,18,39,-4,8,-37,65,6,1,-13,-28,60,-35,-22,-31,32,-20,18,4,-10,16,17,32,31,-1,54,50,-63,-15,-10,-10,-19,-107,64,53,24,4,-10,80,32,-4,29,46,24,27,-32,28,-2,-22,12,30,56,12,56,44,56,-52]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.127","t":"Feel the sand under your feet... you decide to stretch out on the warm, fine, white sand... breathe deeply... feel the warm air. Your body is completely relaxed, and you have an overall feeling of warmth and comfort. You look up at the clouds passing by slowly across the beautiful blue sky. You are feeling rejuvenated and completely at peace. Remember that you can visit this place as often as you want and that it is wonderful. Say to yourself, “I am relaxed here... this place is special and makes me feel peaceful and content.”","e":[46,51,-205,-35,45,23,40,36,60,-76,3,33,17,47,12,15,-10,-75,53,-13,-63,-39,-18,-1,-8,60,-4,80,-20,-24,47,-6,14,27,12,-82,36,33,45,9,40,-51,43,-16,71,-51,55,-33,31,-18,-43,-31,-44,-32,63,-22,45,-13,22,7,83,26,-19,80,35,-14,-70,43,3,4,80,-7,10,24,-74,12,5,19,12,13,51,-7,69,-31,70,-14,2,-17,-25,44,16,-12,28,46,-51,5,43,101,-56,-59,-60,18,-16,7,34,8,-19,24,6,-21,-22,17,-12,-10,13,10,72,-38,51,52,-6,46,-4,-1,26,38,-18,-20,8,-22,29,-22,-30,45,-29,43,-37,-11,-9,-4,32,-10,26,-6,-18,-64,5,-40,-16,35,1,14,25,23,41,-56,-6,12,84,47,71,16,12,49,18,-45,24,52,33,19,-37,-51,-20,-26,7,-16,43,-52,6,-52,45,-1,6,15,3,-9,22,-52,-48,-34,-13,1,-55,-51,-38,-13,42,-31,3,-24,3,26,16,-3,5,82,-21,-5,-10,-10,66,-29,17,-12,19,9,-7,-33,-13,11,19,-3,-5,-24,49,1,-69,-11,-21,11,-24,-102,72,50,21,1,18,42,12,-2,12,7,5,-16,-56,57,2,-64,7,-14,55,33,33,12,36,-42]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.127","t":"When you are done with your visit, open your eyes and stay in your comfortable position. Continue to breathe smoothly, in a relaxed and rhythmic fashion; take as long as you want to enjoy and relax. You feel at ease knowing your special place is always available to you, and you find that you feel relaxed even after you leave. In-Session Example 16.3","e":[13,27,-192,-24,-3,-2,52,13,70,-28,-19,9,14,22,38,-27,20,-101,0,12,-54,8,-29,9,3,74,34,32,-41,21,52,-7,42,-15,9,-43,0,50,9,-9,62,-59,14,-59,57,-55,57,-20,19,-29,19,-27,-79,3,96,46,64,16,45,-10,115,-11,6,91,42,-41,-58,59,-17,-25,35,-25,17,1,-88,31,5,6,9,20,18,-44,90,-49,34,13,-9,-39,-20,57,36,-47,23,59,-57,43,2,71,-13,-71,-27,-21,-9,-13,34,1,-12,27,13,-39,-55,17,12,12,-15,26,65,-65,42,25,-35,18,-25,-4,26,51,-46,-40,29,-6,11,-20,-42,67,-4,58,-4,-21,6,-2,53,-24,-4,4,-64,-45,42,-60,-12,16,26,5,2,40,36,-86,-20,33,61,20,75,-12,-10,46,-2,-14,15,26,20,-1,-44,-57,-26,-4,40,-31,31,-52,9,-71,48,-14,-16,-20,-12,-19,24,-57,-39,-38,39,-3,-30,-30,-83,-26,29,-19,-7,-24,-9,-8,-25,17,-36,79,-9,0,-14,1,54,-14,15,3,-18,2,10,-36,-19,37,24,-1,-24,-8,48,-13,-56,-1,-9,24,-18,-95,38,53,36,-10,28,58,-3,-11,38,1,24,-24,-67,45,15,-64,31,8,9,8,45,7,18,-47]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.127","t":"Script #3 – The Meadows: Imagine yourself walking through a lovely meadow. The breeze feels pleasant against your skin. You are looking out over the calm, beautiful green grass. The blades of grass are gently swaying in the breeze. You feel the pleasant warmth of the sun on your skin… it’s a perfectly comfortable temperature outside. Breathe in deeply. There is a gentle breeze, and the sun is shining. Big, cotton-like clouds drift by as you hear birds in the distance. You hear the wind blow gently through the trees. You taste the sweet summer air on your lips. You are completely relaxed... there are no worries in this meadow. There is nothing to distract you from feeling tranquil. Worries drift away. Notice the sounds, the sights, the smells, and how it feels to be in this very special place.","e":[9,-13,-195,-40,15,27,33,44,1,-44,18,25,64,70,-27,28,-38,-39,64,29,-40,-17,-18,-5,48,55,-14,13,-45,-19,24,-15,-45,30,-18,-85,9,65,-27,-2,96,-30,12,8,44,-61,100,7,15,-41,-18,-14,-48,8,33,-14,81,-37,74,16,104,27,-19,73,51,-18,-36,32,-28,-49,48,-10,22,34,-42,32,-30,2,22,19,-8,6,36,-17,59,8,9,-37,-41,46,-13,-6,13,4,-54,2,-2,61,-57,-91,-42,-8,-5,-5,56,12,-8,-8,11,-7,-16,40,-14,11,3,4,75,-19,53,66,-23,57,-47,-10,27,39,-24,-36,-5,-22,14,-1,-15,38,17,69,-14,-4,-20,-4,66,-42,5,-55,-43,-54,-32,-15,-10,-28,35,10,36,20,-15,-43,11,-13,48,66,37,-9,36,39,-1,-17,10,58,31,38,-59,-33,-18,-37,25,-49,31,-49,-6,-94,51,-9,39,4,1,-42,-8,-44,-22,-38,-17,3,-51,-59,-15,-12,23,-45,28,0,6,12,-44,0,-46,80,-9,50,-11,-35,89,-33,13,-8,6,-3,10,-54,-12,29,4,-21,39,-10,5,20,-42,2,-3,-21,-36,-79,44,49,6,-6,14,53,-4,-9,33,25,35,12,-27,47,25,-28,15,30,82,37,96,45,55,-39]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.128","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 16 Feel the cool grass under your feet... you decide to stretch out on the soft, cushiony grass... breathe deeply... feel the warm air. Your body is completely relaxed, and you have an overall feeling of warmth and comfort. You look up as the clouds pass by slowly across the beautiful blue sky. You are feeling rejuvenated and completely at peace. Remember that you can visit this place as often as you want and that it is wonderful. Say to yourself, “I am relaxed here... this place is special and makes me feel peaceful and content.”","e":[27,6,-211,-34,45,19,48,18,25,-79,-8,10,19,18,18,20,-38,-67,24,-21,-48,-10,6,6,27,62,-11,70,-33,-24,48,-36,0,1,-30,-44,62,19,-38,11,80,-44,19,-30,44,-16,99,6,21,-13,-50,-46,-14,-56,99,10,35,6,8,-33,105,47,-38,75,28,-28,-67,30,-29,0,68,-21,-3,56,-43,-17,-51,15,5,21,20,-13,80,-17,62,-31,-1,-27,-32,49,23,-13,14,29,-49,28,36,47,-37,-72,-66,15,-36,3,-9,33,-35,-17,7,-28,-46,21,-35,3,-3,18,48,-38,24,46,2,26,10,-4,51,71,-43,-31,4,-34,18,9,-30,7,-15,42,-19,3,9,26,27,-7,27,-12,-18,-51,0,-44,-20,-20,8,-6,44,2,41,-35,0,-10,67,59,28,0,-3,30,14,-32,-4,53,64,30,-62,-59,-33,-24,16,-1,18,-14,22,-78,48,30,9,47,-4,1,3,-41,-15,-37,-18,13,-75,-34,-60,-28,40,-16,7,-36,-1,23,3,1,-24,61,-16,25,-14,-66,92,-20,9,0,-11,10,6,-42,-30,19,34,22,7,-18,2,-1,-35,-3,-16,4,-20,-77,59,36,12,24,25,48,7,18,44,29,17,1,-76,62,-5,-32,10,4,43,26,52,5,18,-22]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.128","t":"When you are done with your visit, open your eyes and stay in your comfortable position. Continue to breathe smoothly, in a relaxed and rhythmic fashion; take as long as you want to enjoy and relax. You feel at ease knowing your special place is always available to you, and you find that you feel relaxed even after you leave. Highlight 16.6","e":[10,27,-190,-21,-4,4,50,20,72,-31,-21,10,19,18,36,-26,23,-102,3,16,-55,8,-27,8,4,75,35,37,-44,26,54,-6,39,-19,15,-39,-3,45,12,-7,65,-54,10,-58,60,-54,49,-18,25,-28,20,-21,-78,7,87,41,62,12,44,-4,111,-9,9,93,44,-42,-53,57,-17,-26,31,-27,15,1,-90,33,12,10,11,21,21,-45,89,-45,31,15,-8,-42,-20,57,38,-46,22,63,-51,48,3,70,-13,-80,-30,-21,-7,-13,37,-5,-13,28,18,-40,-60,17,15,12,-16,28,61,-74,40,25,-33,25,-24,-5,19,49,-42,-39,29,-7,10,-25,-44,67,-10,58,-8,-16,4,-3,54,-27,4,2,-64,-47,39,-60,-12,11,24,9,3,38,34,-84,-20,38,58,19,75,-15,1,48,-2,-14,15,22,18,5,-47,-53,-18,-3,41,-43,25,-49,10,-72,46,-11,-14,-19,-11,-18,22,-55,-40,-37,42,-2,-28,-32,-83,-21,24,-16,-9,-29,-8,-10,-27,16,-33,80,-9,-2,-17,0,49,-16,17,1,-18,1,12,-40,-16,39,21,2,-23,-1,53,-11,-61,-4,-11,22,-11,-98,47,59,37,-12,30,57,-2,-12,35,-1,29,-19,-63,45,22,-61,37,6,6,7,40,14,19,-50]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.128","t":"Other Guided Imagery Scene Suggestions: • A garden where you watch big, beautiful clouds in a blue sky, while you inhale the scent of flowers and feel a gentle breeze on your skin as the sunshine warms you. • A mountain scene where you feel calm and relaxed as you look out over the valley. Just you and the vegetation and you dip your feet into a cool mountain stream; and let your foot rest on a big, slippery stone as the sunshine warms you and the wind blows through the trees. • Advanced scenarios developed with assistance of patient (family, past experiences, etc.).","e":[-18,56,-194,-60,-15,5,35,-11,15,-40,42,24,70,106,-46,44,10,-32,14,-3,-93,-20,2,9,-23,48,-2,14,-36,2,35,-39,-25,1,-12,-68,60,73,26,2,82,-22,-6,-18,21,-42,99,19,36,-9,-7,14,-8,-55,70,20,55,3,51,-28,106,42,-12,8,30,-24,-106,30,-3,11,51,-21,28,37,-32,-12,-50,-3,33,25,46,-8,65,-46,43,21,38,2,-30,34,5,-11,15,15,-51,25,-5,66,-36,-36,-73,-12,34,-10,22,2,3,-5,-8,-9,-4,11,-54,-33,-17,-23,90,-38,54,68,7,42,-12,-18,24,59,-61,-40,-12,-46,18,-51,-23,33,2,59,6,-12,12,20,6,-19,-18,-39,-3,-53,32,-8,-1,-18,35,41,32,26,45,-71,-4,12,33,28,62,27,-29,24,16,-65,52,6,60,12,-71,-23,-26,-17,59,-15,75,-33,19,-23,60,-44,7,11,-6,-29,6,-38,-40,-33,1,28,-79,-39,-58,-22,57,-26,17,0,16,17,-4,46,-47,81,-7,19,-26,-56,54,-30,22,11,-12,2,4,-23,-47,-9,41,-2,17,-30,43,23,-36,4,14,33,-36,-37,70,2,43,11,12,12,-4,1,-5,4,21,-18,-92,40,1,-16,10,26,32,21,35,7,18,-38]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.128","t":"HOMEWORK ASSIGNMENT EXAMPLES 1. Practice PMR before you go to bed each night this week. 2. Attempt your deep-breathing exercise during a stressful time this week. 3. Create your own personal guided imagery script, and attempt to use it this week. Bring it to the next session. SUPPLEMENTAL READINGS Cormier, S., Nurius, P. S., & Osborn, C. J. (2016). Interviewing and change ctrategies for helpers, 8th Edition. Boston, MA: Cengage Learning; Chapter 13. 128","e":[26,-25,-174,-27,5,-28,13,-53,30,14,-6,-7,36,78,-18,-14,1,-53,-31,9,-23,-39,-34,20,25,12,-14,-44,-50,24,9,-8,-11,-66,-44,-72,82,30,-23,3,39,-24,32,-57,47,-38,60,-14,18,3,59,-33,30,-9,63,26,19,-16,65,-34,115,28,-62,67,6,-34,-46,76,-22,33,65,0,70,11,-70,-17,-24,-42,44,28,45,16,99,-21,64,47,4,0,-45,70,1,14,14,23,-34,21,-5,19,-44,-52,-65,-21,29,-10,8,51,31,-17,-20,40,-69,25,-22,-14,8,24,78,-56,33,57,-16,-19,-8,22,-27,40,-52,-34,20,-13,3,-56,-41,25,-7,50,-32,-18,24,13,43,-20,-16,-2,-1,-16,-11,-29,-57,28,22,7,44,-11,45,-3,-70,-11,59,28,48,-25,-68,69,7,-24,18,85,36,22,-17,-69,11,-2,37,21,90,-18,19,9,78,-23,22,-9,-13,-40,20,-10,-85,-16,-34,49,-9,-4,-95,-64,37,-20,20,-22,-11,0,0,27,-47,75,-8,-11,3,-6,55,12,1,23,-16,14,-23,26,-46,28,5,-22,-7,-5,38,19,-7,5,-14,33,-23,-73,47,14,42,12,8,47,10,57,19,36,51,-21,-69,34,17,-33,-10,53,40,-3,41,35,13,-41]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.129","t":"Special clinical populations present unique life experiences, therefore requiring a therapeutic approach that understands this uniqueness and appreciates the context of the individual when engaging in clinical interventions. We describe four general clinical populations that may require more critical analysis of how best to apply brief CBT techniques. Military Populations","e":[-1,30,-164,-52,55,44,57,-7,63,-14,-4,-7,81,-11,-38,-104,-23,-42,2,69,-64,-15,12,-17,13,43,-12,51,-67,-37,28,-6,50,-31,-28,-63,43,30,8,7,38,-2,15,-103,12,16,64,36,43,-29,30,-47,17,-21,96,15,-33,36,-34,-51,74,40,-82,25,40,-5,-40,36,-22,-46,72,-44,51,29,-42,-23,-46,-20,-6,14,59,-2,61,-37,54,24,-15,-21,5,50,49,20,34,41,-111,0,-18,1,-18,-33,-25,-22,-15,-27,-14,5,-6,44,-5,-39,-87,22,-28,7,-8,-5,14,-73,-1,40,10,-1,-17,25,-40,48,-46,-21,31,-29,-6,-16,-25,-10,24,46,-7,-6,5,47,50,6,1,28,-3,-28,8,-19,-53,8,32,37,24,33,25,-42,-22,41,37,26,15,-7,-54,23,-50,-33,-22,5,50,58,-31,-27,-11,6,91,7,60,-42,25,-62,-4,-33,7,-2,10,-8,8,-26,-12,-61,17,30,-19,-45,-87,-25,38,-11,0,-83,-10,45,-56,30,-19,64,-30,19,-12,-44,53,-49,-21,31,-45,-11,-14,-18,-37,39,33,20,-16,4,33,27,-54,-26,21,35,-25,-69,67,-26,8,38,3,3,15,24,-2,30,47,33,-81,-8,-10,-55,1,16,-30,-10,18,5,36,-34]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.129","t":"Military personnel face unique and often intense physical and psychological challenges when serving their country. A 2014 research article (JAMA Psychiatry, 2014) found that one in four active duty military personnel had signs indicating the presence of a mental health condition. Common mental health disorders in military populations include depression, anxiety, substance abuse and posttraumatic stress disorder. Individuals may also face physical health changes due to injury. Common somatic and emotional health symptoms may include chronic pain, insomnia, and anger management difficulties. Notably, somatic symptoms may be related to emotional health difficulties; and substance abuse issues may “mask” other mental health difficulties – especially those related to trauma. Finally, military personnel are at increased risk of suicide regardless of service era – but personnel from the recent Iraq and Afghanistan conflicts have been found to have high rates (20% or greater) of traumatic brain injury (TBI), which further elevates mental health difficulties and suicide risk.","e":[34,5,-189,-50,58,52,6,-4,54,-2,42,29,1,5,45,-29,-25,-44,-22,15,-54,-21,-15,-25,15,96,-3,0,-17,4,37,-23,-12,-35,-6,-69,20,65,45,41,37,-66,-11,-84,-22,-5,50,53,60,-25,5,-101,4,-25,67,-40,-5,-9,8,-61,99,11,-71,5,34,-36,-37,39,15,4,47,-39,13,27,-75,6,2,4,-5,5,40,13,63,-57,71,29,2,16,9,88,17,40,-6,54,-88,-3,10,26,-20,-38,14,-54,-16,14,23,25,-2,32,-30,7,-60,70,11,-8,36,-44,33,-64,-21,39,-24,-26,3,24,-28,-9,0,-6,50,-23,-22,-25,-25,-14,1,27,-22,-31,-21,-18,86,6,2,28,-11,-18,14,-29,-44,-22,14,68,-24,-15,23,-51,-60,36,40,36,29,43,-45,71,35,-64,-3,77,29,64,-32,-42,19,-9,76,27,81,-49,35,-32,-4,-60,57,19,-7,-34,23,-9,-70,-46,-20,54,-40,-12,-58,-24,23,-28,45,-48,22,20,-24,11,20,74,-54,-14,1,-54,52,-42,22,-2,30,2,-5,-27,-43,6,52,7,-26,-12,45,-2,-63,-19,-15,-20,9,-35,128,-10,-24,3,-9,33,25,-31,16,7,30,17,-60,11,-38,-27,-4,35,10,-2,-16,19,45,-32]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.129","t":"While on active duty, military personnel often face challenges that range from mild but chronic stressors (e.g. requiring to be “on guard” while in combat environments regardless of actually being in conflict) to acute and severe stressors (e.g. physical injury or death or injury to a colleague or civilians). Although combat stressors are commonly associated with increased stress and mental health demands, other aspects of military life create challenges that may include post deployment reintegration into civilian life, social isolation, or possibly even severe non combat trauma such as military sexual assault. Regardless of the specific stressors or “triggering events,” it is important to recognize that not all military personnel require mental health services. However, many military personnel will face mental health challenges that do not reflect weakness on the part of the service member. These challenges must also be understood within the context of the service","e":[41,4,-202,-24,73,50,13,-35,37,-4,-19,18,-17,5,44,-65,-15,-46,-8,-2,-30,-42,10,-14,5,67,33,-18,-42,26,47,-2,-2,-61,-11,-58,23,71,26,25,33,-64,12,-83,-5,-15,35,34,67,-44,21,-78,-46,-41,76,-33,-12,-10,-1,-76,111,27,-75,24,-4,-38,-30,48,2,16,45,-50,14,15,-66,-7,-16,-10,-7,10,54,-2,83,-46,71,31,-1,0,-5,65,45,45,6,23,-116,17,23,30,2,-32,1,-39,-16,8,20,14,4,33,-18,-8,-74,82,-20,12,31,-9,37,-47,-18,34,12,-21,2,47,-28,8,12,1,71,-36,-1,1,-22,-15,1,23,-29,-43,-14,18,63,31,-10,7,-19,-44,-13,-34,-32,-6,7,64,-22,8,23,-20,-40,14,9,30,40,4,-51,60,38,-33,-12,52,39,39,-37,-58,22,-22,86,28,66,-29,45,-60,-14,-60,46,-7,3,-31,16,-18,-74,-21,-7,38,-43,-22,-68,-41,30,6,43,-49,14,1,-30,23,0,85,-47,-11,-20,-66,77,-60,-4,-6,12,-27,14,-18,-39,7,40,-4,-6,13,35,-1,-61,-19,-13,7,-16,-30,101,10,-27,39,31,35,8,-16,22,1,33,11,-45,25,-30,-6,-35,-2,6,-33,-15,25,43,-53]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.130","t":"THERAPEUTIC CONSIDERATIONS AND ADAPTATIONS Providers are encouraged to explore the meaning of military service and the possible relationship between military service, military-related stressors, and resiliency factors. Military culture may play a significant role in the way in which service members approach mental health treatment. For example, military culture places a premium on strength and resilience, which may be at odds with help-seeking behaviors. In some instances, emphasis on strength and resiliency may lead to social isolation and/or limited sharing of emotional or psychological struggles. Additionally, service members may face ramifications for seeking help that impact their careers such as pilots no longer being allowed to fly or security forces no longer being allowed to carry weapons. Stigma around seeking help can carry over for Veterans if they continue to work in national security positions as civilians or contractors. For all service members and Veterans, providers must attend to suicidal ideation and/or plans and should be prepared to actively manage these concerns using a comprehensive suicide assessment and safety plan (where needed). Importantly, this population tends to have greater access to firearms and lethal means than civilians. Providers should know their state laws for how to ensure lethal means safety for at risk groups.","e":[17,10,-182,-23,69,35,7,-16,67,13,-31,-20,25,27,43,-46,25,-22,-21,6,-84,-68,-15,-22,22,58,27,7,-30,8,29,-5,-10,-31,-9,-56,18,77,9,0,2,-19,-4,-59,44,-18,55,-7,40,-32,32,-62,-39,-38,80,-54,10,18,-25,-58,114,61,-112,3,19,-11,-54,33,-17,-22,45,-32,2,24,-68,17,-35,4,-24,-1,63,-8,69,-45,15,41,27,-16,5,77,-7,40,-4,49,-104,16,-2,8,-44,-26,-23,-60,4,6,-6,47,27,24,-21,12,-73,45,-40,-23,7,-45,35,-53,18,26,6,-13,8,54,-48,39,-27,3,35,-12,8,-35,-36,-13,-6,30,-36,-60,-20,27,71,-10,13,15,-13,-39,-19,-21,-38,-34,1,67,-20,10,22,-24,-23,26,54,33,48,32,-34,55,15,-25,-10,44,8,8,-49,-37,27,-20,102,-6,97,-38,-4,-31,-26,-52,49,13,1,-23,42,-12,-83,-62,-17,73,-18,-14,-77,-42,12,-17,31,-30,-6,33,-50,33,-16,62,-43,21,-15,-56,80,-64,34,-8,16,9,4,-3,-35,36,11,-9,-6,-26,21,4,-50,3,3,-2,-9,-57,73,18,-22,15,3,23,36,-4,0,6,52,34,-61,61,-26,-15,-21,30,20,5,-11,1,12,-53]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.130","t":"POTENTIAL BRIEF CBT ADAPTATIONS Providers may wish to consider the following adaptations to their traditional CBT approaches when working with military personnel and Veterans: 1. Integration of prior military experiences. For military personnel who strongly relate to their current and prior military service, providers are encouraged to explore the patient’s military experiences for examples of challenges, coping, and successes. These examples may provide valuable information for treatment planning while also helping in understanding the patient’s military context and developing rapport. 2. Peer support and social connection. Given the elevated potential for suicide, social isolation can be a critical contributing factor to the maintenance of emotional health difficulties. Many military personnel place a high value on service, family, and country. Although they do not want to be a burden on others, they are often willing to consider the value of others in their lives and the need to connect (re-connect) through the encouragement of a planned therapeutic plan. 3. Romantic relationship status. Among military members, relationship problems are among the most common antecedents for suicide. Routinely monitoring relationship status is important and can signal any acute mental health status changes that may arise. 4. Attending to physical health and functional changes. Many military personnel will face physical and/or functional health changes that require lifestyle modifications. Many of these challenges push patients away from activities that previously brought them pleasure. Providers are encouraged to consider these prior activities (and the losses) the military member is now facing, and then identify new activities,","e":[12,-10,-165,-55,66,31,6,-21,60,2,-9,7,35,23,36,-44,22,-46,-26,-4,-64,-57,-13,-3,13,41,-14,61,-58,-13,68,-19,-1,-34,-14,-45,28,59,-5,19,18,-41,1,-88,36,-20,127,35,49,-14,21,-46,-3,-34,95,-37,6,18,-8,-88,91,39,-76,33,35,-20,-38,40,-28,-14,41,-6,-6,47,-61,12,-53,-36,-25,0,51,0,56,-59,51,8,35,12,-10,76,0,27,14,33,-81,20,-1,-14,-16,-19,-29,-39,14,4,-24,63,13,-4,15,-3,-106,40,-29,-19,13,-20,23,-47,-1,69,0,-7,9,26,-42,45,-83,-23,39,-39,4,-15,-23,9,16,11,-6,-48,-4,1,69,-28,11,30,1,-16,-24,-5,-58,13,4,49,7,4,45,-38,-44,5,40,34,41,14,-69,39,18,-31,-16,57,34,31,-38,-64,3,-9,71,15,66,-33,-15,-19,-2,-36,46,40,-6,-10,19,0,-52,-56,-7,35,-36,-29,-84,-29,57,-15,20,-76,-5,53,-35,47,8,56,-41,9,-20,-64,75,-49,13,-10,0,33,10,10,-58,29,50,0,-7,-9,-2,7,-26,-22,1,-1,5,-29,65,6,-20,32,-5,32,-1,21,37,9,45,19,-85,18,-5,-36,2,32,-2,16,7,10,16,-36]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.131","t":"SPECIAL POPULATIONS CHAPTER | MODULE 17 especially social activities, where possible, that remain available to the patient. For example, a patient who had been runner who is now no longer physically able to run may identify meaning in being outdoors, being with others during early morning runs, or feeling a sense of accomplishment. Although running is no longer possible, activities that are outdoors, involve others, and provide as sense of accomplishment are often possible. RESOURCES www.mentalhealth.va.gov Veterans Crisis Line 800 273 8255 Option #1 Older Adult Populations","e":[26,32,-208,-15,60,88,49,5,52,-35,-20,21,38,44,-5,-56,8,-55,-59,7,-19,-9,-6,23,83,50,16,-12,-61,-10,38,-3,48,-5,9,-24,31,11,50,17,23,4,3,-55,36,-24,40,4,56,-44,9,-56,-36,14,75,-21,47,15,-14,-26,109,22,-37,0,76,-39,-29,2,-26,-36,92,-21,26,52,-40,58,-56,-7,-6,17,27,8,56,-38,101,14,-10,-18,0,82,-5,22,31,53,-101,-14,-11,36,-9,-48,-56,-41,9,-44,33,4,1,61,-6,-3,-20,30,-52,-10,-10,-18,31,-45,38,2,20,18,-1,54,1,39,-50,-18,25,-19,-12,-17,-13,12,5,8,-35,-10,-4,-20,66,2,-7,7,-12,-22,6,-47,-60,4,-6,69,-3,11,37,-68,-36,39,29,0,51,8,-40,37,-42,-48,-23,17,32,18,-27,-24,-7,10,54,-17,38,-29,-35,-13,15,-51,61,7,-9,-41,17,-16,-66,-73,-31,28,-11,-56,-85,-47,13,-23,33,-38,11,20,-45,15,-5,30,-11,-2,8,-20,85,-71,-14,-38,-2,-3,7,-8,-20,31,24,-46,-23,-17,28,8,-46,-20,-58,9,-19,-78,36,-17,26,11,-2,17,34,31,14,10,-10,3,-31,66,-21,-11,-18,29,13,-9,22,-15,71,-19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.131","t":"Older adults, particularly those ages 65 and up, represent a unique population that often face life circumstances and challenges related to work and retirement and changes in family dynamics or living arrangements, as well as increased attention to physical health conditions including changes in cognition and memory. These changes may include physical or functional changes but many individuals will face these challenges especially with advanced age. Older adults are at increased risk for social isolation and suicide, and these issues are further complicated when combined with a physical illness or changes in cognitive functioning (e.g. dementia).","e":[-7,18,-163,-49,-1,93,27,-13,84,13,-1,11,51,-1,30,-51,-3,-29,-4,52,-39,-11,-31,28,0,91,-10,13,3,62,60,45,41,2,-27,-66,58,49,91,12,-5,25,9,-63,12,-47,44,-37,70,15,-20,-87,-24,16,56,-28,-1,49,27,-31,73,44,-69,30,48,-30,-32,31,24,-49,46,-43,-5,25,-21,49,-15,12,54,41,39,-1,64,-29,54,17,-22,21,-8,83,34,-11,10,13,-102,-14,-1,21,-55,7,-52,-26,16,16,26,20,0,37,-60,11,-88,18,-17,24,1,-11,52,-44,-6,25,-4,18,37,43,-24,32,-50,-6,46,-38,2,-2,-1,4,42,53,-60,-8,-12,1,95,7,54,-5,-2,-14,12,-9,-47,22,-7,17,-27,-3,46,-49,-53,15,27,10,-4,30,-38,73,-24,-17,4,31,22,75,-25,-45,-10,6,117,-18,94,-35,13,-24,7,-82,30,-17,-4,-54,15,-7,-31,-25,-35,14,-16,-27,-38,-32,36,-21,19,-35,-30,-16,-15,47,-10,69,-20,-19,-30,-65,67,-21,-4,-22,-24,1,-20,6,-29,53,34,-32,24,3,14,-21,-58,2,-18,45,-5,-76,84,47,-8,-16,-41,4,53,-16,-15,27,29,8,-37,10,-8,-49,-33,15,28,1,-4,20,41,-48]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.131","t":"POTENTIAL ADAPTATIONS TO CBT FOR OLDER ADULT POPULATIONS 1. Speed and pace of therapy. Older adults, especially those new to psychotherapy, are likely to benefit from a pace of therapy that meets their emotional and cognitive needs. As a population, older adults vary greatly in their functional and cognitive abilities, and you must be prepared to adapt your approaches accordingly. Some older adults will require no modifications while others will need a pace and speed of therapy that are slower and use simplified language and intervention approaches. For example, some older adults may better identify and grasp the concepts of behavioral activation (e.g. pleasant events) versus more psychologically complex concepts, such as exposure or cognitive/thinking patterns that maintain behaviors. 2. Inclusion of caregivers and significant others. Although not appropriate for all older adults, the inclusion of caregivers may offer unique opportunities for providers to engage family or friends for at-risk older adults – especially those facing cognitive impairment, increased suicide risk, or social isolation. Caregivers may serve as passive supporters or as active members that facilitate treatment planning and/or between- session skill assignments. 3. Auditory or visual impairments. Providers are encouraged to assess for any auditory or visual needs when working with older adults. Specific needs may require alteration in telephone or other virtual platform delivery and may be important for written between-session assignments. 131","e":[0,14,-154,-59,17,25,65,16,80,10,-13,-13,43,20,16,-57,23,-41,-18,35,-43,-48,-36,-18,-3,64,-26,76,-19,30,64,2,11,-24,0,-29,72,13,27,26,14,2,13,-88,45,-55,121,0,28,28,-1,-56,12,-5,87,-18,-11,58,-14,-83,73,45,-68,24,50,-16,-34,43,-14,-27,36,-5,-2,52,-25,3,-76,-34,19,39,25,6,51,-56,58,2,5,26,-1,58,25,-35,-3,54,-57,11,-25,-18,-36,8,-66,1,24,16,-30,34,-3,-13,-49,9,-93,15,-34,7,-34,-20,47,-25,1,40,19,27,-1,20,-19,89,-106,-23,26,-34,-18,5,8,15,37,31,-19,1,2,21,57,-37,45,19,9,-7,-13,-4,-30,22,-16,16,35,29,62,-49,-24,-11,42,23,15,-6,-59,31,-10,-21,6,53,36,50,-41,-46,-14,10,91,3,79,-27,-3,-36,1,-59,11,8,19,-23,8,-28,-15,-31,-11,13,-59,-12,-80,-46,57,-26,19,-58,-37,23,-7,28,-8,69,-21,4,-10,-66,79,-5,-6,-18,-39,32,-29,6,-19,47,67,-35,25,-4,-6,3,-13,9,7,67,-6,-74,26,34,12,19,-32,-6,42,41,17,15,56,6,-67,18,-7,-46,-16,22,-2,22,12,-12,36,-28]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.132","t":"SPECIAL POPULATIONS CHAPTER | MODULE 17 4. Cognitive impairments. Patients with cognitive impairments may benefit from simplified treatment plans and the incorporation of caregivers and/or significant others to facilitate treatment plans. See below for a specific section on cognitive impairment. Medically Ill Populations","e":[-4,28,-147,-58,42,50,33,32,47,-30,9,20,84,28,-3,-50,-26,-34,-15,69,-48,8,-54,-12,57,88,-3,28,-51,0,43,25,40,-24,-29,-51,94,11,19,22,22,-17,6,-96,30,46,91,-12,46,-16,22,-48,-16,26,97,-3,-41,27,-5,-20,99,57,-54,15,31,-17,-43,54,-24,-26,58,-7,53,3,-50,4,-22,1,-12,21,45,-29,74,-43,43,42,5,-28,-2,64,-20,4,-15,59,-95,-12,-34,-65,-20,-54,-40,-3,21,-11,14,61,-8,36,7,-2,-39,-10,16,-9,-8,-21,23,-47,5,49,-12,-5,28,83,1,66,-49,1,71,-33,-17,-16,-15,-12,17,38,-21,10,-19,20,65,19,3,-7,15,-64,22,-8,-48,-3,-1,42,21,19,26,-72,-33,17,17,3,50,52,-50,57,-31,-31,29,20,-12,53,-20,-28,13,5,94,-16,34,-38,21,-42,-13,-16,-12,28,13,-13,16,7,-37,-43,-1,2,-17,-42,-85,-61,32,-1,30,-71,-34,22,-55,14,-8,68,-8,-2,-25,-37,61,-20,3,2,-29,-20,-21,-49,-2,26,13,-30,-5,-7,65,15,-41,15,-11,8,-28,-81,56,8,41,11,-12,16,51,33,-5,39,33,-10,-71,23,-23,-57,-15,44,-22,11,13,2,42,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.132","t":"Patients that present with chronic medical diagnoses or with terminal sickness include a wide array of medical conditions such as cardiovascular disease, diabetes, cancers, HIV/ AIDS, and autoimmune disorders (i.e., rheumatoid arthritis, lupus, and multiple sclerosis). These vulnerable health populations often have comorbid mental health diagnoses or related symptomology. Individuals with chronic or long-term health conditions are two to three times more likely to present with mental health disorders, including anxiety and depression (Hudson & Moss-Morris, 2019). Due to the likelihood of acute changes in health care and status, use of brief CBT techniques is optimal to deal with specific and short-term distress concerns.","e":[54,7,-184,-36,19,13,-2,-5,44,-65,26,49,69,-6,0,-32,-57,-33,-21,35,-77,7,-9,-15,-5,83,-11,44,-4,26,63,-22,39,-33,-20,-74,59,44,41,34,58,-16,32,-128,-40,8,44,55,13,-38,29,-79,-4,-18,83,-4,-44,39,-1,-56,96,43,-54,20,85,-42,-23,58,-6,-15,90,-9,36,37,-39,37,-27,6,-8,17,42,-25,38,-26,45,21,-6,-1,-3,79,36,-10,19,77,-84,20,20,-13,-41,-48,-31,1,9,-9,-1,3,17,-17,-30,2,-65,46,-13,11,41,-15,27,-35,-23,47,-32,-20,20,61,7,45,-22,-12,80,-34,-34,-7,-9,20,-8,39,1,15,-26,25,69,-17,6,4,6,-2,12,-36,-50,0,-2,44,-7,38,34,-31,-45,11,22,4,27,24,-60,62,-1,-67,20,75,16,88,-51,-51,10,8,86,-2,46,-43,18,-67,31,-43,31,36,-3,-36,22,-41,-33,-51,0,16,-58,8,-65,-47,18,-12,7,-59,11,25,-22,5,-48,60,-10,-36,-12,-56,48,-41,-2,-5,-40,2,-34,-55,-29,6,40,-34,1,-25,37,19,-73,1,2,-2,33,-63,100,19,-15,31,-38,25,38,34,-28,17,39,10,-32,17,-46,-28,0,35,-30,-6,20,13,47,-35]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.132","t":"POTENTIAL BRIEF CBT ADAPTATIONS Providers may consider the following when working with medically ill patients: 1. Prevalence of health-related distress. Experiencing acute distress in response to receiving medical diagnoses or sudden changes to health status are expected within this population. Providers should keep in mind that health-related distress may be the focus of much of the therapy. Patients’ anxiety or depression may be symptoms of coping with their changing health status. Providers may consider introducing behavioral activation activities that require low levels of physical involvement and cognitive restructuring around any thoughts related to negative views of the self or world in this new stage of life. 2. Need for flexible treatment delivery. The setting of the therapy will be dependent on patients’ current health status. Providers may have to shift from their traditional office setting to treat patients that are in the hospital or cannot leave their home. Providers are encouraged to pay special attention to the patient’s medical appointment schedule and allow for flexibility in the timing and amount of allowed session cancellations. Additionally, use of telehealth services becomes more important with this population and can increase the level of access to mental health treatment. 3. Between-session workload. Homework and in-between session practice are important to treatment success with CBT. However, providers should consider each patient’s health status and use judgment in the amount and appropriateness of in-between session expectations. Talk with your patients about how feasible and/or likely it is they will be able to complete activities for that week. 4. Caregiver presence. Patients with severe health complications or dealing with functional impairments may require assistance from caregivers. Be mindful that caregivers may become integral in facilitating therapy for patients. Also, be aware that caregiver concerns and interpersonal issues between the patient and caregivers may be a central focus in therapy.","e":[-4,19,-143,-44,46,-5,20,38,74,-32,-11,10,50,28,22,-36,8,-30,-45,17,-74,-6,-29,-15,-21,39,-11,88,-12,5,60,-7,29,-57,-37,-20,80,47,8,48,47,-47,19,-125,33,-27,104,45,10,-12,12,-48,3,-24,133,7,-41,64,-5,-95,105,37,-70,37,28,-27,-34,47,-31,7,57,15,23,55,-28,2,-63,-28,-10,8,50,6,57,-64,58,-16,7,11,15,87,6,-26,0,48,-83,2,-18,-48,-20,-31,-57,-11,7,-19,-38,50,9,-9,-19,-13,-76,25,-19,-22,4,-4,46,-25,-6,51,21,-5,5,50,4,60,-65,3,57,-3,-16,-23,-3,29,4,22,29,-15,1,11,77,-1,20,4,30,0,5,-19,-41,31,-14,28,14,59,74,-30,-32,13,24,26,62,-13,-56,42,15,-46,17,78,27,52,-42,-74,-6,2,59,28,71,-22,-2,-43,16,-41,2,28,17,-19,30,-43,-11,-59,30,34,-43,-4,-73,-47,33,-20,9,-74,-13,44,-12,30,-32,68,-2,-8,-22,-69,61,-29,0,-4,-43,43,-24,-15,-53,46,49,-40,18,-16,-5,24,-39,21,7,14,10,-40,48,10,-4,40,-33,9,24,56,13,26,56,8,-63,10,-23,-53,-22,41,-4,-4,27,11,29,-39]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.133","t":"More than 16 million people in the United States are living with cognitive impairment such as mild cognitive impairment disorder, traumatic brain injury, Alzheimer’s disease and other dementias, and developmental disorders (e.g., autism spectrum disorder) (Centers for Disease Control and Prevention, 2019). Cognitive impairment can affect individuals of all age groups and impact an individual’s memory, concentration, and decision-making. These difficulties can cause issues with processing information, ability to communicate effectively, and everyday functioning. Patients will have related mental health concerns stemming from their clinical diagnoses or related to distress of coping with functional changes.","e":[25,41,-148,-31,49,80,45,14,84,-22,6,-15,33,48,25,-37,-66,-29,-29,67,-59,21,-53,2,19,113,-29,0,-23,61,32,43,-18,-35,-61,-49,49,19,91,39,11,-1,-10,-78,9,29,60,-11,71,-11,16,-93,-7,8,61,-8,-49,29,13,-11,102,43,-61,11,16,-16,-63,54,11,-41,68,4,52,34,-35,25,16,-4,-6,67,59,-32,59,-22,63,10,-7,24,-6,85,6,14,4,35,-69,-6,-25,-19,-33,-10,-45,-12,-7,12,60,21,-35,10,-29,44,-74,9,10,-31,13,-30,46,-30,-15,23,-33,-38,19,59,4,31,-62,-14,67,-30,-36,-17,12,-1,22,58,-31,40,-16,40,88,6,9,-8,-3,-14,25,-24,-28,-23,24,41,-4,10,49,-63,-51,13,30,-8,28,61,-53,72,-11,-50,11,42,11,53,-33,-41,27,-10,75,1,51,-37,18,-11,-8,-50,6,6,4,-12,16,0,-34,-11,5,6,-36,-22,-63,-86,23,13,52,-47,-25,7,-25,-5,19,51,5,-9,-31,-53,56,-43,-5,5,-36,-9,-25,-55,-11,29,11,-34,-8,-10,61,-18,-74,-4,3,16,1,-60,94,15,34,28,-29,2,36,18,-29,44,32,5,-47,4,-28,-35,-24,4,0,24,17,27,47,-12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.133","t":"POTENTIAL BRIEF CBT ADAPTATIONS Providers may consider the following when working with medically ill patients: 1. Timing and pace of therapy. Patients in this population may struggle with maintaining attention, processing information, or communicating their treatment needs. Consider a slower pace when communicating information and routinely checking in with patients to ensure they are keeping up with you during the session. Also, allow more time during the assessment phase to gain understanding of the patients’ needs and to develop a treatment plan tailored to their clinical presentation. 2. Patient support. Providers should consider integrating caregivers, family members, or other support for these patients. These individuals will be liaisons between sessions, communicate information that the patient might have missed during the session, and help maintain treatment progress throughout the course of treatment. 3. Technique appropriateness. Consider the appropriateness of cognitive restructuring techniques for this population. These techniques are based on abstract themes and can be difficult for patients to understand, especially if cognitive impairment exists. Use aspects of patients’ interests when describing examples of CBT and cognitive restructuring to aid in their understanding. If patients lack the capability to grasp this technique, focus your energy on behavioral activation or problem-solving techniques that are safe for patients to integrate into their schedule.","e":[14,25,-139,-56,50,-17,31,18,66,-15,4,8,51,32,18,-51,5,-41,-37,36,-61,0,-28,-29,-11,30,-15,86,-30,7,68,12,18,-44,-28,-43,82,20,-5,34,36,-41,33,-101,50,-10,120,22,-12,-7,18,-34,-4,-38,130,13,-19,60,9,-77,102,31,-56,46,28,-12,-31,53,-30,-6,51,20,33,62,-22,3,-67,-24,-13,17,45,-7,65,-51,51,-8,12,8,8,82,-13,-34,17,33,-84,10,-32,-50,-29,-23,-66,3,4,-19,-36,63,3,-10,5,-9,-79,-8,-13,-15,-14,-12,52,-8,11,52,15,-25,8,40,12,73,-87,-8,68,-13,-23,-11,-8,20,0,40,31,-20,4,17,54,-16,31,0,30,2,-12,-12,-38,26,-4,30,33,36,75,-36,-10,2,21,24,66,-9,-84,44,8,-45,31,63,36,27,-49,-47,-4,18,64,33,75,-12,-22,-36,5,-25,-8,25,6,-17,34,-17,-29,-46,23,9,-51,-4,-75,-42,62,-3,15,-68,-16,25,-27,32,-18,57,2,4,-25,-39,70,-9,-3,1,-55,36,-30,-7,-39,45,43,-44,9,-20,2,1,-35,28,9,19,2,-37,31,13,22,32,-25,10,18,48,13,28,64,8,-74,12,11,-48,-15,41,-15,15,26,0,33,-23]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.134","t":"End-of-treatment planning is the collaborative process of preparing the patients and assessing their readiness for ending treatment and moving beyond reliance on the provider to apply skills. Planning allows the patient to prepare for the end of treatment, to review skills learned in treatment, and to vocalize and problem-solve concerns about functioning outside treatment. All these factors reduce anxiety and allay fears a patient might have about ending a therapeutic relationship. When? (Indications/Contraindications)","e":[54,53,-119,-62,26,-12,14,-5,27,23,-19,-9,85,-29,35,-27,21,-54,-57,20,-29,-49,-28,17,-7,55,30,-28,-18,1,32,5,52,-25,-45,-86,84,18,-19,-46,36,-15,17,-77,33,-11,49,28,3,-21,24,-17,-64,-13,83,34,9,47,-9,-52,99,57,-76,63,77,-55,-51,15,16,-9,62,-14,29,19,-23,8,-13,-2,-32,22,14,-43,56,-21,-11,41,-10,-48,-45,67,-28,17,-13,45,-100,32,-31,-21,-34,-58,-38,-16,-23,-43,0,30,19,-18,22,15,-28,53,-51,3,27,-19,73,-24,48,22,33,-47,41,-19,-2,66,-11,-17,21,29,6,4,4,26,15,86,-13,-38,-2,37,48,-12,-20,-16,-46,27,38,-15,-33,7,-15,13,16,26,31,-18,-52,17,70,9,77,25,-81,53,-84,-52,17,11,9,-22,-51,-39,44,3,111,17,85,-14,-15,-37,36,-14,62,20,-3,-4,48,-42,-35,-78,55,49,-2,12,-84,-27,7,-11,39,-31,-38,19,-79,37,-26,51,-7,14,0,8,37,-24,30,-2,-10,-5,11,-6,-42,16,26,-35,-20,-2,20,14,-68,16,-10,-1,-10,-69,24,15,37,-27,-9,32,23,71,-15,11,12,5,-84,40,6,-61,-35,66,5,9,19,9,41,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.134","t":"End-of-treatment planning begins at the first session when you give the patient some indication of the frequency and duration of treatment. End-of-treatment planning is an ongoing process, culminating in the final sessions with a review of treatment and introduction of relapse-prevention skills.","e":[57,38,-128,-50,43,-32,12,-3,32,6,-24,-3,78,-4,20,-32,15,-82,-52,29,-45,-51,-49,-20,-12,60,18,-14,0,18,42,-14,44,-14,-27,-73,66,5,-19,-53,31,-5,18,-58,6,-48,40,28,-12,-11,50,15,-78,-21,63,44,-19,31,17,-56,119,60,-80,55,48,-40,-37,40,14,-27,55,-14,26,-2,-7,11,-18,1,-35,30,3,-16,73,-37,8,54,-21,-13,-40,42,-24,23,-4,40,-102,-6,-30,12,-25,-37,-46,-29,11,-42,26,41,31,-20,2,10,-47,46,-41,3,7,11,103,-30,52,43,24,-70,47,27,4,57,-14,-2,10,35,8,4,-16,21,32,77,27,-40,5,14,17,-11,-2,-14,-47,3,54,-23,-14,3,-18,6,13,21,28,-49,-41,8,66,-10,56,1,-57,42,-70,-63,7,9,25,-37,-31,-50,13,-4,108,39,96,-15,7,-45,55,-35,43,59,22,-23,36,-37,-50,-61,38,60,-19,-24,-85,-6,29,-25,29,-32,-4,13,-87,50,-44,66,-9,24,-33,32,54,-21,6,1,-33,17,-6,4,-37,47,13,-15,-21,-34,23,15,-67,22,-8,1,-25,-85,2,-7,35,-38,-5,18,18,39,-29,23,48,6,-96,21,-9,-56,-15,42,8,14,16,30,56,-12]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.134","t":"Patients with personality disorders or disorders of attachment may be particularly sensitive to feeling abandoned or upset as a result of ending the therapeutic relationship. For these patients, it is important to discuss treatment termination in an empowering and thoughtful way—recognizing and normalizing their fears, assuring them safeguards are in place (e.g., emergency resources, booster sessions), and encouraging them via reminders that the purpose of CBT is self-management of symptoms.","e":[62,17,-156,-88,31,21,-3,17,55,-6,-33,21,37,14,15,-24,-21,-37,-63,52,-58,-10,-26,35,-12,74,-2,33,5,50,44,16,40,-31,-70,-56,66,50,20,5,64,-11,-3,-117,5,-11,71,43,46,-20,54,-52,9,-48,109,5,15,51,2,-92,88,22,-59,39,69,-27,-50,4,-27,-49,74,24,34,85,-29,29,-23,-54,-16,26,39,-10,21,-57,57,17,41,6,-41,45,32,-25,7,12,-87,13,22,-43,-31,-50,-45,-1,-33,-23,24,-1,-6,5,13,17,-59,66,-41,14,20,-23,30,-99,-13,49,7,17,14,52,34,43,-19,-19,25,-2,-26,-22,-14,2,5,49,16,-12,-20,-11,46,-2,0,24,-30,2,26,-20,-59,5,47,21,6,27,52,-38,-39,10,33,11,41,0,-31,47,-22,-59,20,25,9,18,-43,-48,20,21,83,18,49,-33,16,-83,44,-28,66,28,14,5,-1,-38,-22,-66,22,61,-58,24,-76,-19,-3,7,8,-40,10,13,-24,10,-67,19,-13,17,-54,-67,55,-51,-8,32,-49,-17,4,-19,-26,10,15,-21,18,-23,18,17,-40,-9,-30,-20,-25,-81,61,33,-8,19,-16,9,-16,8,10,29,32,20,-76,34,5,-52,0,0,0,11,21,-9,71,-3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.134","t":"Measurement-based care used throughout treatment will inform an appropriate time for end-of-treatment. You can decide if additional sessions, a complete end-of-treatment, or booster sessions are needed depending on the type or intensity of symptoms the patient is still reporting. However, measurement-based care should be used in addition to ongoing conversations with the patient, your clinical judgment, and clinical requirements and procedures of the clinical facility. How? (Instructions/Handouts)","e":[50,38,-150,-52,31,-11,13,-31,53,-20,15,-3,74,8,3,-51,10,-79,-43,71,-31,-63,-35,-36,-15,27,26,44,-29,4,41,9,77,-44,-31,-39,47,64,-3,-28,42,-21,1,-56,47,4,61,40,28,4,12,-68,-35,22,124,1,0,11,17,-66,121,43,-81,14,84,-27,-13,8,-35,-13,58,-11,75,24,-13,12,-44,-15,-1,55,28,-11,82,-53,39,15,-24,6,0,75,-10,-15,46,44,-105,1,-12,-17,-5,-24,-23,5,1,-20,30,65,42,20,-34,-36,-54,18,-44,3,-24,-2,68,-9,-25,-5,27,-6,45,40,-9,62,-29,1,17,19,2,-6,-46,20,6,82,37,-30,-2,14,20,-9,5,-6,-18,1,64,-11,-13,24,-9,20,-4,35,52,-40,-46,37,76,27,47,-7,-79,27,-11,-57,9,28,2,2,-36,-54,-11,-10,76,26,89,-31,15,-79,34,-39,33,6,0,-25,45,-50,-53,-35,29,20,-24,-5,-98,-51,53,-13,22,-44,-2,26,-47,30,-16,44,-20,27,-23,-4,66,4,-4,4,-54,-18,-15,-20,-24,79,2,-26,34,-47,63,-5,-48,23,-4,6,-2,-73,30,5,24,-4,-14,25,25,59,7,28,39,1,-68,36,19,-35,-19,36,-18,29,30,0,36,2]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.134","t":"REVIEWING WHAT WAS LEARNED The last session of brief CBT should be spent reviewing and recording the different cognitive and behavioral skills the patient has learned. Use Socratic questioning to elicit this list (“What have you learned as a result of our time together? Is there anything that was particularly meaningful to you about your time in therapy?”), as patients may generate skills or benefits of therapy not known to you. Patients should have a list of 134","e":[39,-11,-154,-62,70,-14,46,-29,36,-2,-14,-1,66,2,-7,-67,0,-89,-16,34,-32,-21,-39,15,11,55,-14,43,-37,-7,46,10,9,-12,-58,-49,92,-4,-38,-24,70,-2,-11,-94,70,-18,89,26,5,0,22,-35,3,-14,112,35,2,18,4,-29,99,8,-56,69,33,-34,-28,70,-54,12,59,11,72,65,-58,-1,-31,-4,-25,23,30,-41,56,-34,52,11,-30,-10,-11,95,18,-4,51,48,-56,61,-15,-23,-31,-22,-56,-18,8,-42,49,51,-23,-3,3,-18,-59,30,-47,1,-24,-6,45,-24,0,44,-33,-2,7,13,15,84,-53,-6,33,-16,-21,-41,-18,4,18,68,13,-4,28,19,40,-2,-11,19,-2,-5,10,-35,-55,12,3,15,19,24,42,-52,-18,-18,48,31,27,-8,-53,45,-33,-27,1,6,28,36,-63,-81,8,-37,54,33,48,-39,-3,-24,33,-23,31,56,17,3,12,-21,-30,-38,-1,18,-65,-8,-82,-58,40,5,22,-49,-13,28,-44,49,-45,43,-31,-27,-24,-38,62,-3,-20,15,-48,16,3,-14,-35,34,6,-8,-32,-34,18,21,-46,-2,-15,50,-36,-81,29,9,6,9,-5,14,10,52,7,29,47,-21,-93,30,13,-31,27,44,-9,50,44,23,22,-22]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.135","t":"RELAPSE PREVENTION Many patients are concerned that they will not be able to manage future psychological problems or psychosocial stressors without the aid of therapy. In planning for the end of treatment, you and patients anticipate potential stressors and symptoms and plan: 1) What tools the patients have learned in therapy that they could use for particular stressors/symptoms, and 2) when patients might need to contact a mental health professional for additional assistance (e.g., suicidal ideation). Preparing for inevitable difficulties is empowering and encouraging for patients. A functional assessment may be used to identify future problematic situations (see Module 4).","e":[41,31,-149,-34,59,-24,18,13,40,1,-49,15,60,20,13,9,44,-54,-38,18,-49,-60,-28,0,-36,98,45,-8,-24,-3,40,-6,-14,-74,-53,-55,61,60,5,-36,27,-3,-5,-94,3,-20,69,15,38,-39,70,-29,-23,-16,93,10,2,20,3,-62,97,59,-64,46,46,-40,-30,42,-16,8,51,1,-8,30,-34,25,-24,32,-12,32,52,-6,87,-50,27,29,19,12,-27,43,-16,31,24,38,-102,21,-19,-14,-25,-47,-19,5,13,-7,16,24,11,-1,4,9,-54,80,-42,-16,10,-2,67,-44,54,53,13,-16,49,51,7,79,-12,-7,40,17,2,-3,-30,9,27,78,-7,-12,9,-4,73,31,-9,-14,-39,-47,6,-23,-37,-13,-44,35,-5,33,34,-27,-55,-2,77,-1,77,-5,-57,41,-49,-43,31,24,16,20,-22,-39,28,-7,98,12,96,-30,26,-60,36,-34,67,48,5,-18,31,-14,-53,-39,30,75,-45,-5,-76,-20,25,-13,32,-30,-8,31,-57,36,-46,73,-19,-14,-40,-12,68,-39,24,2,-20,-13,-2,0,-41,31,-11,-33,-18,-27,8,25,-58,-15,-16,-6,-26,-112,43,20,14,-1,-38,51,11,39,10,4,56,22,-51,18,7,-38,-3,31,8,11,-3,28,42,-19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.135","t":"In-Session Example 18.1 Relapse-Prevention Questions 1. When I feel (symptom), I will (tool learned in therapy). 2. If (stressor), I will (tool learned in therapy). Example: When I feel sad for two days, I will go for a walk and call a friend to have lunch. When I feel depressed for a month, I will schedule an appointment with my primary care physician/mental health provider. If my boyfriend breaks up with me, I will do a Thought Record to evaluate any unhelpful thoughts.","e":[41,-35,-162,-37,62,-21,51,-25,50,-50,-69,44,30,35,-8,-5,25,-96,-41,25,-33,-50,-69,-1,26,79,0,5,-33,7,5,-41,9,-51,-61,-36,42,34,7,-32,41,-4,18,-100,38,-54,92,17,33,-38,43,-46,-6,-25,97,21,33,6,11,-23,102,30,-52,41,53,-24,-43,66,-45,9,63,23,12,21,-45,20,-13,30,-10,43,39,4,73,-62,39,40,-17,16,-14,64,-10,7,23,20,-78,-6,-28,-11,6,-11,-13,-16,-3,-11,15,39,23,-19,-21,15,-59,48,-33,-8,-6,-1,71,-46,24,31,-16,7,8,72,33,51,-28,30,-8,4,2,-21,-38,47,12,25,21,-27,5,8,63,14,-18,1,-21,-70,11,-42,-28,3,-20,-7,-5,18,42,-51,-47,-3,81,-2,55,-4,-52,44,-10,-38,50,72,37,11,-36,-56,-21,-26,56,18,44,-19,33,-47,49,-38,40,12,0,-67,31,-48,-39,-31,-9,40,-42,-17,-101,-46,43,-27,20,-4,10,7,-26,22,-62,43,-12,-13,-32,-14,100,-24,-1,-7,-31,-4,7,10,-25,29,6,-31,-26,-50,10,28,-21,-21,-14,8,-29,-110,22,2,28,21,-24,44,23,18,44,35,38,2,-43,21,-21,-25,34,21,21,6,11,5,33,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.135","t":"TROUBLESHOOTING END OF TREATMENT Give Yourself Adequate Time to End Treatment. Plan on an entire session devoted to ending treatment, wrapping up, and maintaining changes. It is highly recommended that you not introduce new concepts during the final session, as new issues may arise; and ending treatment during the session may become impossible. GIVE THE PATIENT CREDIT Patients often attribute positive change to external entities and negative change to themselves. Therefore, at the end of treatment, discuss the patient’s progress (using objective data, such as symptom-rating scales, when available), praise the patient, and emphasize the patient’s role in positive changes. 135","e":[64,7,-143,-70,44,-26,0,-14,39,4,-6,-4,43,31,18,-33,39,-62,-39,57,-23,-54,-48,1,-13,80,7,19,-2,17,42,-3,41,-18,-48,-32,62,35,-9,-10,54,-15,10,-85,31,-35,57,26,10,-13,50,-19,-54,0,77,56,4,39,33,-75,104,31,-63,56,59,-33,-39,12,-10,-12,59,22,34,46,-36,10,-12,2,-40,1,12,-29,94,-47,23,29,8,4,-48,64,-11,-4,16,23,-111,22,-7,46,-49,-46,-29,-19,-15,-40,15,67,23,11,19,14,-58,15,-55,-12,10,-37,81,-73,20,42,-4,-25,20,13,27,57,-14,-35,26,13,-9,-17,-48,34,29,84,40,-33,10,3,35,-8,-11,26,-31,-5,29,-42,-22,3,15,4,-2,18,30,-51,-40,9,46,6,49,-13,-68,41,-44,-39,-15,34,14,-7,-52,-45,25,-15,105,35,77,-31,-21,-37,28,-33,51,37,28,6,51,-49,-64,-48,43,50,-22,2,-76,-31,52,-4,16,-40,-22,41,-60,42,-30,30,-18,-10,-61,-3,58,-17,13,25,-32,10,14,-20,-45,58,15,-2,-3,-23,45,15,-51,20,-29,-10,-22,-70,17,-6,26,-23,-5,35,16,57,-8,24,34,-4,-92,49,0,-36,-17,53,21,36,25,36,45,-38]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.136","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 18 RESPOND TO CONCERNS Checking in with the patient regularly about questions or concerns about ending treatment helps maintain the therapeutic relationship and offset negative emotions about treatment that could result in negative outcomes, such as feeling abandoned. If patients seem particularly concerned about ending treatment, they could use a Thought Record to identify and challenge unhelpful thoughts associated with leaving therapy.","e":[20,-13,-157,-89,68,17,43,-5,33,-37,-24,12,52,16,13,-17,40,-63,-43,15,-26,-32,-36,9,22,68,13,57,-47,33,49,-24,19,-45,-63,-34,60,13,-65,3,75,-29,18,-86,30,19,68,37,39,-25,39,-60,-3,13,100,21,15,37,-28,-55,96,28,-57,68,38,-56,-26,22,-31,-12,54,-11,14,64,-43,32,-31,-14,-2,28,16,-33,73,-41,24,1,-11,-15,-41,52,-3,-16,8,1,-92,49,-5,-38,-23,-48,-37,-28,-17,-40,0,48,-17,5,15,6,-55,26,-40,5,23,-8,54,-48,8,30,-15,-6,18,33,40,54,-4,6,6,-1,-4,-21,-31,-8,6,43,7,-19,22,4,34,0,4,23,-13,-14,36,-28,-32,-42,-6,-13,4,29,37,-24,-42,-4,52,28,38,-14,-44,55,-41,-38,11,18,25,23,-49,-66,17,-14,80,39,45,-24,44,-78,16,-12,76,60,2,-3,14,-40,-31,-61,12,40,-55,-6,-85,-31,2,-18,24,-31,13,20,-40,21,-78,12,-13,20,-42,-72,88,-33,5,34,-35,0,14,-7,-37,44,1,13,15,-25,10,12,-47,-9,-27,7,-35,-102,36,23,4,13,-2,50,5,41,40,54,40,34,-74,41,-25,-14,9,40,-5,-10,13,-8,33,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.136","t":"PLAN SELF-MANAGEMENT TIME Patients may be interested in planning self-management time when preparing for the end of treatment. Self-management times are a few minutes each week that patients set aside, once therapy is complete, to check mood and use of skills and problem solve situations or feelings that may be negatively affecting their mood. These times last approximately 10-15 minutes and follow a structure similar to therapy. Self-management time is beneficial because it is free, can be conducted at and when and where it is convenient for the patient, and helps prevent relapse. A self-management worksheet (found at the end of this module) may be used during these times.","e":[21,25,-189,-57,-9,-60,61,-41,73,10,-52,5,58,30,-6,-18,27,-44,-70,42,-21,-76,-64,-16,-21,51,37,10,2,25,12,11,6,-54,-32,-73,49,0,-4,-30,43,-28,43,-70,52,-23,58,8,11,-28,7,-47,-29,-12,96,-18,5,54,-10,-15,132,19,-52,81,51,-33,-35,11,-17,-11,55,-7,8,14,-18,27,-16,18,-5,-4,40,-29,50,-73,45,-12,12,11,-12,80,-26,17,-10,42,-87,32,2,32,-31,-36,-19,-25,-9,-23,2,46,-16,18,18,13,-43,23,-26,29,40,-5,83,-67,27,47,-3,-9,15,30,29,59,-17,1,11,19,-2,-5,-64,13,4,46,30,-13,-13,16,48,-1,-4,18,-44,-32,25,-38,-66,31,-25,5,17,40,34,-26,-54,11,67,26,45,1,-55,39,-34,-45,19,35,-15,-9,-52,-24,-9,-11,69,-7,71,-47,12,-15,52,-32,15,26,-3,-7,66,-35,-38,-38,60,33,-60,-12,-83,-13,27,-14,-2,-45,-4,-9,-20,51,-23,33,22,1,-7,-18,57,7,5,-15,-1,-16,-31,1,-25,18,28,-26,11,-56,35,-3,-61,16,-29,-14,-17,-97,18,0,-3,18,-43,34,8,56,46,16,41,44,-99,13,4,-45,-8,59,4,7,2,-29,28,-25]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.136","t":"BOOSTER SESSIONS Booster sessions can be scheduled approximately one month following the end of treatment and then as needed thereafter. During a booster session, you: • Check in with the patient about self-management of symptoms and stressors. • Refresh skills learned in therapy. • Discuss questions or concerns the patient might have about the transition. • Review treatment goals and maintenance of treatment gains.","e":[19,37,-182,-28,-3,-30,19,-17,55,-31,-33,68,15,13,34,-30,10,-89,-49,22,-43,-55,-61,-26,-13,62,5,40,-4,-24,64,-38,24,-8,-18,-14,43,26,-41,-45,50,-33,15,-76,17,-55,74,33,-11,-38,36,-25,-83,0,66,-3,22,-11,31,-48,146,31,-39,36,53,-9,-1,38,-36,-1,44,5,37,34,-1,-21,-32,3,0,16,27,-14,54,-80,34,18,-10,33,-43,80,9,4,9,35,-63,22,22,13,-18,-67,-32,3,39,-19,-3,42,-4,9,6,0,-81,4,-30,6,1,9,38,-25,5,11,-8,-25,0,35,52,43,-37,-15,9,1,-15,-26,-54,43,-11,50,65,-36,18,-15,51,6,-20,1,-15,-27,47,-50,-19,36,-2,14,32,17,73,-48,-28,-3,71,49,50,-31,-73,38,-15,-54,19,32,-6,30,-34,-52,-11,-29,67,21,59,-39,-1,-58,33,-41,29,53,10,-34,43,-34,-55,-47,49,22,-51,-51,-97,-40,89,-19,15,-18,13,31,-40,8,1,61,13,-23,-25,-24,52,-6,3,-9,-15,-2,-5,-34,-2,48,29,-8,-19,-62,43,-2,-13,8,-14,8,-28,-42,-1,-14,-11,-16,-16,37,32,46,30,47,59,22,-121,8,10,-30,-2,13,-7,44,27,20,13,4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.137","t":"ESSENTIAL BRIEF CBT SKILLS | MODULE 18 SELF-MANAGEMENT TIME GUIDE 1. Mood Check a. List five emotions you are feeling right now, and rate their intensity from 0- 100%. b. List three emotions you have felt this past week, and rate their intensity from 0-100%. 2. Review the Previous Week a. Did I use any tools I learned in therapy this week? i. If I did not, what problem did I have this week that could have been helped through the use of these skills? b. What good things happened this week? i. How did I make those good things happen?","e":[-8,-36,-179,-73,40,-6,77,-39,32,-43,-27,12,46,34,17,-8,28,-35,1,32,-5,-41,-27,5,33,55,-13,53,-43,20,6,-24,4,-77,-47,-45,59,6,-45,-4,64,-17,22,-92,33,0,93,32,11,-18,4,-59,34,-38,120,16,11,36,17,-18,103,8,-33,59,24,-55,-24,37,-53,0,53,-7,29,41,-56,5,-41,2,3,12,45,1,93,-57,47,-33,-28,-5,-21,54,-5,22,11,35,-68,50,-1,9,9,-62,-45,-21,-12,-25,-12,31,-31,-18,-18,7,-70,14,-21,-8,4,11,56,-20,-15,61,-15,13,4,34,54,25,-19,-4,13,-9,18,-43,-41,-8,-9,27,13,20,18,25,20,-15,-10,27,-28,-38,-12,-40,-61,-8,4,-16,34,24,38,-29,-24,12,58,28,38,-22,-20,40,-17,-31,19,37,49,61,-57,-40,-16,-38,25,38,48,-20,45,-59,46,3,54,47,-12,-28,27,-41,-30,-4,30,41,-68,-28,-66,-44,23,-27,8,-67,-6,31,-5,47,-72,39,-6,6,-8,-76,67,-10,-14,11,-36,18,-18,-18,-41,-2,5,10,18,-11,10,30,-10,-13,-8,23,-2,-112,16,5,1,47,-15,54,10,67,71,59,69,9,-80,37,-5,-26,15,46,-2,-8,14,-1,26,-14]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.137","t":"3. Current and Future Problematic Situations a. What are my current problems? i. How can I think about these problems in a different way? ii. What can I do to change the feelings associated with these problems? b. What problems can occur before my next self-management time? i. What skills can I use to deal with these problems? 137","e":[11,-1,-130,-22,49,41,36,-57,46,-7,-23,10,36,42,-13,5,18,-39,-25,58,-25,-49,-32,-14,-12,40,-14,-33,-40,-2,19,-10,9,-69,-52,-67,86,0,26,-45,60,-20,27,-132,36,-54,51,-6,83,-53,21,-45,20,-10,75,21,34,0,8,-29,83,24,-34,74,2,-43,-38,54,-21,-26,69,7,14,17,-47,-22,25,5,27,21,30,-6,104,-63,27,2,-20,22,0,57,-36,52,37,18,-94,8,-23,25,-31,-47,-8,-55,28,1,15,44,27,18,-3,-1,-80,40,-7,22,27,-10,44,-9,48,70,-13,28,14,45,52,18,-55,12,55,3,10,-32,-13,19,-7,59,-11,-6,-1,13,126,-9,-1,38,-24,-33,3,-14,-47,-16,-18,46,-18,10,53,-26,-43,12,61,-25,30,-11,-28,63,-16,-5,2,45,4,70,-45,-14,29,-1,87,26,86,-32,-1,-40,18,-41,36,16,-20,-26,22,-26,-44,-20,17,60,-24,-46,-41,-94,31,9,14,-65,31,24,-9,58,-9,61,-8,20,7,-19,47,-65,-16,-11,-30,-14,7,3,-35,9,-36,-36,-8,-11,35,19,-41,-12,-22,39,-32,-114,61,51,10,37,-24,57,-4,43,10,46,65,40,-13,13,34,-35,-3,67,11,1,16,34,-17,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.139","t":"REFERENCES Supplemental Readings and References Allsop, S. & Saunders, B. (1991). Reinforcing robust resolutions: Motivation in relapse prevention with severely dependent problem drinkers. In Miller, W.R. & Rollnick, S. (Eds.). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press, pp. 236-247. American Psychiatric Association. (2020). Telepsychiatry Toolkit. Retrieved July 02, 2020, from https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit American Psychological Association. (2013, July 31). Guidelines for the practice of telepsychology. http://www.apa.org/practice/guidelines/telepsychology","e":[43,28,-178,-30,30,-50,-2,23,52,20,0,-26,53,30,-18,25,21,-71,-61,31,-60,-73,-7,-58,23,49,6,-5,-46,-2,27,-12,-7,-58,-77,-5,66,33,4,-8,13,31,15,-60,-5,-43,40,-3,15,-26,43,-19,-1,-26,74,-5,-50,43,-8,-49,100,34,-65,35,62,1,-43,84,-46,-15,42,-31,11,24,-42,10,-15,-41,-16,18,82,-7,76,-21,32,-5,4,33,-14,32,0,37,30,52,-61,15,-27,-33,-40,-21,-78,-5,23,-14,45,23,28,-10,16,28,-28,74,3,-13,15,-8,89,-46,26,30,-1,-30,28,70,-17,46,-43,5,1,22,6,-35,-51,-16,27,0,-26,-35,0,1,70,35,4,-13,-27,-45,5,-33,-25,-19,5,48,13,-7,27,-69,-33,-24,38,48,66,1,-27,65,-19,-1,32,2,40,14,-57,-41,40,-22,71,14,69,-39,34,-52,53,-33,31,58,22,-30,12,-13,-52,-49,-8,69,-51,-66,-89,-35,64,-43,47,-35,-28,20,-55,42,-52,65,-33,-29,-58,12,45,10,-11,-9,-19,-26,-12,-13,-9,68,-20,-18,-11,-12,12,-38,-37,8,8,0,0,-107,38,9,41,25,-49,62,32,38,9,12,21,18,-22,11,23,-51,17,21,31,1,17,24,12,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.139","t":"Folkman, S., Lazarus, R. S., Gruen, R. J., & DeLongis, A. (1986). Appraisal, coping, health status, and psychological symptoms. Journal of Personality and Social Psychology, 50(3), 571–579. https://doi.org/10.1037/0022-3514.50.3.571 Greenberger, D., & Padesky, C. A. (2016). Mind over mood: Change how you feel by changing the way you think (2nd ed.). Guilford Press. Hoffman, J. L., & Hoffman, J. L. (2006). Sculpting race: An innovative approach to teaching racial identity development. Retrieved from Summary Stages of Racial Identity Development: https://www.racialequitytools.org/resourcefiles/Compilation_of_Racial_ Identity_Models_7_15_11.pdf 139","e":[41,9,-178,-51,33,6,25,-17,24,4,23,4,81,64,-3,-45,-7,-53,-15,18,-76,-32,-22,-5,48,56,-48,-17,-32,14,21,16,7,-9,-40,-27,49,26,34,5,48,20,29,-80,8,13,24,-9,44,4,20,-10,36,-25,92,-30,-2,38,16,-35,61,95,-97,60,82,-33,-1,65,-37,-39,63,-14,24,26,-46,21,-8,-1,37,1,25,17,64,-39,69,-7,10,31,-25,94,31,53,-9,41,-48,27,-31,-14,-35,-39,-75,-19,-7,-52,41,7,-19,1,-15,27,-72,41,-22,-15,12,-28,45,-52,41,40,-1,-7,14,46,18,-2,-56,-22,-8,-14,-11,-27,-52,-10,-23,46,-10,11,-14,15,101,-9,-7,3,5,-42,18,-62,-32,-7,25,40,5,27,-22,-25,-49,7,42,17,45,-29,-9,66,10,-52,-8,13,-9,24,-23,-42,28,19,46,-4,49,-54,29,-29,71,-61,58,31,13,-73,25,-24,-57,-55,-8,42,-39,-32,-58,-68,47,-2,8,-32,-4,36,-30,36,-63,62,-2,-2,-5,-22,58,14,30,2,0,36,-5,-27,-4,6,-23,-7,-5,12,22,1,-33,-5,-4,8,-23,-95,52,-42,1,0,-13,32,38,34,32,56,8,49,-51,14,-7,-48,6,55,-22,24,13,23,41,-27]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.140","t":"Safran, J. D., & Greenberg, L. S. (1982). Eliciting \"hot cognitions\" in cognitive behaviour therapy: Rationale and procedural guidelines. Canadian Psychology/Psychologie Canadienne, 23(2), 83–87. https://doi.org/10.1037/h0081247 Shore, J. H., Yellowlees, P., Caudill, R., Johnston, B., Turvey, C., Mishkind, M., ... & Hilty, D. (2018). Best practices in videoconferencing-based telemental health April 2018. Telemedicine and e-Health, 24(11), 827-832. Turvey C, Coleman M, Dennison O, et al. ATA practice guidelines for video-based online mental health services. Journal of Telemedicinie and e-Health. 2013;19(9):722-730. doi:10.1089/tmj.2013.9989 140","e":[47,29,-193,-37,50,5,25,0,32,-9,16,2,79,53,-8,-52,-37,-65,-61,6,-86,-44,-32,-35,15,2,-24,16,-34,-1,59,5,-27,-18,-55,-45,71,-21,-45,-2,47,-11,56,-83,35,-4,47,9,34,23,15,-57,-4,-60,118,-45,-22,71,10,-44,105,72,-52,14,54,-11,-76,72,-32,30,32,-21,28,29,-41,-7,-42,-36,5,42,35,-37,55,-45,46,12,-9,40,29,67,15,54,1,39,-36,9,-22,-22,-45,-35,-50,-24,15,1,-18,56,1,-5,-8,10,-6,52,-20,-35,23,-15,42,-7,34,61,-1,-26,-19,48,9,13,-44,-17,-34,-18,-16,-8,-5,14,-29,70,13,-17,28,14,79,-12,-4,-32,-2,-21,4,-33,-11,-14,7,55,22,12,26,-67,-52,6,63,15,40,-11,-34,45,9,-43,-10,43,23,20,-91,-17,-11,-36,22,9,53,-54,20,-31,8,-31,35,44,23,-38,20,-2,-45,-26,-50,16,-85,-38,-95,-58,63,-31,53,-35,-4,8,-35,38,-44,67,-11,35,-10,-39,35,20,17,5,-27,6,-25,-32,-73,33,12,10,22,-7,-7,-13,-34,-6,24,32,-18,-99,36,-7,20,26,-3,64,10,33,30,39,-4,10,-48,3,-20,-41,-31,31,31,10,7,-4,41,-4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.143","t":"APPENDIX A • PATIENT HANDOUTS Bridging Sessions 1. What main points did we reach in our last session? What did you learn from last session? Did anything come to mind in the past week about our last session that you’d like me to know or that you’d like to discuss? 2. Were you uncomfortable about anything we talked about in our last session? Is there anything you wish we had discussed that we didn’t? 3. How is your mood? Compared with last week, is it better or worse? 4. What treatment goals would you like to work on today? What problems would you like to put on the agenda? 5. What homework did you attempt or complete for last session? What did you learn from doing it? 143","e":[22,-3,-120,-108,31,-20,32,7,46,-24,-13,8,12,27,45,-53,42,-58,-33,12,-16,-27,-48,-16,36,46,-10,16,-74,-30,43,-14,71,-18,-36,-2,82,29,-19,6,82,8,-9,-74,16,-53,79,10,58,-6,-2,-11,-58,19,85,6,6,36,76,-15,98,29,-35,87,55,-60,-17,54,-34,2,57,18,49,5,-68,21,-2,-25,-11,26,6,5,76,-30,15,1,-20,-1,-50,99,-29,0,32,16,-65,21,-27,-21,-45,-53,-45,-10,12,-16,43,42,8,10,3,-16,-43,36,-26,-16,14,13,40,-35,30,28,0,17,19,19,61,23,-47,-16,25,10,1,-5,-45,45,29,54,-22,-27,16,-20,69,12,-35,22,-9,-40,25,-27,-48,25,-3,11,34,47,29,-36,-20,-38,8,27,47,-39,-62,59,-6,-34,35,26,50,47,-17,-49,12,-19,24,39,69,-13,0,-41,66,-18,18,8,-12,-45,0,-25,-77,-32,12,38,-27,-55,-76,-50,64,-12,9,-18,-4,43,-64,30,-14,74,-13,-25,-5,-45,49,-16,5,25,-35,11,28,-20,-20,44,20,-37,17,-21,38,31,-20,28,-51,19,-31,-108,-4,-30,-6,-38,-18,32,8,50,13,28,39,-11,-76,49,-9,-48,19,62,21,35,34,51,3,-24]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.144","t":"APPENDIX A • PATIENT HANDOUTS Unhelpful Thinking Styles 1. All-or-Nothing Thinking: Viewing situations on one extreme or another instead of on a continuum. Ex. “If my child does bad things, it’s because I am a bad parent.” 2. Catastrophizing: Predicting only negative outcomes for the future. Ex. “If I fail my final, my life will be over.” 3. Disqualifying or Discounting the Positive: Telling yourself that the good things that happen to you don’t count. Ex. “My daughter told her friend that I was the best Dad in the world, but I’m sure she was just being nice.”","e":[56,23,-153,-68,39,42,-15,4,33,-21,20,-5,97,78,17,6,4,-54,9,45,-38,2,-37,13,58,26,-29,0,-93,22,6,-4,13,-36,-71,-3,85,37,19,-21,17,24,43,-62,24,-52,48,-1,48,-30,27,-70,6,-3,104,24,27,23,18,-15,77,41,-16,47,38,9,-68,55,-28,-22,56,-3,8,-11,-51,44,-39,12,-3,34,33,-13,73,-12,19,18,2,4,-46,89,-36,11,-18,16,-93,34,-19,-16,-35,-52,-70,-19,-13,-54,4,31,15,0,6,-32,-24,72,-40,-41,-11,-18,51,-22,20,53,1,31,21,50,17,60,-47,3,-9,-24,-6,-30,-14,2,6,82,-18,-18,3,16,41,21,-1,15,-3,-54,28,-24,-37,1,-35,38,3,44,20,-38,-26,0,20,-25,62,1,-57,30,-40,-24,20,64,14,49,-40,-46,53,-25,70,-33,54,-33,-42,-37,17,-18,27,38,9,-53,37,33,-43,-45,65,53,-20,-21,-53,-61,33,-11,32,-57,5,8,-54,23,-44,49,2,29,-12,7,71,-11,-12,23,-20,-13,19,-21,-55,35,25,8,4,-6,22,10,-8,13,-36,-15,-48,-108,26,16,10,-13,38,27,6,59,-14,53,14,10,-71,12,41,-66,19,33,5,52,9,-13,19,6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.144","t":"4. Emotional Reasoning: Feeling about something overrules facts to the contrary. Ex. “Even though Steve is here at work late everyday, I know I work harder than anyone else at my job.” 5. Labeling: Giving someone or something a label without finding out more about it/them. Ex. “My daughter would never do anything I disapproved of.” 6. Magnification/Minimization: Emphasizing the negative or downplaying the positive of a situation. Ex. “My professor said he made some corrections on my paper, so I know I’ll probably fail the class.”","e":[78,17,-166,-70,49,34,49,-37,-4,17,-12,15,83,74,27,-5,9,-42,-1,60,-14,-10,-31,-15,18,2,-28,-48,-57,18,-49,-12,11,-70,-85,-56,37,74,21,-12,28,4,34,-39,27,-40,34,29,56,-53,10,-60,18,-23,88,41,21,63,26,-17,60,49,-69,65,57,-8,-48,42,-7,-31,47,-35,-19,10,-54,-10,-44,17,40,19,65,-2,73,-19,63,22,-36,-7,-7,91,-3,11,13,14,-70,31,-9,-15,-34,-63,-61,-57,-14,-39,31,12,-1,28,7,-3,-25,55,-64,-23,-10,-13,82,-36,-30,47,24,14,0,23,-19,24,-16,8,-22,-46,17,-51,-12,6,-36,67,-30,-9,11,35,72,14,-19,-9,-32,-38,14,-22,-33,-2,7,32,8,5,24,-10,-7,17,30,5,42,19,-49,69,-27,8,12,52,-1,25,-63,-38,21,2,48,10,71,-53,-10,-7,-7,1,75,13,-5,-53,33,-25,-40,-26,19,47,-20,-20,-77,-83,7,15,30,-24,-1,-5,-20,22,-30,47,-14,15,-8,-8,40,-19,-10,-2,25,-16,13,16,-23,0,14,-30,4,5,-3,14,4,10,-57,16,-52,-84,66,10,22,45,-2,14,25,61,-2,49,-5,-1,-38,-1,30,-50,1,44,1,36,35,-42,64,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.144","t":"7. Mental Filter/Tunnel Vision: Placing all your attention on the negatives of a situation or seeing only the negatives of a situation. Ex. “My husband says he wished I was better at housekeeping, so I must be a lousy wife.” 8. Mind Reading: Believing you know what others are thinking. Ex. “My house was dirty when my friends came over, so I know they think I’m a slob.” 9. Overgeneralization: Making an overall negative conclusion beyond the current situation. Ex. “My husband didn’t kiss me when he came home this evening. Maybe he doesn’t love me anymore.”","e":[63,29,-164,-62,64,42,23,-23,38,-14,-4,45,72,103,3,-24,12,-56,3,25,-43,-3,-27,-5,14,37,-27,-25,-27,43,-17,-17,-55,-79,-82,-20,65,37,40,-5,36,5,8,-121,48,-13,59,5,44,-38,14,-40,10,-2,93,14,-3,-2,9,-22,53,12,-44,77,4,-30,-54,58,-24,-28,30,-18,-16,17,-44,10,-38,18,45,25,50,-20,52,-42,40,32,-6,-22,-12,62,-5,21,-11,59,-103,30,-30,4,-45,-18,-64,-16,14,-36,43,46,-36,-10,11,1,-65,37,-19,-33,-11,-51,91,-29,-4,40,21,32,-11,29,16,51,-61,2,13,-26,42,-40,32,25,6,56,-5,-3,-17,40,91,-10,-5,-23,-27,-51,-1,-57,-63,-20,-11,13,-8,21,65,-52,-28,-6,33,6,40,15,-65,95,-33,-45,19,37,17,26,-32,-28,10,-34,42,35,49,-89,-14,6,14,-35,55,27,21,-46,57,1,-24,-7,-4,13,-39,-47,-55,-64,14,17,9,-61,-23,-18,-19,41,-11,44,-17,-5,-36,10,29,-18,-6,-16,-27,-24,40,-6,-55,6,6,-24,-14,9,55,29,-40,-24,-35,32,-36,-102,70,19,-1,7,6,40,24,45,-8,57,-21,-12,-55,29,9,-38,-22,17,-3,53,11,-8,51,-6]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.144","t":"10. Personalization: Thinking the negative behavior of others has something to do with you. Ex. “My daughter has been pretty quiet today. I wonder what I did to upset her.” 11. “Should” and “Must” Statements: Having a concrete idea of how people should behave. Ex. “I should get all A’s to be a good student.” 144","e":[42,16,-130,-32,64,45,42,-38,20,8,-28,26,50,90,19,-47,11,-68,3,81,-35,-37,-13,-20,31,35,6,-37,-28,13,-24,-2,-12,-19,-75,-19,35,53,-4,-52,45,45,20,-87,29,-41,88,-20,70,-15,31,-70,19,-22,110,50,18,9,-10,-22,92,73,-99,48,40,-16,-81,49,-43,4,64,-9,16,29,-39,-6,-28,6,28,42,45,-34,58,-40,53,2,0,-15,-22,75,-1,10,-3,24,-70,19,-13,4,-8,-38,-41,-56,-26,-10,19,29,-9,25,23,0,-55,43,-29,-33,-8,20,108,-63,9,81,-7,-2,15,36,-27,21,-6,-12,-13,-19,20,-62,-10,1,-12,68,-5,-39,4,21,81,42,-42,9,-11,-60,9,-33,-42,7,19,7,12,19,16,-20,-24,30,70,-5,55,1,-61,76,-43,-38,-6,42,4,7,-39,-5,10,-22,70,11,37,-60,-35,-42,25,-27,43,19,19,-62,63,-10,-19,-37,4,45,15,-7,-83,-67,11,-10,15,-48,-24,-14,-26,52,-30,26,1,35,-7,-11,38,-36,0,3,-20,-21,0,-19,-59,13,-24,-9,-33,24,8,21,-24,3,-63,37,-40,-85,67,29,19,48,7,-38,4,31,-14,66,34,11,-54,29,23,-28,-49,34,-28,20,5,-14,22,-19]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.145","t":"APPENDIX A • PATIENT HANDOUTS Thought Record (1) (2) (3) (4) (5) (6) (7) Situation Automatic Emotion(s) & Evidence Evidence Alternative Rate Mood Thought(s) Mood That That Doesn’t Thought Now Supports Support Thought Thought What actually What What What has What has What is Rate from happened? thought(s) emotion(s) happened happened another way 0-100 Where? went through did you feel to make you to prove the to think of (worst to What? How? your mind? at the time? believe the thought is not this situation? best) When? How much did Rate how thought is true? you believe intense they true? it? (1-100) were (1-100). 145","e":[62,16,-168,-91,64,10,12,36,31,-30,-1,-1,55,47,16,-37,19,-39,-14,41,-15,-65,-72,-19,45,41,-53,-22,-81,-7,15,-9,38,-44,-77,-35,56,16,22,5,44,-4,23,-49,31,-10,52,51,64,-3,13,-2,7,0,124,66,15,52,47,-19,91,20,-22,28,74,-11,-26,66,-45,-29,29,7,-19,-7,-66,17,-22,-5,1,32,76,-24,97,-34,56,-17,3,15,-29,98,-15,-14,31,-2,-89,13,-52,-6,-27,-32,-64,-32,-21,-46,34,8,-8,30,11,18,-13,36,-33,-19,23,-25,60,-37,18,51,3,65,2,58,11,25,-5,10,-5,-43,-1,-47,-39,24,-3,60,-10,-31,-5,12,71,12,-1,-5,-36,-16,18,-38,-56,20,22,18,10,41,-3,-43,-21,30,21,22,63,13,-49,40,-8,-28,29,56,3,26,-56,-65,39,2,57,18,52,-14,14,-26,55,-40,50,-1,9,-83,34,30,-39,-29,5,38,-61,-44,-71,-42,38,-15,33,-21,39,31,-76,0,-51,62,6,-11,-1,-38,63,1,-14,54,-30,19,17,-32,-8,30,18,-9,6,-6,22,4,-42,19,-16,7,-32,-100,10,-19,-10,-17,-29,3,38,35,6,23,4,8,-74,17,26,-34,41,65,-12,42,32,-8,42,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.146","t":"• What happened? What • How were you feeling • What was going through were you doing? before this happened? your mind before you started to feel that way? • Who was there? • How did you feel while it was happening? • What made you feel that • Who were you speaking way? to? • What mood were you in after this happened? • Do you have any other • When did this happen? thoughts? • Can you rate your mood • What time of day was it? on a scale of 1-100? • Which thought bothered • Where did this incident you the most? occur? • What images did you have with these thoughts? • What are you afraid might happen? • What if this is true? What does this say about you? • What could happen if this were true? • What other ways could we think of this?","e":[55,-16,-144,-58,59,43,65,-12,29,-64,-18,39,47,74,-7,-72,15,-46,-8,54,-90,-37,-50,1,10,14,-45,6,-48,2,3,-3,5,-68,-54,-54,4,9,44,-15,92,-28,-7,-106,27,-1,31,-7,34,-42,2,-4,-4,-36,104,40,73,27,60,28,76,19,2,10,32,-28,-44,80,-26,-42,66,-3,1,16,-70,0,38,-14,9,9,62,-13,104,-36,28,10,-39,30,-16,72,21,-15,37,11,-97,-12,-49,17,-28,-64,-44,-41,-15,-25,49,38,-25,17,-11,-26,-44,22,-3,16,5,1,80,-35,43,36,1,39,-31,42,28,21,-23,-5,-7,-29,31,-43,-12,35,-22,75,-10,-3,11,30,109,-10,-22,-11,-22,-36,25,-41,-22,-6,14,17,26,24,22,-51,-31,45,23,17,60,17,8,31,-4,-29,6,34,24,72,-39,-44,11,-26,39,46,43,-31,46,-9,35,-32,43,-23,-9,-99,40,-17,-47,-8,-34,0,-23,-64,-70,-55,22,5,27,-52,6,11,-67,60,-37,94,3,14,2,-24,57,-11,-3,18,-44,42,27,-6,10,47,-16,-23,-27,16,33,12,-20,-12,-22,30,-37,-77,38,19,-21,48,-18,14,9,20,3,17,58,-13,-71,7,15,-29,58,38,-6,2,27,7,38,-30]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.147","t":"APPENDIX A • PATIENT HANDOUTS Thought Record (1) (2) (3) (4) (5) (6) (7) Situation Automatic Emotion(s) & Evidence Evidence Alternative Rate Mood Thought(s) Mood That That Doesn’t Thought Now Supports Support Thought Thought What actually What What What has What has What is Rate from happened? thought(s) emotion(s) happened happened another way 0-100 Where? went through did you feel to make you to prove the to think of (worst to What? How? your mind? at the time? believe the thought is not this situation? best) When? How much did Rate how thought is true? you believe intense they true? it? (1-100) were (1-100). 147","e":[62,18,-168,-89,65,9,10,36,33,-29,-1,-1,55,48,16,-36,19,-39,-13,40,-16,-65,-72,-21,46,41,-54,-21,-81,-8,16,-9,38,-44,-77,-34,53,16,21,6,43,-6,24,-50,31,-10,52,49,63,-2,14,-1,9,-1,124,67,16,52,47,-20,91,20,-22,28,72,-11,-27,65,-45,-29,30,7,-18,-7,-67,16,-22,-6,1,32,76,-23,97,-35,56,-17,3,15,-29,99,-16,-14,31,-1,-89,14,-52,-5,-27,-32,-66,-32,-21,-46,34,6,-8,30,10,20,-13,37,-33,-19,24,-24,60,-37,19,51,4,64,1,58,12,24,-5,10,-6,-42,-1,-47,-39,25,-4,59,-10,-31,-5,12,72,10,-2,-5,-35,-17,19,-38,-56,20,23,19,11,41,-4,-43,-22,30,22,21,64,12,-48,40,-8,-28,29,56,3,26,-56,-65,39,3,57,17,50,-14,15,-26,54,-40,49,0,11,-83,33,30,-40,-30,4,39,-60,-43,-71,-42,37,-15,34,-20,39,30,-76,1,-51,63,5,-10,-3,-37,63,1,-14,52,-31,19,16,-32,-7,31,18,-10,7,-6,21,4,-42,18,-16,6,-34,-100,10,-20,-11,-17,-28,4,38,36,6,23,4,8,-73,17,26,-35,41,65,-11,42,32,-9,42,-20]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.150","t":"APPENDIX A • PATIENT HANDOUTS Activities Checklist SOCIAL ACTIVITIES AND EXCURSIONS/COMMUNITY 9 INTERACTIONS WITH OTHERS 9 • Going to the park or beach • Going together with friends • Going out to dinner • Visiting a neighbor • Going to the library • Having family visit or visiting family or a book store • Going to the movies • Eating out with friends or associates • Going shopping • Going to a local community center • Playing bingo, cards, dominos • Going fishing with others HEALTH AND WELLNESS 9 PHYSICAL ACTIVITY 9 • Putting on makeup or perfume • Walking for exercise or pleasure","e":[-2,35,-163,-36,13,18,40,-22,57,-21,-16,-6,44,48,6,-61,-32,-39,-26,12,-15,-5,-35,25,67,50,48,-5,-106,-25,-15,11,15,-16,-9,-44,34,38,2,36,13,59,21,-68,49,-72,92,-12,79,-9,7,-55,-78,47,64,2,34,19,36,-10,106,21,-21,56,58,-36,-32,41,-60,27,75,-10,66,18,-48,49,-20,-24,-9,9,-4,-4,127,-31,27,-11,-26,-17,-39,65,-8,40,47,43,-76,7,-10,13,-3,-64,-46,20,15,19,28,1,3,37,4,8,28,20,-23,-26,37,-18,44,-41,51,19,5,9,20,33,37,-1,-62,4,-22,-28,-17,-15,-34,25,1,-2,-50,-18,0,-16,40,54,-17,11,-8,-38,12,-48,-39,8,-9,46,-3,42,20,-47,-27,-7,31,1,71,15,-40,72,-50,-41,37,56,18,30,-22,-59,-9,29,14,-42,13,-15,-17,-25,42,-56,19,33,-16,-35,3,-34,-63,-53,-19,46,-5,-75,-44,-16,29,-12,-6,-42,-10,18,-47,21,-9,69,-17,-23,14,-40,71,-58,19,0,-47,16,12,-37,0,20,22,-23,-17,-39,58,51,-47,34,-36,5,-59,-51,0,-16,12,-12,-12,12,16,32,-2,45,48,11,-69,49,-21,-7,-19,40,23,40,14,27,44,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.150","t":"• Eating healthier • Light housekeeping, such as sweeping • Relaxing, meditating • Swimming or doing water exercise or doing yoga • Improving one’s health • Gardening or planting SPIRITUAL, RELIGIOUS, RECREATIONAL AND OTHER AND KIND ACTS 9 LEISURE ACTIVITIES 9 • Going to a place of worship • Knitting, sewing or needlework • Attending a wedding, baptism, • Writing in a journal or diary or keeping bar mitzvah, religious ceremony a scrapbook or photo album or function • Reading the Bible • Playing with or having a pet","e":[2,40,-167,-23,39,-28,71,-10,70,-66,-13,-2,93,110,-19,-17,6,-31,-17,20,-44,-18,-37,4,0,64,25,12,-15,-13,-17,-71,15,-2,-7,-32,55,52,37,-21,19,10,8,-56,37,-57,102,-37,45,-9,18,-95,-32,-27,98,-8,16,-9,40,-8,124,51,-65,77,13,-35,-27,58,-55,24,74,-23,42,17,-63,20,-29,-7,13,4,7,14,90,-31,27,1,-33,-36,4,58,15,24,7,51,-79,32,33,27,-28,-36,-37,-6,72,12,59,10,5,43,-69,26,-27,9,0,-11,-16,1,100,-20,25,57,4,9,0,28,-17,33,-41,-22,-22,-1,11,-25,-23,43,21,42,-28,-28,19,-17,76,7,-22,-15,-23,-40,19,-36,-11,22,13,10,-1,7,52,-55,-27,20,53,35,56,32,-36,77,-16,-9,10,51,26,43,-18,-26,-33,10,38,2,24,-64,-19,-36,35,-42,7,27,-34,-37,78,-55,-99,-20,-30,43,-15,-56,-46,-41,16,16,11,-27,-27,-5,-30,22,-3,77,-18,-17,-16,-15,87,-41,42,-41,-15,5,-22,-48,-27,9,26,-56,-10,-30,37,45,-25,-22,-35,5,-14,-43,43,-14,3,24,2,17,39,45,-12,10,54,-49,-50,48,-4,-47,-33,18,53,52,18,26,5,-37]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.150","t":"• Attending a Bible study group • Drawing, painting or crafts • Doing favors for others • Singing or listening to music or volunteering • Volunteering for a special cause • Reading the newspaper or magazines • Watching TV or listening to the radio • Doing word puzzles or playing cards Source: Adapted, with permission, from Lejuez, C.W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activation treatment for depression. Behavior Modification 25:255–286.Worksheet 150 – Identifying pleasant events and meaningful activities","e":[-7,15,-158,-60,50,-33,73,-22,72,-64,-10,3,94,50,12,-41,-28,-34,-49,68,-26,-34,-33,-20,21,49,22,24,-50,13,-22,-3,-2,-34,-21,-15,67,75,18,2,-7,16,2,-76,34,-57,102,-24,50,-36,39,-73,26,-48,110,-2,3,-3,14,-12,144,65,-45,41,52,-10,-26,69,-79,-22,77,43,29,41,-51,-13,-27,-5,11,-1,41,-30,72,-63,63,-2,-20,1,-23,38,19,17,-6,59,-72,10,21,-3,13,-36,-45,-32,25,-1,35,53,16,2,-24,9,-53,39,4,-57,-22,12,37,-28,10,46,-12,2,-15,30,5,16,-15,-15,-1,-30,-25,-26,-25,25,36,6,-5,-14,-5,7,48,8,-31,29,-44,-46,4,-7,-13,-6,-22,23,57,-14,43,-59,-28,4,58,35,71,11,-39,73,-17,0,5,52,56,38,-69,-48,-37,-18,74,-8,46,-46,0,-35,23,-77,30,19,-18,-34,23,-13,-61,-17,-16,20,-44,-57,-111,-41,8,-5,24,-68,-26,12,-30,45,-6,67,-5,23,-34,-7,59,-28,37,-15,-32,22,-37,-46,-31,9,12,10,-19,-7,46,50,-26,1,-27,34,-32,-49,31,-7,10,24,-10,12,16,25,-13,27,61,27,-43,42,-30,-16,-29,13,19,20,-20,5,46,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.154","t":"APPENDIX A • PATIENT HANDOUTS Tensing Instructions Model each tension procedure: Dominant arm: Make a fist and tense biceps; pull wrist upward while pushing elbow down against the arm of chair or bed. Nondominant arm: Same as above. Forehead, lower cheeks and jaw: Lift eyebrows as high as possible, bite teeth together and pull corners of mouth tightly. Neck and throat: Pull chin down toward chest; at the same time, try to prevent it from actually touching the chest. Counterpose muscles in front part of neck against those in the back part of neck.","e":[40,16,-182,-43,11,-30,15,12,33,-32,-26,-22,43,3,80,14,28,-83,9,11,-35,-33,-26,12,45,32,21,22,-96,-53,29,28,39,-40,-26,-33,60,-9,-42,57,13,-25,16,-58,19,-38,41,11,17,19,-1,-59,-50,-88,77,-26,46,31,101,-21,85,23,-42,66,31,-4,-35,74,14,12,34,9,74,-17,-64,6,-32,-43,-15,0,11,-12,85,-46,42,-26,-6,-13,-25,79,19,47,36,35,-37,-18,32,23,-31,-95,-36,17,-26,-19,-35,37,50,25,-1,-5,-26,53,6,2,17,-8,47,-26,5,26,-7,-7,-15,-9,5,7,-74,19,-1,-35,11,-20,-41,-7,48,65,-50,-61,31,-21,26,30,-33,-38,1,-36,4,-14,-44,15,18,5,29,31,48,-5,-3,-22,13,32,54,-44,-47,50,8,-62,25,72,43,36,-42,-60,-17,-22,15,45,43,-48,31,-41,42,-31,12,24,-40,-24,-29,7,-54,-62,27,71,-30,-29,-42,-32,63,1,20,12,-14,-28,-5,10,-42,59,-10,7,18,-26,37,-21,-4,-21,-6,-7,8,-53,-27,45,19,4,-1,-9,15,-9,-16,22,0,-25,-31,-44,14,-11,10,-10,13,74,1,26,-18,25,28,-26,-79,56,22,5,27,23,14,24,4,-27,-6,-24]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.154","t":"Shoulders, chest, and upper back/abdomen: Take a deep breath and hold it. At the same time, pull the shoulder blades back and together, trying to make them touch. Try to keep your arms as relaxed as possible while tensing this muscle group. At the same time make stomach hard by pressing it out, as if someone were going to hit you in the stomach. Dominant leg: Lift foot off the floor, and push down on the chair with thigh. Nondominant leg: Same as above. 154","e":[46,33,-191,-7,51,4,-17,20,-4,-69,-21,18,36,24,58,-10,-11,-89,22,5,-58,-6,-7,-19,28,30,16,26,-29,21,-11,-13,42,-57,-10,-46,48,15,-6,27,12,-61,22,-54,35,-4,49,9,25,36,-14,-71,-46,-123,43,-64,57,-5,124,-64,48,0,-37,77,17,-10,-56,82,18,-5,54,16,62,-3,-57,10,-18,-28,35,-2,50,25,73,-43,56,-4,-3,8,-5,80,27,31,20,60,-65,31,46,57,-35,-88,-25,37,3,-19,-12,1,35,14,-1,0,-39,22,5,-20,4,16,80,-33,7,14,-24,5,21,-14,14,34,-53,-9,29,-26,-16,-17,-23,15,42,53,-33,-40,22,-6,22,1,-30,-40,-13,-27,-2,-29,-34,39,18,5,7,-4,100,-18,13,27,55,29,36,-1,-28,21,3,-57,-17,67,69,57,-64,-44,-20,0,20,13,32,-74,34,-61,4,-17,16,33,-35,-14,1,13,-62,-45,-6,69,-22,-45,-35,-17,73,-19,12,-40,-29,-50,-7,16,-35,85,-34,10,9,-10,40,-21,5,-8,-7,5,-15,-35,-9,44,1,-17,-7,9,40,-11,-10,9,5,-8,16,-60,55,-17,-8,3,9,87,-22,30,12,-2,57,-5,-68,51,38,-38,5,6,9,55,13,1,-13,-15]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.155","t":"APPENDIX A • PATIENT HANDOUTS Deep-Breathing Technique Step #1: Put one hand on your abdomen, with the little finger about one inch above the navel, and place one hand on your chest. Step #2: Pay attention to your breathing (pause for several seconds to assess your breathing). Ideally, the hand on the abdomen should be moving, while the hand over the chest remains still. This ensures that the breaths are deep. Step #3: Take deeper breaths by getting the hand over the stomach to move, while having little movement of the hand over the chest. NOTE: If you have a lung or heart condition and you are having difficulty with this exercise, slow the process down to your comfort level.","e":[61,30,-181,-40,10,36,26,45,14,-63,-47,28,56,22,33,-24,5,-83,-12,-11,-41,-34,-41,-9,53,-12,12,47,-73,-14,24,-26,44,8,-4,-63,40,27,-13,34,24,-54,38,-38,30,-8,39,-6,5,-4,-12,-52,-78,-40,50,-11,8,-11,91,-47,69,34,5,50,31,-1,-62,58,0,11,35,-16,60,20,-61,35,-54,-33,35,10,16,-14,123,-10,48,-4,9,-16,-33,71,4,14,38,75,-26,-6,37,80,-44,-108,-57,34,-24,19,-19,28,45,-2,2,-13,-48,-5,6,-28,10,40,36,-24,30,43,-23,33,33,-2,27,35,-83,-12,22,-21,-18,-8,-37,4,5,8,-63,-16,-16,-3,3,11,4,-31,12,-38,-2,-62,-46,-4,25,19,53,53,78,-11,-19,13,30,44,41,3,-14,47,-12,-38,-17,53,29,48,-22,-42,3,-8,24,18,67,-48,-13,-76,84,-11,-1,37,-21,-24,-1,-4,-35,-96,21,18,-7,-11,-56,30,53,-13,-13,-8,9,-29,22,-3,-26,70,1,21,-16,-22,48,-12,-18,-6,8,56,-21,-35,-24,36,15,-11,-1,-29,27,8,-33,3,5,-34,4,-59,38,-19,11,-25,-25,58,-14,56,13,2,42,-10,-55,60,19,-47,6,13,-14,28,52,-21,-3,-17]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.155","t":"Step #4: Continue your slow, even, deep breaths. To pace yourself, you can say the words in and out slowly while taking breaths. Inhalations and exhalations should build to approximately three seconds in duration. Step #5: Repeat the breathing exercise three or more times.","e":[60,27,-174,5,12,-7,51,-2,15,-58,-54,28,12,69,8,-19,27,-125,-4,24,-44,-19,-25,-50,13,57,21,-7,-45,-29,63,-7,29,6,-17,-60,44,3,-4,16,40,-82,65,-1,96,-27,18,12,30,-22,-7,-52,-80,-45,37,42,1,-29,38,-35,84,-40,-20,67,66,-24,-55,71,-1,20,42,-42,47,-18,-47,19,-30,16,34,37,14,-31,132,-21,60,-13,-23,-12,-20,77,-2,8,28,46,-35,-4,12,67,-35,-61,-69,-12,20,-38,14,12,3,9,6,-16,-71,4,0,-16,-35,58,64,-18,12,82,-13,-12,-2,-12,16,-4,-61,-61,13,-19,28,0,-39,8,-43,15,-26,-3,-11,-31,13,-3,45,-5,-26,-35,30,-64,-30,12,9,-7,37,48,60,-15,-34,9,47,8,41,-7,-50,53,-27,-13,-6,76,18,27,-59,-46,-24,21,17,18,53,-53,-47,-92,53,-12,-15,23,-30,-29,8,-25,-39,-35,22,-3,-13,-29,-48,-8,63,-46,27,-19,5,-27,-1,10,16,38,-16,19,-1,7,94,20,-43,-26,20,-10,-16,-8,-17,37,23,-20,-23,-59,31,-35,-40,-20,-16,34,-16,-70,41,12,43,-1,-10,46,8,41,28,-7,69,-2,-62,10,26,-33,-11,23,-5,33,38,-3,10,-1]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.155","t":"Other tips for deep breathing: 1. Inhale through your nose and out your mouth. 2. Purse your lips (as if blowing out hot soup) while exhaling. 3. Do not pause between inhales and exhales. 4. Close your eyes during the exercise. 5. Use a mantra such as “relax” during each exhale 6. Pair up deep breathing with imagery once you have mastered the breathing skills. 7. REMEMBER: Deep breathing is a portable skill that can be used in a variety of situations and relatively without notice of others. 155","e":[27,18,-166,-20,37,2,34,1,23,-59,-38,23,26,61,12,-19,-19,-120,3,25,-73,-58,5,-36,-14,20,13,17,-23,-24,45,-50,6,0,12,-25,36,45,-7,23,55,-63,53,-6,47,-13,7,-2,3,-24,60,-36,-77,-58,67,-4,26,-12,68,-47,85,-4,-21,60,50,-9,-69,93,-11,15,59,-30,55,15,-42,18,-11,-16,41,48,-1,-11,116,-28,67,24,-18,-8,-9,49,7,19,55,91,-18,33,27,91,-41,-83,-38,24,28,9,3,29,49,4,-14,3,-66,12,1,-25,-41,57,66,-40,26,42,-24,37,21,-33,7,25,-56,-82,3,-37,-14,-12,-49,6,-10,29,-60,-7,1,-23,38,-8,11,-28,-22,-58,-39,-68,-38,19,18,2,39,30,93,-5,-48,-6,55,27,17,-5,-45,38,8,-20,-12,73,41,32,-51,-25,-25,-11,33,-17,86,-53,-30,-65,64,-14,-28,61,-4,1,16,-4,-57,-46,-5,9,18,-31,-54,-16,51,-25,29,-18,-29,-41,-1,39,10,70,-10,8,-5,-1,56,3,-11,-39,1,58,-28,-20,-53,31,8,-20,-41,-24,31,-12,-47,5,23,13,8,-95,58,16,17,-21,-8,81,-11,24,14,-7,45,-31,-73,21,-15,-41,8,2,-1,47,50,-15,14,-7]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.156","t":"Once your whole body feels relaxed, travel to your favorite place... it can be any time or any place. This place is calm and safe... there are no worries here... Look around this place. What do you see? Do you hear the sounds around you? What are some of the sounds you hear in this place you are imagining? How does this special place smell? Walk around a little, and take in all the wonderful sights... Feel the air around you and relax.... The air is fresh, and it’s easy to breathe here. Pay attention to how your body feels..... Say to yourself, “I am totally relaxed... without worries... all the tension has drained away from my body.” Take a moment to fully experience your favorite place.... Notice the sounds, the sights, smells, and how it feels to be in this very special place. Remember that you can visit this place as often as you want and that it is wonderful. Say to yourself, “I am relaxed here... this place is special and makes me feel at peace.”","e":[28,34,-189,11,35,-4,19,60,46,-65,-29,20,5,26,-14,-10,4,-73,41,8,-67,-20,-10,-9,-7,61,-4,23,-29,18,5,-48,16,25,19,-74,9,53,46,26,68,-21,25,-57,85,-38,73,-31,40,3,-11,-19,-60,-32,56,-10,40,-6,38,-14,103,-4,-15,85,40,-15,-86,48,14,5,47,-22,-1,6,-85,18,36,12,27,5,41,-41,85,-59,25,4,16,-55,-21,55,43,-18,40,52,-17,24,28,70,-15,-77,-44,8,-23,25,9,1,-5,16,-5,-18,-24,-17,9,11,-3,27,86,-69,52,28,-25,58,-10,-21,20,35,-8,-13,29,-20,6,-21,-35,52,-8,76,-26,-11,-10,-3,48,-26,-2,-19,-47,-94,2,-54,-19,-8,24,0,-2,-14,16,-85,3,36,92,14,55,5,26,61,13,-25,-12,72,27,-1,-75,-36,-34,3,25,-51,33,-60,23,-66,39,-2,-17,-8,-3,-1,21,-37,-32,-40,26,-4,-76,-44,-56,-6,25,-19,2,-30,-4,-24,2,18,-33,82,-18,2,-17,2,61,-30,0,1,-28,-7,-6,-38,-16,25,21,-22,-3,-6,24,0,-58,-30,-16,13,-13,-89,66,55,26,-3,-7,36,-9,-9,29,14,17,6,-52,24,10,-60,55,-16,14,40,27,-1,27,-47]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.156","t":"When you are done with your visit to this special place, open your eyes, and stay in your comfortable position. Continue to breathe smoothly, in a relaxed and rhythmic fashion. Take as long as you want to enjoy and relax. Feel at ease knowing your special place is always available to you, and find that you feel relaxed, even after you leave. Script #2 – The Beach:","e":[14,14,-188,-26,12,15,54,45,57,-46,-19,39,30,32,29,-39,19,-98,24,-1,-57,-11,-24,23,25,55,27,33,-38,-3,33,-12,10,-15,25,-79,-1,40,2,10,40,-37,11,-39,66,-85,44,-20,11,-46,30,-31,-61,14,75,31,49,18,22,5,112,0,7,106,54,-3,-47,40,-29,-29,47,-35,7,14,-100,29,-6,16,15,34,26,-15,79,-68,27,13,13,-37,-23,54,42,-22,18,64,-60,35,13,77,-26,-74,-41,-19,19,-2,30,-3,-3,42,18,-33,-43,17,-8,11,-17,35,70,-74,41,17,-42,37,-11,8,5,32,-30,-21,32,-9,9,-17,-32,47,-13,47,-18,-22,9,4,51,-17,8,-4,-49,-69,32,-41,-26,-1,30,20,-2,40,45,-49,-7,39,67,28,66,-4,-6,49,-44,-24,23,39,6,7,-58,-55,-39,1,33,-24,21,-52,16,-72,35,-16,10,-7,0,-33,20,-45,-58,-47,21,-4,-28,-33,-76,-19,28,-24,-12,-20,0,20,-25,27,-30,72,1,-7,-10,-7,60,-24,-15,-4,5,-16,-5,-32,-4,34,12,4,-12,-8,45,13,-50,-18,-7,25,-22,-120,58,63,33,-18,-3,56,11,-14,18,14,23,8,-49,52,26,-55,23,21,16,2,49,32,31,-53]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.156","t":"Imagine yourself walking down a sandy beach. The sand is white and warm between your toes. You are looking out over the calm, blue water. The waves are gently lapping at the shore. You feel the pleasant warmth of the sun on your skin... it’s a perfectly comfortable temperature outside. Breathe in deeply. There is a gentle breeze, and the sun is shining. Big, cotton-like clouds drift by as you hear sea gulls in the distance. You taste traces of salt on your lips. You are completely relaxed... there are no worries on this beach. There is nothing to distract you from feeling tranquil. Worries drift away. Notice the sounds, sights, smells, and how it feels to be in this very special place.","e":[23,42,-191,-54,59,62,43,14,46,-79,20,46,37,74,12,11,11,-88,71,-14,-56,-31,12,22,-9,56,-13,56,15,-19,17,-28,-28,24,10,-101,-11,12,40,23,56,-16,62,-15,61,-49,84,-13,7,-29,-12,-26,-30,-40,14,-8,58,-3,15,34,113,5,-30,91,44,-19,-50,34,3,9,62,-15,-2,4,-56,30,3,25,14,38,53,-26,47,-36,80,-17,6,-18,-26,29,1,-24,49,45,-52,8,27,82,-28,-83,-15,-5,10,-7,42,3,-1,29,0,-23,-8,14,-11,-20,4,15,54,-47,77,54,-18,45,-17,12,53,36,-26,-12,7,-24,14,-5,-36,27,-1,46,-30,1,12,9,33,-16,3,-7,-27,-62,-22,-38,-7,34,15,5,30,51,38,-53,16,42,66,30,67,7,17,30,-13,-36,21,39,4,24,-40,-31,-36,-10,15,-14,28,-44,-5,-40,35,0,21,11,11,-29,11,-81,-31,-13,-21,-4,-72,-65,-27,-15,42,-53,9,-17,22,25,9,1,-22,71,-8,-3,-6,-37,56,-29,-14,-31,18,-5,14,12,1,12,18,33,7,11,56,25,-79,-19,-15,-6,-14,-92,97,47,22,27,18,62,18,-1,23,33,5,18,-54,38,-10,-41,17,7,58,19,48,26,52,-50]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.156","t":"Feel the sand under your feet... you decide to stretch out on the warm, fine, white sand... breathe deeply... feel the warm air. Your body is completely relaxed, and you have an overall feeling of warmth and comfort. You look up at the clouds pass by slowly across the beautiful blue sky. You are feeling rejuvenated and completely at peace. Remember that you can visit this place as often as you want and that it is wonderful. Say to yourself, “I am relaxed here... this place is special and makes me feel peaceful and content.”","e":[46,51,-205,-35,45,22,40,35,59,-75,3,33,18,47,12,15,-11,-76,53,-13,-63,-40,-17,-1,-8,60,-5,80,-21,-23,47,-6,14,26,12,-81,37,32,46,9,40,-52,43,-16,71,-51,56,-32,31,-18,-44,-31,-44,-32,62,-22,46,-13,21,6,83,26,-19,80,36,-14,-69,44,3,4,81,-6,10,24,-73,11,5,19,12,13,52,-7,69,-32,70,-13,2,-17,-24,44,16,-13,28,46,-50,6,43,101,-56,-60,-60,17,-16,6,34,8,-19,24,7,-22,-22,18,-12,-10,13,10,72,-38,50,52,-5,46,-4,-1,26,38,-17,-20,8,-23,30,-23,-30,45,-29,43,-37,-11,-9,-4,32,-10,27,-7,-18,-64,5,-40,-16,34,2,14,25,24,40,-57,-6,12,84,46,71,16,11,49,18,-45,24,53,33,18,-38,-51,-20,-26,8,-16,43,-52,5,-52,45,0,5,15,3,-10,21,-52,-48,-33,-12,1,-55,-51,-38,-13,42,-30,3,-24,3,26,17,-3,6,84,-21,-6,-10,-11,65,-29,17,-12,19,9,-8,-33,-13,11,19,-3,-5,-23,50,1,-70,-11,-20,11,-24,-102,72,49,21,1,19,41,13,-2,11,7,6,-17,-56,57,2,-64,7,-14,55,33,33,12,36,-42]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.156","t":"When you are done with your visit, open your eyes and stay in your comfortable position. Continue to breathe smoothly, in a relaxed and rhythmic fashion; take as long as you want to enjoy and relax. You feel at ease knowing your special place is always available to you, and you find that you feel relaxed even after you leave. 156","e":[11,29,-188,-20,0,4,49,18,73,-30,-19,7,19,16,38,-27,25,-102,3,16,-56,10,-29,6,-3,73,32,35,-43,27,55,-3,42,-22,12,-43,-5,46,17,-9,63,-54,11,-64,62,-53,47,-18,24,-28,18,-26,-79,7,87,43,62,13,48,-6,111,-6,5,93,45,-43,-55,60,-16,-24,31,-30,14,1,-85,34,13,11,13,23,23,-47,91,-47,31,17,-8,-39,-21,57,38,-43,23,61,-49,45,4,69,-11,-80,-29,-22,-3,-16,43,-5,-10,27,20,-35,-63,21,15,11,-14,28,62,-73,37,30,-31,26,-25,-5,21,48,-42,-42,26,-5,10,-23,-41,66,-8,56,-7,-17,2,-4,58,-29,5,3,-64,-43,35,-60,-12,14,27,11,4,37,35,-86,-22,39,60,16,78,-15,0,50,-3,-14,14,22,17,6,-46,-52,-21,-2,43,-41,28,-49,11,-73,48,-9,-10,-17,-10,-21,20,-54,-41,-36,42,-1,-27,-32,-80,-20,26,-15,-12,-28,-9,-8,-27,18,-34,80,-6,-2,-16,-1,46,-16,18,2,-22,-1,11,-39,-19,37,22,0,-22,1,50,-10,-63,-4,-9,24,-12,-95,50,57,38,-13,30,53,-1,-14,33,1,26,-17,-64,42,22,-62,38,6,10,9,38,14,18,-47]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.157","t":"Imagine yourself walking through a lovely meadow. The breeze feels pleasant against your skin. You are looking out over the calm, beautiful green grass. The blades of grass are gently swaying in the breeze. You feel the pleasant warmth of the sun on your skin... it’s a perfectly comfortable temperature outside. Breathe in deeply. There is a gentle breeze, and the sun is shining. Big, cotton-like clouds drift by as you hear birds in the distance. You hear the wind blow gently through the trees. You taste the sweet summer air on your lips. You are completely relaxed... there are no worries in this meadow. There is nothing to distract you from feeling tranquil. Worries drift away. Notice the sounds, the sights, the smells, and how it feels to be in this very special place.","e":[34,6,-197,-23,16,39,46,52,14,-54,12,9,54,76,-2,25,-50,-62,63,16,-67,-12,4,-14,5,60,-14,36,-9,-5,19,-10,-4,49,-18,-64,-3,52,25,0,89,-27,51,-3,54,-14,110,1,28,-27,-39,-15,-62,-20,39,-24,96,-27,71,23,103,24,-24,53,35,-17,-44,47,-14,-22,55,-7,15,33,-9,29,-1,21,14,5,14,-27,36,3,71,-9,-9,-20,-26,44,4,-3,40,20,-59,1,6,70,-36,-89,-25,-5,-24,8,55,5,-16,17,-7,-10,-21,16,-28,15,7,2,74,-40,67,69,-17,54,-36,0,44,65,-17,-46,-2,-27,16,-3,-19,51,13,61,-26,9,-3,-7,68,-37,18,-45,-55,-41,-21,-38,-13,-9,28,6,37,17,6,-71,23,9,66,16,49,1,46,48,2,-19,1,33,30,13,-73,-35,-31,-25,33,-50,40,-41,13,-78,34,0,21,-6,-12,-25,-6,-67,-12,-32,3,-9,-67,-73,-17,-10,11,-51,21,-23,3,-2,-26,-4,-23,90,-30,23,-2,-46,88,-24,23,-8,-2,13,3,-45,-9,26,0,-3,20,7,20,2,-62,-8,-8,-1,-22,-63,75,41,0,13,41,51,-17,-12,21,17,8,7,-52,51,18,-34,22,12,73,35,75,22,48,-38]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.157","t":"Feel the cool grass under your feet... you decide to stretch out on the soft, cushiony grass... breathe deeply... feel the warm air. Your body is completely relaxed, and you have an overall feeling of warmth and comfort. You look up as the clouds pass by slowly across the beautiful blue sky. You are feeling rejuvenated and completely at peace. Remember that you can visit this place as often as you want and that it is wonderful. Say to yourself, “I am relaxed here... this place is special and makes me feel peaceful and content.”","e":[41,41,-207,1,26,11,24,50,36,-73,4,16,15,47,18,30,-34,-73,38,-18,-64,-19,-6,-2,-4,74,-6,62,-18,-18,32,-10,10,33,5,-36,42,44,36,13,54,-41,28,-16,60,-50,65,-19,48,-33,-49,-24,-70,-61,62,-2,61,3,44,-11,96,35,-20,63,39,-10,-61,20,-3,1,74,-10,-3,32,-39,2,-5,25,25,9,42,-18,62,-26,66,-1,3,-30,-27,51,25,-5,27,39,-52,18,31,90,-65,-69,-63,35,-36,13,26,20,-32,22,3,-25,-33,28,-17,0,6,5,62,-43,50,52,-6,51,-3,-14,30,42,-34,-41,-5,-12,21,-10,-36,46,-13,50,-35,-13,-4,8,58,-24,40,-26,-30,-62,6,-40,-12,4,0,7,31,-2,35,-53,0,4,82,43,51,13,18,47,37,-33,4,42,38,16,-51,-53,-35,-25,12,-22,40,-34,10,-78,51,2,4,10,-7,-7,26,-56,-42,-34,-11,6,-54,-55,-38,-7,34,-21,0,-19,-2,-6,1,-1,11,84,-19,19,-9,-39,88,-35,28,-14,0,17,-1,-47,-14,24,26,3,-1,-24,26,-2,-63,1,-24,-1,-25,-75,63,45,19,4,19,40,5,0,19,8,15,-4,-64,65,6,-43,13,-12,73,55,55,8,23,-55]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.157","t":"When you are done with your visit, open your eyes and stay in your comfortable position. Continue to breathe smoothly, in a relaxed and rhythmic fashion; take as long as you want to enjoy and relax. You feel at ease knowing your special place is always available to you, and you find that you feel relaxed even after you leave. Other Guided Imagery Scene Suggestions: • A garden where you watch big, beautiful clouds in a blue sky, while you inhale the scent of flowers and feel a gentle breeze on your skin as the sunshine warms you.","e":[-6,40,-198,-44,-13,3,55,11,52,-37,1,13,28,51,15,3,25,-85,3,7,-71,8,-11,0,-20,69,23,25,-44,21,53,-16,10,-14,11,-52,8,60,25,-3,76,-47,12,-39,47,-50,73,-7,19,-26,8,-1,-64,-15,79,51,77,0,47,-13,123,15,6,77,42,-46,-78,45,-10,-13,42,-26,13,19,-57,23,-2,10,24,27,39,-45,80,-49,37,27,14,-37,-27,41,28,-47,23,50,-38,48,-5,76,-24,-62,-52,-19,-2,-17,28,2,-8,16,9,-33,-43,5,-7,2,-23,10,84,-71,46,38,-22,33,-14,-22,32,55,-44,-46,5,-17,5,-35,-32,64,-6,56,-2,-9,3,7,36,-32,0,-11,-54,-49,39,-49,-4,5,33,18,15,41,49,-88,-15,26,52,18,88,-1,0,38,12,-34,32,13,36,-3,-59,-50,-39,-17,48,-33,52,-43,17,-59,56,-26,-12,-3,-3,-26,14,-50,-36,-47,35,6,-49,-31,-81,-24,33,-23,-1,-25,-2,-5,-7,23,-43,81,-8,6,-23,-22,57,-19,25,12,-16,-3,10,-32,-23,18,23,2,-5,-17,54,7,-54,-5,-8,24,-13,-85,58,46,47,2,31,38,-9,-22,23,2,27,-2,-77,42,22,-48,36,6,27,16,43,11,20,-53]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.157","t":"• A mountain scene where you feel calm and relaxed as you look out over the valley. Just you and the vegetation and you dip your feet into a cool mountain stream; and let your foot rest on a big, slippery stone as the sunshine warms you and the wind blows through the trees. • Advanced scenarios developed with assistance of patient (family, past experiences, etc.). 157","e":[36,52,-201,-1,33,3,30,-11,50,-61,27,9,60,68,-22,0,-11,-25,44,-13,-97,-11,0,12,4,59,-9,38,-33,-9,18,-16,8,41,-28,-84,71,59,35,-21,51,-34,13,-41,40,-52,56,-20,38,-28,-17,-38,-41,-35,65,5,60,24,35,-4,79,6,-30,53,43,-12,-85,26,36,-26,53,-33,2,18,-32,-28,-47,3,29,27,42,-14,82,-18,62,-10,2,0,-46,70,7,22,24,19,-86,2,12,66,-35,-43,-52,-20,25,-7,58,8,-40,-1,-11,-23,-17,53,-40,-33,17,-11,65,3,53,50,13,59,-47,27,12,58,-67,-9,3,-20,29,8,-20,6,0,64,-14,-2,6,13,47,-7,-29,-32,-20,-43,20,-23,2,-16,9,30,17,-8,9,-70,14,38,52,33,25,36,-38,29,-28,-70,23,9,52,39,-34,-24,3,1,49,-27,69,-54,-6,-53,45,-16,9,-10,-27,-30,21,-72,-31,-47,-16,-1,-68,-54,-46,-28,45,-13,27,-19,6,18,-33,57,-32,78,-32,22,-33,-16,48,-28,28,-15,-10,-8,16,-26,-33,-5,41,-5,-17,2,15,4,-43,16,3,33,-56,-41,31,38,26,-15,39,49,17,13,-7,-3,9,-27,-76,66,-7,-46,2,-6,17,9,51,5,28,-64]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.159","t":"APPENDIX A • PATIENT HANDOUTS Self-Management Time Guide 1. Mood Check a. List five emotions you are feeling right now, and rate their intensity from 0- 100%. b. List three emotions you have felt this past week, and rate their intensity from 0-100%. 2. Review the Previous Week a. Did I use any tools I learned in therapy this week? i. If I did not, what problem did I have this week that could have been helped through the use of these skills? b. What good things happened this week? i. How did I make those good things happen?","e":[12,-26,-189,-89,-9,-16,53,-14,40,-32,-13,23,54,34,31,1,51,-29,-8,45,0,-56,-58,-21,35,57,-4,21,-73,-10,-3,8,32,-64,-44,-23,65,23,-15,20,51,10,29,-82,18,-38,67,11,35,-17,-5,-46,-9,-15,107,10,14,51,75,-14,115,10,-4,63,57,-37,-10,35,-55,-9,50,14,33,28,-63,26,-24,-1,0,-3,30,8,104,-54,45,-19,-21,7,-38,80,-22,36,29,26,-64,35,-14,23,-19,-74,-50,-3,-18,-32,11,22,-17,5,-4,22,-45,47,-8,-25,24,1,54,-36,5,62,-14,46,18,47,66,10,-29,7,-5,-7,1,-35,-56,33,12,44,-1,5,-3,-4,48,10,-26,13,-23,-38,1,-48,-61,13,7,12,27,40,28,-40,-37,-7,31,12,52,-22,-39,70,9,-38,29,44,22,51,-27,-42,7,-29,20,24,64,-20,36,-42,76,-34,40,20,-18,-57,43,-30,-59,-19,38,56,-57,-39,-66,-31,30,-25,-3,-42,2,35,-24,41,-63,57,24,-18,-12,-57,47,-28,4,29,-20,24,-6,-26,-15,-2,10,-1,20,-18,6,40,-21,20,-27,-17,-26,-108,0,-11,4,-8,-29,37,23,54,44,55,61,16,-73,33,0,-38,30,63,-2,18,16,14,13,-21]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.159","t":"3. Current and Future Problematic Situations a. What are my current problems? i. How can I think about these problems in a different way? ii. What can I do to change the feelings associated with these problems? b. What problems can occur before my next self-management time? i. What skills can I use to deal with these problems? 159","e":[12,-2,-128,-23,49,40,37,-59,46,-7,-22,11,38,43,-15,3,17,-38,-24,61,-23,-48,-32,-13,-14,39,-14,-35,-40,-2,18,-9,9,-69,-50,-66,86,1,27,-44,60,-19,28,-131,37,-54,53,-7,82,-54,20,-44,18,-12,76,20,37,2,9,-29,83,24,-34,74,2,-44,-38,55,-23,-26,69,10,12,16,-46,-22,25,5,27,21,30,-5,103,-63,24,2,-20,20,-1,57,-35,53,39,19,-94,8,-23,26,-31,-49,-8,-54,29,2,14,45,26,17,-2,-2,-80,41,-8,23,27,-10,44,-8,49,70,-14,29,12,44,51,19,-54,11,56,4,12,-31,-14,21,-7,60,-11,-6,0,14,125,-8,-2,37,-23,-33,4,-14,-47,-16,-17,46,-18,10,54,-26,-43,12,60,-25,30,-11,-28,64,-16,-4,3,44,5,70,-45,-14,29,0,86,27,87,-32,0,-39,18,-42,38,13,-21,-26,21,-24,-42,-21,17,59,-22,-48,-41,-96,29,9,13,-64,31,25,-10,60,-8,61,-9,19,8,-18,48,-63,-16,-11,-32,-11,7,3,-35,7,-37,-38,-11,-11,35,20,-40,-12,-24,40,-31,-116,61,51,12,39,-24,57,-5,45,9,45,65,37,-12,13,35,-34,-4,64,12,3,17,33,-17,-31]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.161","t":"Patient Description Maria is a 60-year-old airline pilot who is about to retire from 15 years of flying. Maria was diagnosed with Type II diabetes five years ago and has had difficulties maintaining her health since that time. She has suffered bouts of severe fatigue and dizziness. Maria says that flying is her “first love,” but that it has become increasingly dangerous for her to fly. She states that she “feels like a failure” because she worked so hard to become a pilot and now “it is over.” Maria says that she is usually a very active person but has lost interest in her hobbies and doesn’t have the energy to do them, anyway. She says that her depression has been worsened by her deteriorating health.","e":[16,2,-201,12,-50,71,-27,-40,-8,-48,-37,19,71,47,42,-25,-38,-57,-48,29,-19,-22,-71,29,55,69,-7,2,-35,28,65,-7,21,-51,-24,-18,-10,75,49,32,35,-80,19,-76,20,-9,46,31,-41,-8,7,-7,38,-12,31,17,-11,40,-27,-45,116,12,-57,63,48,-67,-61,40,-40,-27,83,-25,32,53,-17,24,-56,-12,13,-16,63,12,51,8,46,-7,-5,3,-30,66,52,9,22,23,-27,-15,-12,-13,-59,-46,-12,-25,-10,34,32,41,15,7,30,-4,-21,30,-29,-39,12,-31,26,-23,-19,-6,-3,-18,29,61,46,36,-52,36,26,6,-5,-5,26,46,42,24,1,-21,-36,-14,63,-19,33,-34,15,11,48,1,-4,6,-2,66,-9,2,42,-57,-40,30,30,-8,92,30,-11,81,-8,-30,-21,52,-6,49,-14,-61,17,-7,43,8,34,-19,-1,-52,55,-37,-2,33,14,-28,28,-1,-69,-71,-58,17,-63,-30,-43,-20,43,-16,-18,-52,-10,-24,0,37,-65,37,3,24,-8,29,4,-37,5,-8,-29,-15,-6,-59,-20,5,54,-52,24,-18,45,-16,-40,-7,-34,-34,-9,-54,91,33,-14,-43,-35,37,10,13,-19,68,21,-20,-24,23,-15,-7,-19,50,-12,-15,46,49,11,-18]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.161","t":"Case Conceptualization: Maria is experiencing depression in response to a diagnosis of diabetes. She is unsure how to change her thoughts and behaviors to adjust to her new medical condition. Therapy will aid her adjustment by targeting unhelpful thoughts about being a “failure” and exploring and increasing the things that she enjoys and feels a sense of achievement from, both for work and recreation. Goals Behavioral Activation Identifying Unhelpful Thoughts/Beliefs Challenging Unhelpful Thoughts/Beliefs","e":[56,25,-158,-30,28,19,39,3,5,-32,-14,18,120,53,-5,0,-10,-27,-39,70,-60,-5,-74,2,35,75,11,23,-31,62,-7,-20,13,-27,-46,-21,61,66,26,4,17,-20,19,-85,11,-9,63,-6,-6,-29,76,-42,60,-42,76,37,18,38,-23,-51,128,45,-61,13,28,-52,-48,38,-73,-28,77,1,-2,42,-18,17,-55,-3,-14,-31,74,-22,63,-25,53,12,2,37,-46,81,20,2,-1,32,-88,2,-1,-6,-37,-26,-50,-29,-7,-2,12,68,-12,21,10,26,-60,41,-26,-66,13,-37,40,-33,-4,1,-1,13,26,64,20,26,-15,27,22,-18,-19,-18,-10,29,28,45,16,-25,-32,19,57,11,-3,-16,-20,-10,30,-10,-29,4,-5,30,16,3,56,-47,-43,32,37,-17,71,12,-37,62,-16,-38,5,76,9,17,-35,-78,-7,0,80,26,61,-25,7,-33,34,-29,23,20,19,-33,56,4,-57,-62,-21,41,-51,-7,-57,-10,14,-31,17,-61,3,17,-35,16,-79,52,1,11,-1,-8,13,-37,17,-8,-41,-1,-15,-37,-14,-23,28,-29,0,2,17,9,-73,-4,-5,-22,-21,-93,78,9,12,-7,-61,0,-5,59,-17,57,19,10,-47,28,17,11,-35,68,-5,27,17,-29,70,-3]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.163","t":"Patient Description James is a 24-year-old college student on a full academic scholarship. He called the provider to discuss his feelings of anxiety and whether there is anything that can help him “calm his nerves.” James said that he is used to getting anxious in certain situations, but that it is starting to affect all areas of his life. He says that he doesn’t have a girlfriend because he gets “too freaked out” to ask anyone on a date. He also says that his anxiety is starting to affect his grades because he gets so nervous during exams that he breaks into a cold sweat and cannot concentrate. He wants to be able to control his anxiety but feels there is no hope.","e":[-10,4,-166,-20,2,103,42,19,52,-14,-50,68,43,22,-16,13,2,-36,-60,-27,-34,-50,-57,18,45,33,-39,-4,-21,51,44,30,-20,2,-48,-11,-18,39,36,25,49,-21,9,-97,14,17,12,3,58,-4,-54,-29,-18,-39,112,43,-55,71,39,-8,120,11,-50,78,92,-43,-22,48,-22,-13,52,-7,39,39,-33,-7,-17,1,12,15,50,10,47,-24,42,-19,-20,-3,-21,78,28,77,-7,20,-13,30,-17,-5,-50,-78,-65,-1,27,2,26,38,-37,3,0,-2,-37,79,-51,-18,38,17,38,-15,42,7,2,32,19,70,24,43,-27,48,49,9,-20,-28,6,13,-16,45,-29,-19,-42,35,71,12,-2,-37,1,-31,44,-31,-52,-29,1,56,25,29,9,-26,-24,9,58,17,65,-30,-28,77,-49,-71,-2,37,1,60,-6,-49,13,2,-9,-35,72,-49,54,-10,15,-105,40,3,18,-23,34,-23,-42,-42,-21,-23,-32,-40,-29,-26,57,24,0,13,-30,-13,9,6,-14,72,22,2,-34,-21,42,-41,-8,5,14,-41,6,-61,-42,50,-1,-16,12,-13,7,16,-30,-14,-23,-18,-14,-59,70,5,-8,42,-26,36,-8,25,-33,52,20,-1,-44,-17,-11,-17,-14,7,-4,24,23,38,17,-5]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.163","t":"Case Conceptualization: James is experiencing cognitive and physiological anxiety in response to evaluative situations. Therapy will focus on stress-management skills for his physiological symptoms and identifying unhelpful thoughts or worries about his performance in academic and social situations. Specifically, therapy will identify catastrophic thoughts he has about failure. Goals Relaxation Identifying Unhelpful Thoughts / Beliefs Challenging Unhelpful Thoughts / Beliefs","e":[40,36,-158,-52,55,49,52,24,29,-5,-6,28,77,41,-20,-27,-1,-24,-24,9,-48,-22,-37,18,17,49,-10,4,-22,29,31,9,-33,-12,-69,-25,29,36,7,-11,42,-33,37,-94,17,23,7,5,32,-7,35,-63,10,-74,140,43,-20,53,-10,-53,110,36,-41,53,46,-54,-39,59,-39,-27,56,-21,6,40,-37,-2,-15,8,8,14,53,-43,86,-45,55,-9,-13,19,-31,85,-7,43,0,11,-64,38,-11,-24,-38,-50,-73,-3,0,-38,1,28,-25,17,-21,22,-70,72,-62,-11,36,-15,49,-31,11,25,-2,6,34,62,25,58,-31,12,-2,-17,-26,-27,-26,5,4,37,-3,-28,-29,34,46,9,-7,-7,-2,-29,50,-51,-65,-31,-21,39,25,20,41,-26,-52,32,47,16,58,-17,-19,78,-42,-64,32,41,13,15,-27,-48,24,20,72,10,78,-51,39,-10,-5,-44,32,11,9,-17,61,2,-55,-39,25,15,-41,-22,-61,-47,23,-5,28,-25,-12,14,-31,22,-66,64,-13,-12,-38,2,38,-44,-10,17,-15,-29,-7,-51,-42,10,-7,2,11,4,-1,21,-54,-4,11,1,-24,-89,81,11,16,47,-28,10,10,47,-3,79,10,-16,-54,21,-12,-26,-35,37,-22,41,20,-24,53,0]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.163","t":"Session 1 Establish relationship. Identify James’ presenting problem. Introduce cognitive behavioral therapy. Introduce the cognitive-behavioral model. Describe problem in context of mode. Set goals. Receive feedback from James. Session 2 Check mood. Introduce and practice progressive muscle relaxation. Set homework: Plan two times during week to practice progressive muscle relaxation. Receive feedback from James. Session 3 Check mood. Review progressive muscle relaxation. Introduce and practice imagery. Homework: 1 progressive muscle relaxation 1 imagery exercise Receive feedback from James. 163","e":[19,19,-168,-45,12,-21,65,-23,33,-23,-19,12,23,68,16,-41,8,-76,-44,28,-24,-19,-17,25,24,82,-25,-3,-16,10,33,8,-10,-24,-43,-29,58,25,-27,-3,19,-30,34,-77,44,-37,63,-20,32,23,32,-37,12,-69,88,19,-4,-3,38,-77,141,11,-29,76,32,-32,-33,86,-42,10,46,-3,49,21,-35,-28,-7,-33,-12,7,42,-3,95,-48,66,-26,-8,35,-19,78,-11,25,7,31,-36,0,-9,19,-62,-58,-57,3,36,-19,-14,64,-5,-1,-18,39,-62,27,-38,-2,8,-20,67,-25,44,33,-26,-27,1,13,-13,49,-82,-6,15,7,-17,1,-38,17,21,48,-32,-13,-13,-7,26,-8,-14,12,-10,-6,45,-48,-34,-10,16,3,17,-25,64,-61,-39,-18,56,27,46,-27,-51,38,-32,-53,28,55,50,3,-48,-56,-10,-8,30,45,53,-48,22,-25,13,-21,20,32,1,7,24,8,-59,-19,-10,20,-50,-48,-45,-59,58,-19,28,-14,-42,9,-9,33,-29,57,-22,7,-19,-17,36,-12,-22,1,-24,-36,6,-16,-45,19,12,-3,-10,-15,28,21,-26,26,-14,39,-54,-95,22,9,60,5,-24,39,-15,31,0,67,63,-1,-77,32,-1,-23,10,16,38,31,1,8,36,4]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.164","t":"APPENDIX B • SAMPLE TREATMENT OUTLINES Sample Brief CBT Outline #2 Session 4 Check mood. Review imagery. Introduce three-column thought record and idea of “hot thought.” Practice three-column with event from past week. Homework: 1 relaxation technique 1 three-column thought record Receive feedback from James. Session 5 Check mood. Discuss progress of therapy and termination. Review homework. Introduce cognitive distortions. Complete three-column in session, and have James identify hot thought. Introduce concept of challenging hot thought. Homework: 2 relaxation techniques 1 three-column thought record Receive feedback from James.","e":[38,-5,-179,-93,15,-26,37,10,0,-24,-17,-1,61,49,2,-58,6,-54,-14,23,-26,-20,-29,-25,23,39,-38,19,-56,-8,39,-2,-4,-1,-67,-48,108,5,-67,11,63,-18,65,-62,40,4,88,10,2,44,24,-33,30,-66,108,12,2,22,21,-31,92,21,-36,76,42,-20,-62,83,-50,0,64,14,62,29,-70,-29,-25,-10,-8,45,43,-17,82,-12,56,-7,-1,-12,-40,36,-18,-6,21,30,-38,26,0,-18,-45,-32,-86,-24,-1,-33,-23,65,-23,24,8,3,-71,19,-42,-3,3,20,39,-24,29,42,-9,9,-4,39,5,50,-44,-13,10,-44,-20,-20,-38,28,17,48,-26,0,-22,9,38,-9,-20,7,23,-4,37,-67,-57,-4,12,8,45,1,31,-28,-10,1,38,39,24,-43,-60,44,-14,-32,-10,58,49,19,-54,-67,-11,-4,29,7,69,-34,28,-37,10,4,15,35,18,-15,32,17,-41,-34,-4,20,-33,-38,-70,-62,50,-24,-15,-31,-2,29,-30,34,-49,66,-29,11,-20,-22,56,12,8,18,-21,8,15,-28,-35,50,8,21,9,-40,16,27,-33,-4,-13,8,-61,-103,41,-15,17,-16,17,37,-24,54,-5,56,45,-6,-71,24,15,-22,14,44,8,16,17,5,20,-10]},{"s":"VA Brief CBT Guide (Cully & Teten 2008), p.164","t":"Session 6 Check mood. Review homework. Introduce challenging thoughts and seven-column thought record. Complete seven-column in session. Introduce concept of challenging hot thought. Homework: 2 relaxation techniques 1 three-column thought record Receive feedback from James. Session 7 Check mood. Review homework. Complete seven-column in session. Homework: 2 relaxation techniques 1 seven-column thought record Receive feedback from James. Session 8 Check mood. Review homework. Review progress of treatment. Complete relapse prevention. Introduce and schedule self-management sessions. Homework: self-management session 164","e":[42,-3,-199,-56,23,-40,43,-12,30,-26,-24,-2,43,78,-17,-30,27,-62,-33,8,-15,-48,-48,-35,17,44,-34,-29,-31,22,8,-20,-14,-8,-46,-35,73,-8,-52,6,33,-21,54,-62,62,-1,53,-36,42,14,16,-41,14,-65,79,45,-16,14,39,-18,91,8,-42,89,4,-12,-53,78,-45,-12,64,-15,49,4,-68,-16,-16,-11,13,12,54,-28,97,-29,68,-7,-16,33,-39,44,3,-10,29,15,-48,41,-4,25,-43,-31,-63,-38,3,-27,3,43,-23,36,6,14,-29,36,-37,5,42,11,68,-21,33,47,0,-16,15,37,9,22,-3,1,1,-26,-15,-31,-52,42,0,38,-36,-25,-28,-39,59,-3,-31,9,-19,-42,34,-71,-59,1,20,-12,42,-5,18,-57,-17,10,50,39,29,-32,-63,52,-20,-28,1,60,30,19,-67,-59,-18,-6,27,14,69,-43,34,-8,33,-20,33,44,15,-19,33,-11,-49,-13,-6,31,-31,-61,-47,-64,41,-29,-5,-16,-13,5,-16,18,-42,78,-16,9,-9,-26,58,4,7,0,-6,-24,-1,-29,-32,29,8,15,3,-42,27,20,-57,-2,-16,31,-65,-130,27,-17,35,-5,10,54,-17,55,-18,45,28,-8,-81,30,-2,-22,-17,42,30,2,-9,0,26,0]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.9","t":"In an effort to bring evidence-based psychotherapies from the laboratory to the therapy room and realize the full potential of these treatments for Veterans, the Department of Veterans Affairs (VA) has developed national initiatives to disseminate and implement evidence-based psychotherapies for depression, posttraumatic stress disorder (PTSD), serious mental illness, and other conditions throughout the Veterans Health Administration (VHA), the health care arm of VA. As part of this effort, VA has developed a national staff training program in Cognitive Behavioral Therapy (CBT) for depression. This training in CBT represents the largest CBT training initiative in the nation. The overall goal of the CBT for Depression Training Program is to provide competency-based training to VA mental health staff, which includes experientially based workshop training followed by ongoing, weekly consultation with an expert in the treatment. The training focuses on both the theory and application of CBT for the treatment of depression on the basis of the protocol described in this manual, which has been adapted specifically for the treatment of depressed Veterans and Military Servicemembers. Initial program evaluation results have shown that the training and implementation of this therapy protocol by VA mental health therapists have significantly enhanced therapist skills and patient outcomes (Karlin, 2009; Karlin et al., 2010). This manual is designed to serve as a training resource for therapists completing the VA CBT for Depression Training Program, as well as for others inside and outside of VHA and the military who are interested in further developing their CBT skills.","e":[13,15,-179,-60,82,7,36,23,51,-33,6,6,32,0,16,-45,-19,-45,-47,-14,-46,-42,-33,-40,46,46,-25,51,-22,1,48,9,16,-25,-14,-15,32,23,19,-7,13,-6,0,-87,-32,-13,84,9,7,-22,40,-59,43,-49,97,-23,-21,16,-28,-50,132,60,-77,46,33,-40,-68,46,-24,-21,49,-31,41,28,-56,2,-25,-51,-59,2,63,-33,29,-54,63,-14,-2,14,5,78,2,29,-20,64,-72,19,-37,-33,-11,-32,-39,-50,34,-27,23,39,-12,-30,-8,13,-68,49,-15,-4,-6,-5,33,-36,-7,42,7,0,-17,22,-10,37,-52,1,18,-5,-6,-5,-28,-12,12,45,-18,-16,-9,26,30,8,-22,24,4,-22,8,-22,-55,-3,-24,51,24,-31,51,-57,-32,18,44,35,34,26,-34,20,14,-59,9,43,46,30,-70,-45,8,-26,96,23,69,-27,3,-26,22,-45,58,42,12,13,-15,-34,-43,-58,9,48,-52,-3,-88,-46,35,-43,26,-50,-8,56,-14,42,-35,57,-27,-11,-30,-20,42,-23,28,15,6,-1,-5,-20,-78,12,45,28,-8,-13,9,6,-46,-14,22,16,3,-73,14,-12,8,22,-32,38,17,59,29,29,29,36,-49,5,-21,-28,1,17,-1,12,-12,6,45,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.9","t":"Although the focus of this manual is on the application of CBT for depression, the manual and treatment protocol are based on core CBT competencies that can be adapted and applied to treat other mental health and behavioral health conditions. In this protocol, cognitive and behavioral theory and strategies are incorporated in an integrated fashion and guided by a careful case conceptualization, which is an important component of this treatment. In addition, the protocol places significant emphasis on the therapeutic relationship, which is a critical We believe that CBT done well contextual variable in CBT. We believe that CBT done well requires a requires a very strong and very strong and supportive therapeutic alliance. In this way, CBT for supportive therapeutic alliance. Depression in Veterans and Military Servicemembers strongly emphasizes the therapy in Cognitive Behavioral Therapy and differs from more psychoeducational or primarily skills-based approaches to CBT. In our experience, case conceptualization-driven treatment and the focus on the therapeutic relationship are especially important therapy ingredients when working with depressed Veterans.","e":[23,0,-153,-57,75,3,34,-12,41,-14,-4,-5,36,-9,29,-58,-32,-15,-33,22,-59,-31,-49,-28,28,55,-26,43,-49,2,47,11,19,-36,-30,-41,41,38,-3,-5,13,3,7,-91,-10,-21,77,16,25,-6,42,-53,28,-85,120,-24,-19,39,-44,-86,126,56,-62,61,51,-40,-61,45,-37,-17,51,-16,35,38,-53,2,-24,-37,-32,5,80,-38,47,-62,51,-5,0,-10,-12,71,13,17,-15,64,-84,12,-44,-23,-20,-7,-42,-19,18,-1,8,56,-9,-18,-11,-3,-89,31,-19,1,-10,-2,31,-33,-7,28,14,-11,29,21,-6,41,-50,-18,35,-28,-15,-23,-12,1,-13,43,-34,-22,-16,13,26,5,-12,22,-1,-14,-9,-13,-42,-8,-16,47,5,13,45,-43,-34,9,38,43,45,30,-49,11,0,-41,3,32,30,29,-59,-55,-14,0,113,43,70,-12,-1,-28,-1,-31,25,29,-16,-4,26,-30,-51,-36,16,52,-40,-4,-94,-37,33,-14,38,-50,-14,58,-9,46,-49,62,-29,14,-20,-41,37,-33,15,23,-22,10,-11,-17,-66,15,33,26,11,1,2,6,-40,13,14,10,-1,-87,35,8,16,30,-28,38,18,66,29,40,30,17,-64,43,-29,-29,2,40,-2,23,-14,-17,59,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.9","t":"Included throughout this manual are fictitious cases that represent composites of depressed Veterans and Military Servicemembers we have treated. These cases are designed to illustrate and make concrete the application of CBT skills with “real-life” patients. In addition to this manual, we have developed a companion therapist training video (U.S. Department of Veterans Affairs, 2010) that demonstrates many CBT strategies with the case examples presented in this manual. Key therapist and patient worksheets and forms for use in implementing this protocol are referenced throughout this manual and are provided in the Appendix.","e":[21,28,-177,-67,67,5,31,-5,39,-22,-45,-17,20,15,-27,-63,-51,-67,-38,0,-64,-32,-25,-14,39,22,-41,46,-50,-51,34,-3,25,-29,-19,-45,55,37,-13,10,36,-8,-13,-77,-31,-4,90,12,9,29,72,-43,36,-33,123,-34,5,28,5,-72,102,66,-51,70,59,-35,-42,65,-58,-15,35,-12,33,54,-70,-2,-27,-12,-53,32,69,-11,31,-58,56,1,1,-2,-29,50,0,29,25,27,-93,-3,-37,-1,-42,-35,-24,-15,26,-23,4,50,17,-5,9,-10,-66,38,-23,20,9,-5,37,-57,12,50,5,7,1,14,5,52,-50,-25,24,-52,-12,-21,-22,-13,5,67,-17,-10,6,32,40,-22,-27,10,9,-24,-24,-16,-62,30,-11,51,29,16,65,-33,-24,4,27,19,64,-5,-46,43,18,-26,5,54,45,31,-30,-64,-18,8,83,6,58,-27,4,-33,19,-27,10,10,24,-24,5,-42,-60,-45,-24,45,-30,-30,-91,-58,48,-2,25,-49,6,37,4,28,-35,48,-26,-6,-26,-23,26,-16,48,30,-26,39,-17,-11,-64,-6,51,19,-3,-10,19,15,-36,-6,9,22,-17,-90,54,-18,-4,-12,-41,52,24,41,31,17,38,7,-64,31,-21,-40,35,49,5,32,3,5,32,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.10","t":"Whether you are new to CBT or are seeking to expand your CBT skills, our hope is that this manual will be a useful resource to you and will help promote the delivery and fidelity of CBT with depressed Veterans and Military Servicemembers. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 2","e":[-18,4,-162,-60,70,30,27,-48,12,-27,-31,20,15,-29,18,-40,-2,-32,-6,1,-42,-46,-56,-41,25,63,-29,40,-36,-4,29,-16,18,-30,0,-35,34,33,-11,6,51,-19,6,-101,-18,-30,91,31,8,-48,68,-77,9,-43,121,-40,-11,0,1,-75,115,54,-65,60,29,-28,-50,32,-41,-1,47,-2,51,38,-80,-15,-25,-10,-29,20,44,10,34,-56,44,12,-6,32,9,63,13,28,11,54,-103,5,-33,11,-12,-51,-24,-24,38,0,38,63,18,-16,-13,-24,-83,37,-22,1,-29,1,54,-24,11,57,12,10,29,47,-10,43,-40,-7,31,-23,0,-15,-16,-7,10,31,-36,-25,7,10,48,-19,-21,14,-5,-24,-8,-10,-42,6,-3,11,13,2,43,-61,-21,21,43,11,45,27,-62,24,44,-20,-11,37,36,30,-28,-58,-15,-17,96,5,35,-13,4,-49,0,-54,33,12,-33,-34,21,-54,-67,-56,-3,59,-8,-35,-84,-34,59,5,24,-18,1,49,-13,10,-52,54,-17,10,-9,-40,40,-45,52,11,-10,13,-2,13,-53,12,39,30,-28,-8,17,4,-26,-16,17,5,-4,-83,28,1,5,0,-17,54,3,47,45,23,81,29,-77,11,-27,-33,43,34,13,9,-25,18,21,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.13","t":"What Is Cognitive Behavioral Therapy? Cognitive Behavioral Therapy (CBT) is a structured, time-limited, present-focused approach to psychotherapy that helps patients develop strategies to modify dysfunctional thinking patterns or cognitions (i.e., the “C” in CBT) and maladaptive emotions and behaviors (i.e., the “B” in CBT) in order to assist them in resolving current problems. A typical course of CBT is approximately 16 sessions, in which patients are seen on a weekly or biweekly basis. CBT was originally developed to treat depression (A. T. Beck, 1967; A. T. Beck, Rush, Shaw, & Emery, 1979), and it has since been adapted to the treatment of anxiety disorders (A. T. Beck & Emery, 1985), substance use disorders (A. T. Beck, Wright, Newman, & Liese, 1993), • Cognitive personality disorders (A. T. Beck, Freeman, Davis, & Associates, 2004), eating Behavioral disorders (Fairburn, 2000), bipolar disorder (Basco & Rush, 1996), and even Therapy schizophrenia (A. T. Beck, Rector, Stolar, & Grant, 2009)! Many patients show substantial improvement after 4 to 18 sessions of CBT (Hirsch, Jolley, & Williams, 2000). Contemporary research shows that CBT is efficacious in treating mild, moderate, and severe mental health symptoms (e.g., DeRubeis et al., 2005; Elkin et al., 1989), that it is equally as efficacious as psychotropic medications in the short term, and that it is more efficacious than psychotropic medications in the long term (see Hollon, Stewart, & Strunk, 2006, for a review). There is a great deal of research supporting CBT’s efficacy for treating an array of mental disorders using both individual (Butler, Chapman, Forman, & Beck, 2006) and group (Craigie & Nathan, 2009) formats.","e":[46,50,-144,-45,51,-18,62,8,34,-35,-5,15,51,8,4,-76,-44,-16,-30,27,-35,7,6,-15,-5,78,-44,50,-5,11,48,9,-7,-17,-46,-15,83,38,-13,2,30,24,27,-111,11,-32,106,31,-4,1,7,-54,58,-53,129,-15,-24,53,-50,-66,113,42,-49,56,40,-30,-59,60,-46,-7,63,-39,35,34,-30,-41,-33,-42,-12,19,57,-50,11,-39,47,1,4,23,1,59,4,-9,-25,35,-47,12,-29,-91,-24,-25,-62,-4,26,-1,8,40,-22,-29,-1,27,-70,28,5,-9,-37,37,38,-22,25,21,27,-7,-9,15,11,86,-65,-7,9,-20,-29,15,-1,-31,7,43,0,1,-24,25,33,-21,9,46,13,-10,5,-23,-14,-5,-9,40,20,4,48,-38,-16,10,44,30,54,23,-33,17,-41,-44,1,43,20,28,-70,-40,1,6,65,34,54,-16,-2,-47,4,1,23,37,24,22,12,-31,1,-37,25,12,-57,17,-89,-42,26,-11,36,-51,-22,31,-10,24,-35,68,-33,8,-25,-31,71,-13,11,33,-43,-10,-13,-34,-38,25,50,4,11,-6,6,18,-23,5,21,47,-37,-64,31,21,37,50,-26,10,-4,65,26,48,30,35,-73,-5,-14,-38,-3,5,-6,11,6,4,56,31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.13","t":"Organization of This Manual This manual is organized into five main parts: (a) cognitive behavioral theory and the manner in which the theory translates to treatment, (b) CBT session structure, (c) interventions that take place in the initial phase of treatment, (d) interventions that take place in the middle phase of treatment, and (e) interventions that take place in the later phase of treatment.","e":[28,47,-147,-61,49,-39,67,-31,15,-18,-1,-35,51,25,30,-79,-17,-16,-9,37,-40,2,-20,-33,15,70,-38,13,-32,-28,63,6,34,-24,-77,-60,79,25,-41,-13,18,23,23,-94,-11,-36,63,5,9,22,25,-4,18,-33,95,8,-1,31,27,-39,124,70,-70,72,25,-25,-39,74,-51,-39,47,-10,49,52,-67,-30,-31,-5,3,36,32,-3,68,-68,46,7,-7,2,-32,42,-31,6,-1,34,-78,7,-34,-5,-29,-61,-71,-20,28,3,16,61,9,-27,-23,23,-86,34,-14,23,-24,23,83,-14,40,37,13,-21,4,7,8,49,-53,6,13,-14,2,-15,-20,-11,8,73,-20,-12,-8,25,16,-13,-1,29,40,-28,30,-23,-30,-5,28,29,-15,11,48,-20,-11,-22,51,23,17,-15,-42,35,-28,-48,11,38,26,43,-33,-45,-26,33,64,59,52,1,22,-27,38,-2,13,60,19,-8,16,-21,-36,-36,34,28,-48,-56,-72,-51,12,-16,24,-36,3,18,-51,28,-25,73,-35,43,-55,-3,76,-6,9,15,-53,-16,3,-25,-36,32,-11,-2,4,-17,22,26,-12,-9,12,5,-66,-66,9,-9,7,13,-18,12,19,49,15,53,61,0,-48,10,6,-45,19,65,-5,32,10,-4,48,10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.13","t":"Throughout these five main parts, case examples created on the basis of actual clinical experience are provided to illustrate the application of cognitive and behavioral strategies. Moreover, specific pointers for implementing the strategies, as well as common obstacles that therapists experience and ways to overcome them, are summarized. This manual was written specifically for implementing CBT with Veterans and Military Servicemembers. The content of the protocol, as well as specific issues in the application of CBT, are presented with this particular population in mind. In addition, certain therapy components and processes are given emphasis in this protocol to address commonly observed issues in the delivery of CBT with depressed Veterans and Military Servicemembers. For simplicity, we primarily use the terms patients and Veterans. These terms are used interchangeably and are inclusive of active duty Military Servicemembers (including members of all branches of the military and reserve forces).","e":[23,1,-166,-59,71,10,42,-30,44,9,-14,-10,33,18,11,-66,-26,-45,-28,-2,-30,-23,-31,-31,29,41,-38,34,-50,-26,47,2,29,-28,-40,-56,38,32,-21,0,46,-8,1,-92,-8,-5,82,17,18,-4,44,-53,18,-48,127,-21,-9,31,-5,-63,113,45,-66,59,33,-22,-58,63,-26,-20,57,-34,34,21,-66,-12,-30,-28,-29,33,55,-18,51,-64,57,13,9,-1,-8,65,-6,26,14,62,-104,5,-43,-18,-21,-31,-41,-24,21,1,12,49,9,-6,1,-5,-91,35,-14,22,-5,14,38,-35,9,52,9,-4,4,14,-4,62,-70,-30,38,-30,-15,-23,-12,-18,1,25,-12,-35,16,10,57,-27,-11,31,7,-18,-19,-26,-37,11,7,68,-3,19,51,-45,-33,9,19,42,42,11,-60,29,-3,-43,-5,41,53,35,-51,-59,-23,4,109,38,61,-4,-9,-35,-12,-43,19,18,0,-15,21,-37,-58,-54,-1,52,-29,-9,-101,-39,47,-4,45,-38,4,51,-33,46,-37,47,-27,2,-31,-36,46,-37,13,25,-34,14,7,-14,-45,5,42,-2,-22,0,18,1,-42,-1,5,13,-25,-82,49,-10,-9,13,-35,41,38,35,17,30,60,36,-79,24,-15,-30,22,42,-2,26,-4,0,57,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.14","t":"JACK Jack is a 63-year-old Vietnam Veteran who has been in and out of mental health treatment for the past 20 years. He has a history of depression, anger, and significant impairment in his relationships with his wife, children, and co-workers. Recently, Jack was let go from his job as a manager at a car dealership; although he was told that he was laid off because the company was downsizing, he believes that the regional manager has “had it out” for him for many years. Jack had expected to work for another five years, but he has been unable to find a new job that is acceptable to him. As a result, he reports significant financial concerns. In addition, Jack’s relationships with his wife and children continue to deteriorate. His children live out of town, and when they call they want only to speak with his wife. He and his wife barely speak, and they sleep in separate rooms. Jack has a few “buddies” with whom he plays poker, but he claims that he does not feel comfortable “crying to them” about his problems. Finally, Jack has been experiencing medical problems that have increasingly been of concern to him. He has recently developed diabetes that is secondary to chronic pancreatitis, and he has expressed frustration at the strict diet and medical regimen that he must maintain.","e":[18,-11,-199,-28,-53,58,-64,-21,64,-35,-40,11,-27,19,18,-45,13,-7,-44,14,-11,-21,-57,-6,51,21,-54,38,-18,66,57,-23,-76,-3,-21,-4,44,63,51,16,-9,15,-3,-110,47,-19,8,58,13,-19,-27,-57,-7,-29,67,19,-30,61,12,-28,70,-17,-37,31,73,-12,-18,47,-30,-29,53,-41,31,14,-39,46,-20,-8,2,13,33,10,32,-46,30,-27,8,56,-40,59,39,77,12,77,-48,21,-52,20,3,-27,-45,-69,14,-14,35,85,-24,40,24,-22,-46,6,0,-5,39,-22,40,2,14,-2,-22,44,-22,31,8,61,-30,46,46,15,-25,13,16,15,10,15,-22,-38,-18,-1,83,-26,38,5,10,-26,3,-24,-63,-16,28,28,15,22,13,-31,-52,-7,39,39,12,-1,8,67,12,-55,-34,70,-19,64,-8,-76,-19,-22,46,-33,70,-24,-20,-28,45,-77,68,39,10,-1,40,-29,-24,-76,-14,43,-36,-15,-37,-35,40,-44,-4,-7,-4,-43,21,11,-23,32,-1,51,-32,-1,29,-27,-46,-8,17,-7,38,-11,-44,-16,17,28,10,-33,-3,8,-8,-15,-74,13,-52,-63,73,21,-41,9,-20,58,2,26,-29,42,17,34,-55,31,-38,-66,16,19,22,-18,29,7,36,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.14","t":"MICHAEL Michael is a 24-year-old, African American, Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veteran who was referred to treatment for depression and suicide ideation. He recently returned from Iraq after serving in the Army for two years. He joined the military as a means of paying for school, and, unexpectedly, he was mobilized for an OIF deployment in his senior year of college. He left a girlfriend, his schooling, and a promising part-time job for a 12-month deployment that ultimately was extended to almost 18 months. During his time in Iraq, Michael survived the force of an IED explosion, after which he was unconscious for two days. In the time since he has returned from Iraq, he has become increasing isolated from others and is estranging himself from his family and loved ones. Michael tried to return to his part-time job, but he left after two weeks because he found it difficult to concentrate and made many errors. He states that he has no plan for the future and wonders whether his life is worth living. Neuropsychological testing at his local VA Medical Center revealed mild brain injury. He has significant concern about his current abilities and his perceived reliance on others.","e":[-16,-11,-174,3,43,63,3,33,53,14,-5,-7,51,-2,11,-52,-13,-20,-41,26,-66,-24,-42,30,71,17,31,41,-90,46,113,-8,-55,-4,-30,-26,-27,79,70,-13,-11,-26,-4,-73,39,11,-4,19,-9,-44,15,22,55,-9,64,-37,2,6,-9,-48,104,18,-47,17,21,-15,-53,45,-32,-75,104,-23,-8,45,-37,50,-21,-41,-4,18,54,34,22,-10,0,-5,25,17,-17,40,16,55,-21,44,-32,16,-35,52,-24,0,-11,-63,12,-4,75,95,-6,2,6,31,-78,36,-20,-22,41,-21,30,-43,30,-12,6,-28,22,1,0,37,0,26,19,7,-45,-26,23,4,-26,41,32,-19,-35,1,57,14,-10,-29,26,-6,32,10,-47,-5,-10,80,-4,34,19,-53,-47,-10,24,39,16,23,-7,56,1,-95,-11,49,5,-16,-2,-81,26,-33,48,-21,36,-8,-13,-26,25,-51,53,30,-6,-11,50,43,-75,-25,-51,24,-49,-26,-62,4,65,-26,13,-34,-14,-19,17,59,-22,83,-5,37,-4,8,47,-43,10,-11,2,2,-2,-23,-32,13,12,33,-22,-6,14,-15,-52,-11,-44,9,-2,12,108,24,-53,10,-3,51,-8,9,-30,55,-8,-22,-44,-28,-13,-20,26,12,-8,-8,13,24,7,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.14","t":"KATE Kate is a 40-year-old National Guard nurse who recently returned from deployment to find that her husband had left her and moved with her kids to another state. In addition, despite thinking that she was going to retain her job upon her return, she found that the hospital where she worked replaced her, given that her deployment was a voluntary extension of her original tour. In theatre, the option of extending was not presented to her as a choice and, thus, she assumed that her previous position would be protected. Kate’s efforts to find a job in her small town have been unsuccessful, and her husband has not been cooperative with arranging times for visitation. Her depression has become increasingly severe, and for the past three weeks, she has stayed in bed most of each day. Kate also reports significant symptoms of anxiety and has had four panic attacks in the past week. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual \u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u0002\u00024","e":[-9,-5,-200,-35,-13,113,-32,-7,38,-16,-82,11,63,9,2,-37,1,18,-42,4,-10,-12,-31,-21,46,71,6,54,-54,27,64,-20,-23,-52,-35,-30,11,11,7,2,75,-5,13,-85,-29,-54,58,46,-18,-14,-67,-30,9,-25,58,6,-4,36,-27,-38,113,-5,-71,68,46,-19,-92,86,-19,-53,24,-4,17,52,-20,2,-59,-31,-38,31,77,1,45,-29,22,12,4,38,-34,51,35,45,6,31,-51,27,-16,0,-44,-39,-50,-43,-13,-11,42,42,-18,24,21,-43,-62,16,-22,-3,27,-18,3,-8,6,-1,19,45,-3,22,15,48,-72,59,27,-4,-29,10,17,43,16,2,-19,-11,-19,12,56,-2,2,-29,22,-16,40,-9,-54,5,20,24,-10,8,36,-45,-19,42,27,35,71,13,-26,67,5,-38,-35,55,-1,18,-47,-101,-8,-40,33,-8,65,-43,9,-23,48,-56,62,24,-18,-11,5,-45,-52,-92,-1,24,-51,1,-67,-18,46,-6,23,-30,-9,2,-12,45,-7,39,16,27,3,-17,23,-29,-12,-19,18,-8,26,-41,-60,14,4,15,1,-5,16,-17,5,0,-8,7,-19,-45,53,8,-23,28,-37,28,-28,-13,4,44,23,27,-39,35,-33,-28,10,28,13,-32,38,6,64,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.15","t":"CLAIRE Claire is a 28-year-old Army CPT rotary wing pilot (Blackhawks) who experienced severe injuries from a crash in Afghanistan. While flying a low-level search-and-rescue mission, her rotary system was hit by a rocket-propelled grenade, and the helicopter lost hydraulic power and ultimately crashed into a mountain side. Two soldiers were killed in action, and most on board were severely injured. Claire endured significant leg injuries, and she is unable to walk without assistance. Claire reports that she has been experiencing a great deal of tension and apprehension over the past few months. She is eager to return to flying, but she is encountering major obstacles from her command and from the military more generally. She is waiting for her medical board to be complete so that she may return to flying and perceives that they are putting her off because they do not believe that an amputee can fly. She has few outside interests and close relationships to keep her occupied as she is waiting for this decision. In addition, Claire becomes extremely irritable when she perceives that she is treated differently because of her injury.","e":[35,-40,-192,-30,46,52,-37,6,20,-12,-41,-12,23,7,73,-43,-31,-46,-25,-48,-38,-38,-29,14,95,46,-37,34,-102,36,78,-21,-67,-82,-8,-27,-17,75,40,31,37,-13,-14,-60,-7,-19,105,3,11,-4,-1,-12,-31,-15,69,-1,10,27,11,-73,89,31,-23,37,20,-20,-61,15,-2,-73,47,-33,23,81,-64,14,-62,-25,-39,-17,44,5,16,-9,28,50,14,45,-35,49,48,64,17,17,-34,3,0,31,-71,-30,-21,-20,-14,31,16,46,-12,12,15,-28,-43,11,-15,-13,29,-31,40,-50,17,-10,-16,-25,20,25,46,42,-80,2,28,26,-46,-2,35,28,6,30,1,-12,-1,33,35,-8,1,-50,20,-32,41,17,-29,-51,0,71,-2,11,36,-36,-43,34,3,35,48,33,-54,64,-16,-33,-26,34,44,65,-10,-52,19,-47,60,-33,35,-34,-32,-61,1,-54,44,41,-7,-10,23,6,-55,-120,-62,18,-56,-5,-60,-36,44,-18,13,-43,4,-11,20,35,-5,48,-22,-23,-16,25,35,-38,-2,34,4,-11,-2,-52,-29,33,64,-12,-11,-4,-11,29,-8,-17,15,-57,-10,-32,63,20,-28,0,-41,53,-7,-1,-11,55,-19,-30,-22,16,-24,-12,-5,37,27,-22,34,45,-5,3]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.15","t":"This manual illustrates the manner in which all four of these individuals are treated with CBT. The next part describes cognitive behavioral theory and the manner in which the theory can be applied to understanding their clinical presentations. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 5","e":[17,4,-150,-60,71,12,52,-42,16,-9,-31,11,31,6,16,-67,-15,-12,-4,17,-50,-22,-55,-35,16,72,-41,56,-33,-10,44,7,21,-55,-32,-43,64,51,-9,17,16,-7,14,-89,-15,-23,92,38,13,-10,36,-59,30,-69,106,-36,-15,23,-9,-53,115,55,-63,52,55,-29,-48,60,-47,-27,62,-18,40,31,-72,-15,-33,-17,-30,0,59,-22,45,-55,64,6,-6,2,-5,39,3,13,3,64,-76,18,-33,-14,-21,-67,-42,-21,10,-11,32,58,11,-12,-13,-17,-92,26,-10,15,-24,12,46,-25,6,60,10,2,4,18,-17,51,-47,6,21,-20,11,-3,-11,-16,11,39,-53,-19,-10,18,45,-22,-15,39,5,-9,0,-1,-37,-16,13,37,26,5,63,-51,-38,16,23,28,31,20,-44,42,0,-31,-9,40,40,32,-42,-48,-20,-1,93,34,40,-21,-1,-40,0,-30,37,38,-12,-29,19,-37,-39,-47,10,39,-31,-32,-80,-54,37,-12,28,-48,-4,58,-11,23,-39,43,-37,7,-19,-41,49,-30,42,21,-36,13,7,-7,-59,16,33,17,-17,9,3,23,-28,-7,31,8,-13,-79,30,1,10,38,-27,30,17,50,13,41,69,24,-67,26,-24,-36,29,51,-3,28,-8,11,43,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.19","t":"PART I: COGNITIVE BEHAVIORAL MODEL Underlying Theory of CBT For any type of psychotherapy, it is important to understand the underlying theory so that patients’ symptoms can be integrated into a coherent conceptualization, and treatment strategies that follow logically can be identified. CBT is no different. According to the cognitive behavioral model, emotional experiences are influenced by our thoughts and behaviors. Mental health problems arise when people exhibit maladaptive and extreme patterns of thinking and behavior, and these often interact with each other to escalate patients’ symptoms and problems. The following is a visual description of the general CBT approach.","e":[40,21,-140,-47,80,25,63,13,35,-6,-19,15,75,38,0,-41,-25,-20,-35,18,-74,-12,9,-31,-14,74,-31,50,-21,13,48,-12,27,-66,-70,-43,58,45,6,25,39,6,4,-96,-13,-40,99,32,8,37,34,-31,22,-57,116,11,7,60,2,-80,78,67,-51,64,27,-35,-48,53,-33,-14,59,-17,13,13,-22,-24,-5,-33,20,23,50,-19,46,-46,78,9,-20,13,-23,69,-9,-9,10,44,-78,4,-54,-32,-31,-23,-50,-12,11,-12,-6,35,-15,-8,-2,21,-86,24,-1,-10,-30,-4,45,-23,16,40,17,7,-14,41,4,69,-65,-15,16,-11,-8,-12,4,0,19,45,-15,18,-2,43,42,-13,7,42,5,-10,26,-23,-33,-8,-7,51,-4,16,40,-46,-25,13,46,1,43,3,-18,26,-24,-52,3,26,32,33,-53,-32,-16,14,88,49,63,-17,20,-52,-5,-22,27,23,7,-15,9,-3,-31,-63,15,33,-55,-20,-73,-76,25,-27,45,-35,-8,43,-18,29,-55,62,-30,-9,-39,-33,37,-20,-4,29,-51,2,6,-11,-48,31,11,-2,0,8,0,10,-21,-8,-7,29,-21,-58,56,15,35,52,-22,14,-2,46,6,49,53,18,-85,-13,-9,-49,17,34,-10,30,3,-24,73,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.19","t":"Figure 1.1: General CBT Approach Situation • General CBT approach Behavior Thought Emotion As is illustrated in Figure 1.1, there is no one cause of mental health problems. Instead, the interplay between stressful life situations, dysfunctional or unhelpful thoughts, highly charged emotions, and maladaptive behaviors causes and exacerbates patients’ symptoms. There are two theoretical approaches that contribute to CBT—cognitive theory and behavioral theory. Both of these theories are described briefly in the following sections.","e":[63,27,-163,-38,84,27,66,-12,43,-28,6,22,60,61,-10,-37,-15,-10,-43,16,-63,-6,15,-35,-2,67,-37,49,-17,9,24,-18,30,-53,-69,-28,32,52,-2,24,34,-4,18,-106,-25,-25,77,58,35,2,22,-59,24,-75,102,42,-2,41,11,-79,69,58,-42,49,27,-29,-51,40,-22,19,50,-31,29,34,-34,-8,-10,9,29,12,57,-17,70,-37,93,25,3,12,-7,67,0,8,8,18,-101,18,-25,-10,-31,-44,-65,-26,-18,-1,3,17,-8,3,-18,28,-103,42,-8,-4,22,17,44,-43,6,51,-7,-2,-15,57,-10,51,-42,-1,30,-10,-10,-40,5,-15,-14,34,-14,14,-1,33,47,-21,0,25,9,-2,19,-23,-28,-9,-7,38,9,24,62,-23,-56,20,44,4,33,-9,-41,26,-9,-44,-7,38,23,45,-60,-49,-1,21,84,58,65,-13,27,-54,15,-22,43,29,26,-21,13,-24,-56,-52,2,31,-40,-25,-75,-56,27,-21,27,-36,-20,33,-31,-5,-35,45,-40,-3,-8,-65,31,-23,-30,5,-54,-21,4,-36,-43,24,9,8,2,-7,11,20,-19,-8,-9,-8,-28,-75,66,-8,18,56,-20,6,2,39,6,54,38,23,-45,2,6,-41,12,42,-4,16,2,-18,63,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.19","t":"Cognitive Theory • Cognitive The word cognition refers to the process of knowing or perceiving. Thus, the central theory focus of cognitive theory is on thinking and the manner in which our thought content and styles of information processing are associated with According to cognitive theory, our mood, physiological responses, and behaviors. According to the manner in which we think cognitive theory, the manner in which we think about, perceive, about, perceive, interpret, interpret, and/or assign judgment to particular situations in our lives and/or assign judgment to affects our emotional experiences. Two people can be faced with similar particular situations in our lives situations, but because they think about those situations in different affects our emotional ways, they have very different reactions to them. experiences.","e":[47,10,-113,-55,65,22,62,-6,-4,12,38,23,98,67,29,-55,-13,18,23,52,-76,3,-23,5,6,63,-34,-18,-22,-2,23,-15,3,-56,-77,-60,34,15,38,7,-22,14,17,-88,14,-12,12,-1,60,1,-12,-26,18,-29,118,63,34,41,34,-50,85,92,-34,78,6,-17,-51,73,-10,-10,32,-44,-22,34,-26,11,8,-36,-1,-8,62,-98,52,-10,51,23,-35,-18,-14,92,2,-14,6,39,-80,39,-42,-14,0,-10,-70,-30,8,-32,40,54,-55,-4,13,26,-82,34,-18,31,4,-1,72,0,29,35,11,0,25,53,-19,78,-58,-41,-8,-13,0,-41,-3,23,12,61,-59,-9,-7,57,40,-14,14,-18,-17,-37,6,-28,-47,-36,8,43,-21,13,32,-32,-49,2,33,19,54,57,-9,40,-53,-45,46,0,11,14,-58,-25,-5,-3,70,26,74,0,3,-23,-45,-37,35,11,4,-27,46,14,-43,-40,14,20,-25,0,-64,-88,-19,-12,33,-41,-35,12,-32,9,-16,78,-19,-5,-32,1,41,-8,-13,44,-13,7,-11,-25,-17,29,25,-9,7,43,-4,-16,-35,-13,10,26,-31,-84,65,33,23,42,-9,-8,38,49,-24,40,6,-19,-83,2,42,-48,-32,40,-8,35,-15,-20,85,-1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.20","t":"CASE EXAMPLES: JACK AND KATE Both Jack and Kate recently lost their jobs, both continue to be unemployed, and both have impaired relationships with their spouses and children. When Jack thinks about these problems, he thinks, The world has screwed me over. Everyone I know makes my life difficult. I’m better off without them. Kate, in contrast, thinks, My life means nothing now. I’m a horrible person because I cannot do what I wish to do. Not surprisingly, Jack and Kate report two different emotional experiences—Jack’s primary emotional experience is anger, whereas Kate’s primary emotional experience is depression. Jack’s subsequent behavioral response is to ignore his wife and children and complain about his life, whereas Kate’s behavioral response is to cry and stay in bed most of the day.","e":[47,-20,-161,-28,1,102,-50,-3,47,-9,-71,7,55,63,-38,18,8,-5,-46,65,-25,-21,-61,28,42,40,-51,19,-78,37,3,-12,-22,-79,-80,-9,71,19,29,-17,47,-11,16,-57,17,-98,53,78,26,-9,20,-64,22,-37,110,59,37,49,9,-54,34,24,-22,55,48,-10,-34,64,-35,-49,28,-2,-17,19,-5,37,-16,5,37,55,66,-26,40,-36,48,1,15,26,-38,43,17,36,41,31,-81,42,-34,14,-13,-2,-59,-47,2,-4,47,37,-27,30,2,-27,-61,27,-15,-20,47,-22,54,-73,-13,34,-14,44,-17,48,32,49,-30,29,29,0,-28,-41,6,32,10,41,-1,-6,-28,11,95,-6,-15,5,-1,-29,9,-39,-68,35,42,-1,20,28,15,-27,-52,33,46,0,41,-17,10,71,0,-8,11,55,16,47,-26,-112,-12,-23,28,6,63,-29,-3,-17,55,-51,57,11,18,-24,-10,18,-39,-73,-9,17,-58,-20,-48,-60,25,15,-20,-29,30,-11,-10,23,-71,51,11,15,-6,-31,37,-3,-42,19,0,22,-17,-21,-52,-33,-8,0,-9,-33,34,4,1,-3,-59,-2,-50,-107,80,16,-17,30,-31,32,-11,42,-44,59,-17,41,-21,25,-6,-40,20,56,-3,19,29,-33,78,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.20","t":"Basic Cognitive Model We refer to the thoughts that arise in response to particular situations or events as automatic thoughts. The term automatic is used because these thoughts occur so quickly that they are often not recognized by the patient and, more importantly, the • Automatic significant impact these thoughts have on subsequent emotional and behavioral thoughts reactions goes unnoticed. Despite the fact that these thoughts emerge very quickly, they often have profound effects on our mood because they offer some sort of evaluation or judgment of our current circumstance. We refer to this sequence as the basic cognitive model. Figure 1.2 is a visual description of the basic cognitive model.","e":[29,10,-135,-48,68,29,69,20,3,-7,-2,18,90,68,15,-40,-28,-40,24,28,-33,-22,-16,-33,28,82,-20,-8,-40,9,37,-16,-13,-74,-67,-48,44,14,10,11,13,10,37,-48,9,34,31,0,42,3,38,-46,30,-18,118,45,45,56,18,-22,92,58,-22,38,24,-5,-34,40,-1,5,44,-28,-33,6,-42,-3,-40,-13,26,37,38,-31,80,-8,87,26,-35,32,8,75,15,8,-6,21,-99,4,-55,-5,-37,-28,-62,-29,-5,-16,32,38,-43,5,8,19,-32,46,-29,-19,-14,-13,65,-1,25,57,15,1,11,56,37,47,-42,2,34,-28,3,-15,4,-2,43,71,1,-19,16,58,42,5,2,2,-39,-37,50,-33,-32,17,-10,9,-44,-1,29,-18,-43,-5,14,-20,46,19,-33,41,-44,-63,51,-5,28,12,-28,-46,-7,18,81,-4,108,-49,32,-50,2,-43,13,12,-16,-36,-8,40,-61,-20,39,18,-37,-47,-88,-43,22,-7,63,-21,22,11,-52,12,-24,100,5,-5,-46,-26,70,21,-28,41,5,-10,-18,-11,7,35,9,3,-19,6,8,-9,-21,2,-2,50,-2,-101,49,3,17,16,-12,25,5,34,-11,44,35,24,-129,-24,9,-49,-4,36,-1,22,-37,-28,86,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.20","t":"Figure 1.2. Basic Cognitive Model Reaction • Basic Situation cognitive Automatic (Emotional, or model Thought Physiological, Event Behavioral) Characteristics of Automatic Thoughts There are some additional important points to keep in mind about the basic cognitive model and the nature of automatic thoughts. First, the situation need not always be an external event in one’s environment. In fact, memories, thoughts, emotions, and physiological sensations can prompt additional automatic thoughts.","e":[28,6,-137,-36,81,31,67,-17,4,-9,9,20,54,66,18,-52,0,-53,42,48,-43,-26,-28,-17,39,94,-8,10,-41,-11,25,-46,-15,-62,-70,-56,33,20,-1,10,42,-1,28,-56,11,34,43,-11,47,34,41,-42,-18,-25,125,62,58,81,25,-34,65,41,-33,19,23,5,-60,55,-14,-8,38,-17,-36,8,-15,-21,-65,-6,25,58,46,-18,109,-24,88,39,-30,19,1,69,6,10,15,16,-71,33,-44,16,-41,-16,-54,-44,-22,-24,39,14,-38,6,-24,10,-26,33,-37,-21,-8,-33,67,4,23,76,9,9,-7,58,15,37,-16,-5,19,-51,11,-15,-8,-3,30,56,-10,-4,21,60,60,20,-10,-3,-34,-21,41,-18,-41,18,-2,7,-44,3,19,-31,-41,0,12,2,31,20,-41,42,-35,-44,29,26,44,9,-51,-26,8,30,74,7,85,-33,39,-40,-9,-38,28,19,-2,-69,-8,50,-50,0,28,13,-42,-69,-76,-50,18,-31,51,-33,35,26,-31,17,-36,89,3,7,-32,-9,56,6,-31,12,6,-14,-16,-23,-15,23,-4,1,-18,-4,-24,-3,-12,10,15,47,11,-81,64,7,22,30,-11,34,25,22,2,42,44,22,-104,-29,-10,-31,-3,28,-14,10,-21,-25,46,-42]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.20","t":"CASE EXAMPLE: JACK Jack often thinks back to an argument he had with his supervisor over a year ago. As he recalls their conversation, he thinks to himself, My supervisor never respected the years of hard work that I put into the company. He subsequently becomes angry all over again despite the fact that he has not spoken to his supervisor since he was laid off. The behavioral consequences of this include moping around, watching television instead of actively looking for another job, and being short with his wife. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 8","e":[60,-5,-181,-73,25,52,0,-30,67,-35,-54,34,20,47,20,-37,18,-49,-38,-2,-10,-30,-56,-10,11,42,-44,18,-43,42,10,7,-18,-43,-57,-26,78,35,12,1,23,-19,1,-119,45,-37,76,79,30,-54,18,-76,7,-25,103,12,16,37,-5,-34,55,28,-34,57,49,-46,-46,49,-60,-6,45,-7,-3,41,-66,48,-30,1,-4,27,38,-24,39,-45,61,-8,14,26,-23,80,10,14,22,59,-84,1,-7,-19,-9,-41,-60,-47,-6,-30,24,49,-16,-11,29,-15,-39,46,-30,-14,28,12,54,-41,-10,49,-2,14,-32,19,1,48,-37,35,33,-29,-12,-13,-16,36,2,5,-18,-30,-8,3,96,-30,-6,24,9,-44,22,-49,-64,19,12,15,14,22,62,-35,-68,27,57,10,47,-25,-18,40,-10,-21,-14,67,18,26,-50,-88,3,-11,50,26,33,-27,-10,-15,21,-40,51,37,9,-37,19,-25,-29,-58,-17,55,-31,-3,-74,-69,41,-23,-8,-47,15,-1,-1,17,-53,20,-6,7,-56,-45,53,-12,-15,10,13,2,9,14,-42,14,13,6,14,-35,4,-5,-17,-38,-52,17,-23,-102,69,19,-7,25,-13,38,25,51,5,61,9,23,-56,26,13,-29,25,16,26,20,14,-9,50,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.21","t":"CASE EXAMPLES: KATE AND CLAIRE When Kate thinks about the fact that her husband left her and took their children to live in another state, she has an image of a new woman in her husband’s life putting the children down to bed and reading them stories. This image represents a “worst case scenario” for the future. When Kate has these images, her depressed affect increases substantially, and she closes her blinds and goes back to bed. In contrast, other patients report vivid images of difficult or traumatic experiences from their past, which in turn facilitate negative emotional experiences. This is the case with Claire, who sometimes becomes agitated when she experiences intrusive memories of the plane crash that led to her injury.","e":[77,10,-145,-41,8,64,-44,10,16,1,-61,-3,91,75,-28,1,-16,-21,-42,17,-57,-4,-78,26,23,85,-23,40,-113,57,54,-16,-40,-116,-67,-24,33,28,30,2,85,-8,9,-48,7,-59,80,20,16,-15,21,-38,28,-41,100,31,44,25,24,-32,67,30,-1,45,35,-21,-56,42,-4,-45,50,11,-23,16,-22,18,-13,-17,-8,50,63,-45,30,-49,52,42,50,35,-28,39,40,12,37,18,-52,46,2,26,-78,-14,-52,-53,-8,-19,0,38,-30,25,16,-30,-80,25,-30,-29,57,-21,51,-62,1,16,-20,30,-7,23,48,52,-53,-9,20,-21,-36,-3,7,43,39,50,12,5,5,38,55,2,-26,-24,-12,-34,36,-7,-49,5,2,4,14,20,39,-36,-42,44,34,1,82,-2,-26,66,-17,-27,10,46,34,15,-53,-67,-7,-13,64,2,43,-40,7,-35,11,-42,49,-9,14,-48,-10,26,-66,-85,-6,30,-56,-21,-75,-48,22,21,1,-47,9,4,-8,54,-59,36,9,-24,-22,-10,13,-2,-9,40,-7,24,1,-39,-40,18,1,-9,-12,-21,32,4,-8,-17,-33,-23,-56,-77,73,12,-3,8,-54,19,-34,23,-29,48,-20,12,-32,16,1,-38,-2,50,-2,15,45,-3,57,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.21","t":"Third, the automatic thoughts that people experience are not random. Over time, • Schemas people develop certain ways of viewing the world, which are represented in schemas. According to Clark and Beck (1999), schemas are “relatively enduring internal structures of stored generic or prototypical features of stimuli, Schemas give rise to beliefs ideas, or experience that are used to organize new information in a people have about themselves, meaningful way, thereby determining how phenomena are perceived others, the world, and the and conceptualized” (p. 79). That is, schemas are like lenses that color future (i.e., core beliefs) and the manner in which people see the world. Schemas give rise to beliefs influence the manner in which people have about themselves, others, the world, and the future (i.e., we process incoming core beliefs) and influence the manner in which we process incoming information in our information in our environment. Maladaptive or unhelpful core beliefs, environment. which can arise from schemas associated with mental health problems, are often targets for treatment in CBT.","e":[8,29,-165,-71,64,3,38,52,15,-3,7,31,75,53,-4,-21,-69,-15,-13,68,-70,-8,6,-19,-17,69,-32,-25,20,4,36,-30,18,-58,-39,-58,52,32,65,-2,22,17,-15,-96,17,32,23,-13,59,-30,14,-54,51,-21,148,16,46,46,37,-51,82,32,-18,57,36,-5,-73,42,-18,-3,46,-2,-17,44,-19,10,-34,12,18,68,50,-48,34,-11,50,63,17,4,-7,68,21,-14,-23,25,-105,25,-46,-4,-15,-5,-79,-56,49,-12,33,27,-53,-19,-14,4,-75,-1,-54,34,-38,-44,106,-26,46,18,1,15,15,76,21,82,-12,-64,43,-17,-5,-30,-35,-7,9,61,-3,-26,8,67,53,-21,-5,-20,-8,-60,3,-32,-15,-5,10,49,-38,25,-6,-31,-28,12,48,-20,45,25,-11,36,8,-41,4,8,19,22,-45,-26,-35,6,96,-5,58,-45,36,-36,-11,-34,32,21,25,-5,12,-45,-25,-47,24,-1,-46,-4,-37,-82,-13,31,44,-61,0,15,-56,42,-24,62,16,25,-18,-13,59,-3,-22,10,-30,21,-9,-10,-30,8,21,0,3,2,27,-14,-48,-25,23,24,-27,-91,80,-20,19,12,5,9,25,12,-2,40,4,3,-35,-39,15,-47,-2,75,19,36,-30,-17,43,-58]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.21","t":"Schemas, in and of themselves, are not inherently problematic. In fact, without schemas we would have great difficulty organizing and making sense of the stimuli that we encounter in our daily lives, as they give us shortcuts for classifying and evaluating information. However, according to cognitive theory (e.g., Clark & Beck, 1999), some people develop schemas and core beliefs that are consistent with mental • Core beliefs disorders such as depression or anxiety. For example, a person with a depression- relevant schema would have negative or pessimistic core beliefs about himself, the world, and/or the future (i.e., the negative cognitive triad, shown in Figure 1.3), and he would filter incoming information through a depressive “lens.” The case example that follows illustrates the manner in which core beliefs are manifest in these three areas.","e":[18,39,-152,-59,38,19,33,37,10,2,0,21,57,55,-16,28,-59,-3,2,93,-83,-14,-18,-43,3,72,-5,-43,-12,52,50,-17,5,-95,-51,-55,47,51,85,4,31,8,-20,-102,-10,39,50,21,56,-52,39,-80,54,-50,98,21,45,40,18,-70,70,25,-15,62,34,-9,-70,44,-10,-8,57,-1,6,59,-32,26,-3,-3,1,17,57,-34,59,-27,58,69,22,-13,20,73,10,-2,-2,27,-76,41,-23,10,-31,8,-53,-22,27,-12,12,16,-24,-19,-3,3,-68,36,-44,5,14,-26,102,-32,27,7,-45,12,34,100,10,56,1,-31,50,-4,-32,-38,-62,-2,15,40,-38,1,-11,60,47,11,5,-28,-18,-58,-14,-44,-39,-9,-14,40,-37,2,14,-24,-29,-4,54,-36,60,16,-11,57,36,-40,-9,34,15,53,-44,-24,-24,-22,91,17,48,-31,49,-34,-10,-24,27,27,21,29,14,-26,-49,-45,18,9,-30,7,-36,-97,-11,23,42,-38,-3,14,-20,30,-32,53,-4,5,-12,-31,57,-21,3,22,-18,-17,-13,-14,-49,17,-5,-13,-10,13,37,-4,-24,-13,2,7,-14,-121,86,-17,45,19,-4,17,19,15,-1,44,27,49,-16,-28,-7,-37,-9,62,-1,31,-52,-14,53,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.22","t":"CASE EXAMPLE: MICHAEL Michael has the core beliefs that he is damaged beyond repair (i.e., a negative belief about himself), that life does not treat him fairly (i.e., a negative belief about the world), and that his life will not improve (i.e., a negative belief about the future). Not surprisingly, he is quick to identify things that are negative and consistent with these beliefs and ignore things that are positive and inconsistent with these beliefs. These core beliefs influence the types of automatic thoughts that he experiences in particular situations. Michael mentioned to his therapist that, recently, his mother had found a job listing that looked promising. Michael’s automatic thoughts were, There’s no use in applying. I won’t get the job anyway. According to cognitive theory, these thoughts stem from his core beliefs that he is damaged, life does not treat him fairly, and his life will never change.","e":[58,0,-139,-39,34,65,32,23,46,-4,-1,4,42,63,-43,17,-43,-19,21,75,-67,-29,-48,-4,26,39,-3,21,-58,34,57,2,-32,-64,-93,-33,60,65,67,-45,-1,2,22,-95,30,-12,35,17,27,-25,26,-71,70,-27,110,37,26,58,-8,-73,84,40,-27,72,33,-26,-58,49,-12,-47,54,-7,-33,26,-17,34,-17,41,18,43,50,-33,50,8,52,22,19,14,-27,71,7,24,-28,13,-67,27,-47,-11,-32,20,-58,-59,-10,-10,24,84,-8,-13,9,35,-33,28,-34,-34,9,-11,91,-35,-5,42,-7,30,-32,96,9,66,-29,-2,23,-2,-4,-70,-8,8,-4,66,32,-8,-42,48,65,11,11,18,-16,-67,24,-38,-49,18,2,44,-4,30,45,-16,-44,26,39,-16,31,16,-12,64,-5,-41,27,79,2,16,-7,-56,6,-18,89,11,44,-38,1,-15,-4,-10,17,24,20,-2,32,22,-45,-43,7,10,-54,-2,-57,-87,11,20,29,-46,4,-4,1,43,-36,42,15,-11,-29,8,47,-14,-33,15,-19,12,-21,2,-28,19,-8,-10,-2,-12,32,-4,-32,-17,-8,3,-25,-100,94,46,9,11,4,33,34,43,-35,87,-1,-11,-34,-9,26,-38,-7,67,-8,76,-30,14,52,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.22","t":"Expanded Cognitive Model Although cognitive behavioral therapists often begin treatment by working with patients in developing skills to evaluate and modify automatic thoughts, as treatment develops, they work to evaluate and modify core beliefs and their associated schemas. Figure 1.4, adapted with permission, illustrates the manner in which core beliefs and automatic thoughts are related. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 10","e":[11,14,-151,-71,62,16,60,8,27,-15,-15,11,65,18,4,-36,-34,-26,-19,36,-31,-34,1,-38,3,53,-44,55,-33,17,65,7,-10,-45,-18,-55,79,54,-4,9,16,11,18,-101,-16,-17,87,14,44,-1,26,-53,26,-40,129,18,-13,53,-16,-61,99,41,-51,40,38,-23,-26,52,-37,-29,40,-14,9,28,-30,-3,-42,-28,-16,27,68,-21,57,-45,52,21,-28,38,-7,70,26,-16,-13,38,-88,-4,-34,-41,-10,-38,-67,-26,29,-39,15,67,-25,-17,12,47,-77,24,-22,-29,-30,-8,45,-11,-1,31,29,1,-2,49,-3,77,-43,-21,20,-10,4,-15,-8,-3,25,41,-25,-25,-6,46,19,-5,8,31,-1,-32,20,-35,-39,2,-10,51,-17,20,41,-42,-46,13,33,3,49,18,-40,51,2,-39,19,23,18,34,-54,-57,-21,-11,95,40,58,-23,34,-31,-14,-37,46,45,3,-8,3,-19,-18,-54,18,30,-42,8,-109,-62,34,-29,50,-51,8,42,-31,28,-20,66,-14,-12,-37,-11,53,1,8,47,-26,1,0,10,-40,24,32,-8,8,0,9,-6,-33,1,29,51,4,-74,50,16,61,3,-26,52,16,53,42,45,36,8,-82,-3,-7,-26,-9,43,-4,43,-34,-8,53,-36]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.23","t":"Figure 1.4. Expanded Cognitive Model Stress Core Beliefs Situation or Event Automatic Thoughts or Images Reaction Wenzel, Brown, and Beck (2009). Adapted with permission. Notice the “stress” icon in the top left corner of Figure 1.4. Core beliefs and their associated schemas related to depression and anxiety are not perpetually active. According to cognitive theory, they develop during childhood or in other formative experiences during adulthood and lay dormant until they are activated in times of stress or adversity. In other words, it is the combination of schemas and stress that typically bring on an episode of depression or anxiety.","e":[10,18,-194,-71,43,15,48,3,13,-35,-34,24,56,27,29,-18,-54,15,-21,64,-50,-45,-3,-20,-1,97,-11,-9,-27,48,77,-27,18,-63,-37,-52,40,48,60,-17,41,-1,8,-65,-26,-12,32,29,61,-24,22,-40,38,-52,112,49,13,36,18,-32,104,34,-5,33,24,-23,-33,70,-15,1,53,-39,-2,26,-35,20,-37,-25,1,25,93,-11,83,-41,74,45,0,-10,-2,72,44,-9,-32,36,-67,23,-5,-6,-19,-10,-65,-55,15,-26,16,13,-78,-35,-16,21,-58,65,-45,-11,-33,-18,56,8,-1,-12,-18,-1,45,102,2,59,20,-23,24,-25,-6,-21,-27,5,30,42,-61,4,-9,70,33,2,-12,-23,-16,-47,21,-49,-44,-14,-11,31,-51,14,14,-22,-46,-18,32,-4,44,5,-9,50,9,-42,15,54,32,24,-31,-43,-24,-35,78,15,72,-20,71,-37,-16,-41,30,40,14,-16,18,-8,-34,-44,-16,7,-46,17,-56,-100,9,11,44,-15,16,5,-13,3,-41,66,12,-21,-14,-26,58,5,-25,34,1,16,-1,-3,-15,19,12,-2,11,15,30,1,-26,4,-4,8,-18,-96,66,16,45,14,-17,42,7,9,13,42,44,20,-31,-3,-16,-25,-15,44,-2,15,-36,-7,56,-65]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.23","t":"CASE EXAMPLE: MICHAEL Michael grew up in a low-income, inner city area where people commonly experienced negative beliefs about people, the world, and the future. He was often told that people from that neighborhood did not have a chance of escaping, so why bother? Nevertheless, before Michael’s time in Iraq, he ignored those messages from people in his neighborhood and was, instead, considered a go-getter. If his mother had found a promising job listing, he would have seen an exciting opportunity and immediately investigated it further. Back then, he would have been more inclined to think, Although it is not certain the job is available, I have nothing to lose but a little time and effort by applying and seeing if I can land it. However, Michael’s core beliefs about himself, the world, and the future were activated only in the context of the stress associated with his injury in Iraq and subsequent adjustment to his previous life. Now, when informed about a promising job listing, he responds with self-defeating automatic thoughts such as, There’s no use in applying. I won’t get the job anyway. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 11","e":[29,-15,-162,-39,54,87,24,19,47,1,-25,8,59,42,-30,-28,-26,-26,-7,45,-77,-27,-37,7,21,24,-33,18,-63,22,39,-4,-20,-33,-67,-26,33,65,34,-34,20,-26,-8,-114,17,-24,63,68,19,-50,24,-66,57,-20,107,-12,11,37,-20,-42,109,42,-22,66,39,-16,-51,54,-26,-58,62,6,-36,42,-29,29,-40,18,-13,24,65,-23,20,-28,23,24,34,3,-23,48,-11,57,-24,27,-66,28,-29,-20,-27,-22,-40,-75,-1,3,18,64,-17,-58,15,16,-45,53,-48,-34,10,17,58,-45,11,38,-5,23,-10,45,20,71,-38,0,17,-19,12,-56,-1,18,-26,44,12,-37,-27,18,90,-13,-5,17,-7,-34,24,-33,-64,9,-17,66,27,27,45,-21,-28,32,39,-1,47,3,-17,45,0,-33,4,79,10,-2,-22,-63,-5,-30,73,-14,45,-16,-3,-12,21,-49,30,18,17,-26,26,16,-47,-58,-20,32,-53,-2,-102,-62,40,-3,17,-27,2,28,1,42,-58,50,21,-3,-23,-7,46,-39,-13,12,-11,3,-4,0,-39,0,-1,-15,-14,8,27,24,-42,-9,-29,7,-21,-70,78,17,-21,23,-8,42,36,37,-34,70,-5,0,-57,-4,15,-45,4,39,-12,40,-23,15,26,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.24","t":"When patients hold rigid core beliefs, they often form rules and assumptions about the way life works. We call these rules and assumptions intermediate beliefs, a term that illustrates the fact that these beliefs stem from core beliefs and then feed into automatic thoughts in particular situations (see Figure 1.5). Figure 1.5. Levels of Cognitive Processing Intermediate Automatic Core Belief Belief Thought","e":[55,28,-170,-88,70,22,34,-24,30,-21,-14,13,16,29,22,6,-16,-21,23,59,-53,-15,7,-24,38,73,-18,-1,-32,-2,39,-15,56,-47,-57,-117,76,18,43,-28,-12,12,21,-54,12,23,47,-17,47,13,9,-66,22,-1,115,47,14,63,35,-40,75,16,-28,53,9,-27,-67,72,-35,-8,27,-41,18,25,-32,-6,-19,32,27,57,52,-30,53,24,32,45,3,13,6,83,26,-47,-4,0,-102,-5,-32,-2,-37,-14,-71,-48,13,-20,11,39,-10,4,6,-8,-11,72,-16,-25,9,-16,90,19,37,44,3,-5,9,112,36,67,-32,-5,31,-26,4,-40,-42,-13,-4,45,1,-15,-1,35,19,2,-5,2,0,-56,44,-48,-6,32,1,25,-12,34,28,-21,-28,2,49,-54,47,9,-53,25,-19,-52,27,50,5,26,-41,-42,-4,-4,111,12,44,-44,25,-39,-21,-8,15,18,9,-26,7,-31,-46,-24,-13,19,-48,-12,-73,-34,12,-3,39,-31,17,20,-40,16,-19,60,2,-11,-22,-5,52,16,-54,40,1,15,-6,2,-8,8,37,-33,10,3,1,-45,-49,24,18,17,-31,-139,50,41,51,-15,-27,24,56,29,-23,30,19,8,-85,32,23,-47,4,50,7,40,-49,15,54,-70]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.24","t":"Like core beliefs, intermediate beliefs are inflexible and absolute. They are often expressed as conditional assumptions (e.g., If people don’t admire me, then I’m a failure. If I don’t complete this task perfectly, then I’m incompetent. If I work very hard, then my hard work should pay off.). These assumptions can set up patients for failure by creating unrealistic standards that they believe they must reach at all costs. Moreover, they can set up patients for disappointment because the assumptions do not account for the unexpected events that people invariably experience in life. Conditional assumptions can be either negatively or positively worded. An example • Conditional of a negative conditional assumption is, If I don’t get this promotion, then I’m a loser. assumptions Such statements establish an arbitrary association between a particular criterion (e.g., getting a promotion) and a maladaptive core belief (e.g., I’m a loser) and ignore the many other factors that would be considered in making such an absolute judgment. In contrast, an example of a positive conditional assumption is, If I get this promotion, then I’m successful. Such statements specify criteria (which are oftentimes unrealistic) that prevent the activation of a maladaptive core belief. Thus, the problem with conditional assumptions is that they are rigid, failing to take into account the ebb and flow of people’s life circumstances with which they are faced and giving excessive weight to some life circumstances or accomplishments at the expense of equally significant life circumstances or accomplishments.","e":[55,24,-165,-67,43,46,29,4,7,-8,-19,3,35,69,9,13,-7,-43,26,76,-61,-12,-32,-7,26,67,-14,-24,-38,18,-6,-25,55,-55,-69,-77,50,60,51,-92,16,35,29,-63,30,-27,76,35,59,-18,0,-49,52,-4,109,35,12,33,20,-46,62,7,-8,64,29,-38,-61,53,-48,-32,11,-7,-28,29,-39,37,-12,-1,11,38,29,-14,79,0,19,6,45,8,-44,51,17,-10,5,18,-101,3,-49,13,-16,1,-21,-51,25,-20,2,39,-14,5,-11,-15,-35,75,-45,-30,5,-35,59,-6,20,32,0,1,20,70,7,63,-39,2,42,-40,12,1,-31,11,-7,53,9,-18,-28,46,24,14,-5,7,9,-46,30,-19,-4,43,-17,28,21,48,3,-5,-1,6,46,-48,94,7,-34,34,-14,-6,2,67,18,31,-30,-20,21,-14,93,0,33,-53,-6,-53,-13,-6,32,6,8,-29,24,0,-57,-17,14,2,-36,-4,-60,-43,37,13,41,-29,41,38,4,33,-37,54,-7,24,-30,-6,75,-14,-15,39,13,10,-11,1,-41,-29,7,-35,2,24,8,-24,-66,13,-19,-10,-31,-137,46,54,44,18,-3,8,43,37,-6,22,8,36,-64,19,-11,-49,3,86,-1,32,8,-5,27,-62]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.24","t":"In addition, people often engage in behavioral compensatory strategies to cope with their painful core beliefs. The particular compensatory strategy exhibited is often • Compensatory linked to the rigid rules and assumptions that form the basis of intermediate beliefs. strategies There are three main types of compensatory strategies observed in depressed and anxious patients: (a) maintaining behaviors that support the core belief, (b) opposing behaviors that are acted upon to prove that the core belief is wrong, and (c) avoidance behaviors that are done so as not to activate the core belief. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 12","e":[50,32,-195,-63,72,-6,57,-28,46,0,-41,-19,31,40,53,-7,-16,1,-2,39,-55,-29,-10,-38,12,61,-15,10,-24,24,29,-8,39,-49,-41,-34,58,57,-2,-6,16,-11,40,-96,-12,-1,54,35,40,9,44,-47,30,-66,111,-26,-4,57,2,-58,98,19,-49,16,48,-29,-43,90,-48,-33,81,-12,32,15,-60,-14,-39,-6,-2,20,56,-26,62,-33,62,15,3,16,-19,54,4,-4,30,46,-98,36,-1,-9,-12,-30,-30,-6,18,-37,17,21,-11,-5,-15,5,-68,57,-11,-13,11,14,56,-31,-2,60,-7,22,-9,57,10,56,-44,10,38,1,6,-26,-29,7,0,26,-23,4,-22,40,10,-14,-22,6,-7,-50,-3,-33,-37,8,2,18,28,41,46,-35,-40,18,52,18,30,-20,-38,71,10,-11,15,68,26,34,-44,-43,-28,-5,106,13,55,-48,-8,-58,3,6,35,57,9,-45,60,-11,-72,-37,-7,39,-29,0,-83,-66,15,-4,40,-41,14,3,13,0,-39,64,-13,15,-2,-21,45,-21,6,19,4,16,-19,-13,-10,-22,25,-22,-25,11,7,8,-34,18,6,11,-6,-117,61,17,34,29,-15,28,41,37,-8,14,65,19,-65,72,-42,-43,19,31,-5,30,-25,-24,52,-45]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.25","t":"CASE EXAMPLE: KATE Kate harbors several unhelpful core beliefs and has exhibited all three types of compensatory strategies. One of her core beliefs is, I cannot cope with adversity, and she often does things that strengthen this core belief, such as letting others make difficult decisions for her and avoiding conflict with others at all costs. By not dealing with adversity, she cannot disconfirm the belief that she is unable to cope. Another of Kate’s core beliefs is, I’m unlovable. Kate often goes to the extreme in order to please close others, such as agreeing to do whatever others want to do and not speaking up when she is being mistreated in order to make it easy for others to love her. Although these behaviors satisfy others in the short term, in the long term others lose respect for her and perceive that she has little to offer the relationship, which in turn causes them to distance themselves from her. This cycle ultimately reinforces her unlovability core belief and activates a related core belief: I am a failure. Kate also has behaved in ways to avoid activating this core belief altogether. For example, in active duty, she rarely spoke to others with whom she lived so that she would not risk the possibility of rejection.","e":[28,35,-164,-45,38,83,-12,-13,41,49,-82,-28,79,88,-10,18,-3,-17,-17,80,-68,-23,-5,-22,28,55,-3,27,-67,9,-5,-30,31,-60,-50,-47,47,30,1,-34,35,22,41,-39,15,-64,55,41,28,21,5,-57,69,-48,93,29,5,33,-38,-59,85,-10,-41,54,22,-21,-76,65,-61,-66,43,-4,-22,-1,-15,12,-47,12,11,45,55,-40,56,-19,64,27,13,34,-33,35,23,22,17,-12,-53,22,-9,-24,-63,6,-49,-36,1,0,10,60,-16,43,5,-4,-52,31,-36,-24,5,-19,57,-41,-6,13,14,20,-23,87,-5,54,-72,6,27,-13,-17,-18,-27,18,-9,51,5,1,-36,42,29,13,0,-16,0,-65,12,-33,-32,32,12,36,-6,32,29,-12,-26,25,38,-25,73,-8,-30,66,-13,31,12,66,23,35,-57,-56,-11,-2,57,-21,65,-42,-23,-23,18,-10,34,42,6,-22,41,31,-56,-52,-29,13,-36,12,-63,-77,15,23,16,-49,14,1,-32,67,-27,24,-4,48,28,-8,70,-29,-46,7,-11,6,19,-15,-60,6,36,-14,-12,11,4,4,-26,17,-21,-27,-42,-96,76,21,1,35,-16,42,-22,3,-47,37,-8,2,-29,34,-6,-15,2,78,-16,52,24,-41,68,-10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.25","t":"Thus, the cognitive model of mental health problems identifies many layers of maladaptive cognition that potentially cause problems for patients. Although the automatic thoughts that arise in particular situations are usually the most easily accessible, lasting cognitive change is most likely when intermediate beliefs and core beliefs are modified. Later in this manual, you will learn specific strategies for addressing problematic automatic thoughts and beliefs.","e":[50,2,-139,-62,81,19,17,19,41,24,-3,14,64,75,32,-8,-39,-37,5,32,-44,-7,-2,-34,-1,88,-22,7,1,41,51,-34,3,-78,-50,-70,72,36,38,29,45,15,31,-112,30,19,49,6,61,-2,38,-57,28,-7,75,43,0,55,22,-56,86,44,-57,32,5,-14,-58,59,-16,14,55,-3,-11,18,-39,-14,-13,-2,19,35,38,-19,81,-61,66,57,4,26,8,95,-15,-1,-12,36,-107,5,-60,-3,-56,-11,-65,-43,10,-8,6,57,-20,2,-4,50,-53,32,-17,-18,14,-25,48,15,28,33,-2,-19,4,70,23,38,-37,8,66,6,-13,0,-10,11,14,65,-5,2,-6,45,66,-20,20,29,-1,-37,37,-23,-31,0,-14,25,-29,-15,37,-40,-31,14,34,-28,30,22,-51,61,-27,-49,23,43,16,40,-60,-31,15,35,96,22,73,-53,24,-45,14,-39,23,11,6,-16,15,-9,-52,-38,22,2,-53,-20,-59,-53,35,-30,50,-29,3,29,-48,18,-39,79,6,-32,-52,-36,81,13,-14,-5,-21,-2,-17,-1,-15,20,-14,-14,-12,-7,37,5,-39,-18,1,35,-2,-96,62,18,42,18,-19,10,30,42,-5,32,30,17,-67,6,0,-42,-12,71,8,24,-33,-1,62,-50]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.25","t":"Behavioral Theory The process of identifying and modifying problematic cognitions is only one route to • Behavioral achieving meaningful change in CBT. Cognitive behavioral therapists also focus their theory work directly on maladaptive behavior. According to Lewinsohn’s behavioral model (e.g., Lewinsohn, Sullivan, & Grosscup, 1980), there are two behavioral patterns associated with depression—a low rate of response-contingent positive reinforcement and/or a high rate of punishment. Positive reinforcement is regarded as person-environment interactions associated with positive outcomes or One central tenet of that, quite simply, make a person feel good. One central tenet of Lewinsohn’s behavioral theory Lewinsohn’s behavioral theory is that depressed individuals do not get is that depressed individuals do enough positive reinforcement from interactions with their environment not get enough positive to maintain adaptive behavior. This pattern creates a “vicious cycle” reinforcement from interactions (Addis & Martell, 2004)—as people engage less actively in their with their environment to environment, they become depressed and exhibit symptoms such as maintain adaptive behavior. anhedonia and fatigue. The more depressed they become, the less they pursue the activities and interactions that they usually enjoy, which further strengthens depression and its associated symptoms (see Figure 1.6). This is very common among depressed Veterans, in which inactivity leads to further inactivity and increased despair. In Part IV of this manual, you will learn strategies to help depressed Veterans break out of this cycle.","e":[39,42,-172,-41,71,12,67,-44,38,-35,-23,30,93,43,6,-40,-15,-27,-13,2,-59,-9,-13,-43,17,95,-14,25,-9,7,24,-26,-5,-44,-62,19,59,57,56,27,10,12,-17,-80,-7,-47,58,28,20,-7,54,-53,31,-43,87,34,13,0,-13,-95,83,72,-45,55,34,-15,-28,36,-29,-18,34,-7,-27,25,-30,49,-4,-23,2,-10,54,-23,34,-63,84,0,8,-9,-19,58,9,18,10,23,-113,24,-35,-19,-58,-54,-27,-15,2,-13,15,25,-10,-21,12,22,-95,45,3,-30,6,-6,45,-37,-4,54,-7,12,4,10,-9,63,-22,-8,41,5,8,-20,-17,13,1,43,-26,-6,-5,8,63,-13,6,26,-8,-16,7,-14,-31,2,-11,53,4,-1,23,-52,-47,13,40,28,74,-1,-11,21,-25,-46,-2,42,29,40,-80,-54,1,-29,72,21,59,-33,-3,-42,10,-17,48,18,38,-26,45,-19,-59,-73,21,46,-44,-21,-86,-58,18,-49,40,-51,-3,2,-3,4,-43,54,-25,11,-11,-12,9,-25,23,28,-31,-9,-13,-14,-23,7,32,-13,-36,26,48,13,-24,-27,-39,24,-28,-100,54,8,23,32,-7,10,27,32,-7,49,11,35,-39,24,-5,-36,-4,39,12,41,-9,14,75,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.26","t":"Figure 1.6. Vicious Cycle of Depression Lack of active Depressive symptoms engagement in one’s (e.g., depressed mood, environment anhedonia, fatigue) According to Lewinsohn et al. (1980), there are three reasons why people might experience low rates of positive reinforcement: (a) there are few available positive reinforcers in their environment; (b) they do not have the skills to capitalize on positive reinforcers; and/or (c) the potency of positive reinforcers is diminished.","e":[47,48,-187,-28,70,27,67,-42,21,-60,-20,18,57,28,-14,1,-6,-41,-5,40,-57,-41,-31,-59,21,103,-11,-19,5,32,5,-35,-4,-48,-26,7,55,49,74,14,37,12,7,-30,-1,-18,55,78,19,-39,55,-72,-11,-41,95,27,-29,-24,16,-61,85,58,-14,66,54,-7,-1,21,16,18,15,-10,-16,-16,-27,52,-24,17,-1,10,53,2,49,-20,84,23,33,-41,-15,50,46,24,16,29,-110,45,-34,17,-37,-31,-24,-12,-12,-21,13,12,4,-16,-2,-17,-63,44,-33,-57,36,-18,72,-24,-18,43,-40,15,-6,33,-14,26,27,-18,61,-8,15,-10,-53,15,13,70,-19,-13,-7,30,63,3,-7,-7,-37,-27,13,-33,-35,2,0,18,19,-6,11,-73,-35,3,50,-9,91,18,-57,28,-25,-23,15,52,17,33,-82,-38,10,-55,58,10,69,-37,5,-67,18,-20,25,29,35,-43,35,-21,-83,-29,6,25,-66,-53,-71,-56,11,-53,20,-44,-13,-15,12,-15,-44,42,-21,42,1,3,2,-58,4,-7,-36,-17,-10,-7,-34,4,25,-15,-33,9,71,11,-41,-15,-36,3,-27,-105,46,-6,13,-4,24,0,-18,15,-33,19,19,32,-17,25,-15,-42,-13,25,12,15,7,30,52,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.26","t":"CASE EXAMPLES: CLAIRE, JACK, AND MICHAEL Claire’s situation fits the first explanation. She had wanted to become a pilot all of her life, and she thoroughly enjoyed flying. At the time she presented for treatment, she was prevented from flying until her medical board was complete; thus, her major source of satisfaction was unavailable, and because her leg had been partially amputated, she was in a position in which she had to negotiate an entirely new way of engaging with her environment. Jack’s situation, on the other hand, fits the second explanation. He lacks the social skills to have satisfying interactions with other people. Although he has several hobbies, his cognitive style often interferes with obtaining full enjoyment from them because he ruminates on conflicts with others while he is engaging in activities associated with his hobbies. Michael’s situation fits the third explanation. He was very close with his mother and his girlfriend before he left for Iraq. Since his return, he perceives that they are burdened by his depression and physical health conditions. The excessive guilt that he experiences prevents him from fully appreciating their support.","e":[56,0,-166,-15,12,78,-43,-23,46,-14,-63,-32,41,71,-10,-16,-29,-43,-20,-10,-77,-8,-76,22,61,27,-34,7,-115,27,46,-15,-57,-85,-33,-17,9,74,13,17,24,-15,-10,-61,30,-54,48,19,24,-40,28,-21,14,-27,117,42,18,29,48,-55,64,18,-27,66,36,-20,-54,38,-7,-35,55,-36,10,33,-49,44,-31,4,4,-6,57,-17,34,-35,51,26,22,7,-34,52,14,53,23,24,-52,11,-21,17,-22,-25,-28,-29,12,50,17,64,-4,16,24,-11,-55,34,-53,-3,28,-11,42,-71,16,31,-37,11,-27,33,22,47,-46,15,42,3,-33,-24,2,40,2,25,26,-44,-14,2,89,-14,-16,-31,2,-35,-2,6,-64,-2,8,57,33,41,10,-33,-33,7,28,22,58,-6,-15,57,-14,-31,7,48,6,38,-29,-68,-10,-14,88,-29,71,-20,-23,-30,29,-65,24,32,-9,-13,16,17,-67,-89,-32,34,-63,-48,-77,-52,50,-10,-23,-15,-13,-23,8,28,-55,40,10,-4,-12,4,26,-49,-33,30,-5,2,-4,-20,-26,18,14,-29,-30,-21,6,23,5,-20,-50,-21,-27,-68,77,8,-13,5,-26,55,4,36,-44,67,3,-16,-37,9,-8,-29,-2,64,18,28,33,17,24,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.26","t":"Although the central feature of Lewinsohn’s model is on the lack of response- contingent positive reinforcement in patients’ lives, it also indicates that depression • Response- can result from a high rate of aversive, or punishing, experiences. Lewinsohn et al. contingent (1980) define punishment as person-environment interactions associated with positive negative outcomes and/or emotional distress. According to this model, depression can reinforcement also result when (a) there are many punishers in patients’ lives; (b) patients lack the skills to cope with adversity; or (c) the impact of aversive events is heightened. All of the cases described in this manual are coping with aversive events—Jack lost his job and is coping with disturbed familial relationships; Kate returned from her duty and learned that she lost her job and her husband had left her; Michael is having trouble functioning in a familiar environment after suffering mild brain injury; and Claire is","e":[56,53,-185,-73,74,29,36,5,42,-35,-47,34,101,25,23,-25,3,-45,-45,6,-58,-8,-33,4,37,85,8,-13,-48,-3,7,14,-22,-58,-83,6,48,66,43,-3,-25,-7,-11,-57,16,-28,52,42,16,-6,23,-63,1,-33,93,15,-5,8,-6,-51,77,77,-37,41,36,-28,-29,77,-11,-13,2,-14,-17,4,-5,50,-37,-4,0,12,59,-12,58,-49,77,17,-3,-22,-26,64,23,9,5,6,-109,6,-35,-38,-45,-26,-45,-33,16,-36,23,36,-6,-3,5,-21,-67,78,-11,-43,33,-25,47,-23,-14,62,-16,19,8,34,-9,48,-14,31,41,-13,-3,-1,-11,10,24,42,-7,-2,-14,39,73,-1,-11,3,-27,-30,39,-4,-31,4,-7,42,-21,7,22,-63,-33,-1,25,-5,95,-1,-30,60,-23,-46,-4,24,32,49,-60,-77,5,-39,67,6,56,-41,-2,-45,13,-25,51,22,30,1,26,29,-34,-56,2,27,-27,-41,-51,-56,21,-50,25,-46,-1,3,11,-2,-65,87,-11,22,10,-18,38,-9,31,16,0,-45,-18,4,-20,7,13,3,-2,5,50,22,-26,-26,-47,19,-10,-91,19,0,27,18,23,7,22,21,-21,31,-6,6,-34,34,6,-31,-16,45,-14,17,-3,10,53,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.27","t":"struggling with the after-effects of amputation and uncertainty regarding whether she will be allowed to return to her post. Thus, another behavioral strategy in CBT for depression is to help patients to develop effective problem-solving strategies and social skills to overcome adversity.","e":[35,15,-156,-63,73,8,51,-1,48,-21,-30,33,61,-15,22,-40,-24,-62,-45,25,-52,0,-49,-2,-2,72,-24,45,-17,29,21,-12,16,-44,-34,5,89,44,31,3,12,-13,19,-98,13,-48,111,28,25,-43,65,-64,18,-64,114,-3,6,52,-3,-75,116,53,-53,15,68,-32,-65,66,-79,-2,54,22,32,41,-35,-2,-34,-20,-23,28,19,-3,44,-46,70,-1,-7,16,-30,85,7,-9,33,56,-100,0,-18,-32,-17,-56,-65,7,23,1,6,49,-7,-9,4,5,-75,49,0,-19,-13,46,32,-59,1,53,-14,-3,14,23,11,78,-47,-9,56,9,-38,-13,-11,6,19,10,-6,-16,15,17,53,-4,-4,10,-5,-33,14,-15,-46,2,-22,-1,53,42,60,-53,-7,43,25,3,45,-17,-43,39,-9,-26,27,33,41,52,-65,-97,-10,-7,98,-2,12,-16,-6,-53,18,-26,45,47,0,-19,14,-10,-39,-70,8,43,-31,6,-87,-45,51,-24,11,-49,-9,32,-14,-1,-39,42,-20,8,-18,-65,40,-11,11,20,-61,6,-28,-14,-56,19,30,-22,-39,2,18,24,-29,1,-13,13,1,-92,31,-8,18,27,-27,7,-4,43,27,26,65,34,-50,47,-21,-18,22,34,17,26,-25,5,56,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.27","t":"The behavioral approach can also be applied to the understanding of anxiety. According to Mineka and Zinbarg (2006), people can develop clinically significant problems with anxiety by having a traumatic experience with uncontrollable or unpredictable events, by watching others having a traumatic experience or behaving fearfully, or by receiving messages from others that certain things are dangerous or should be avoided. Anxiety is maintained and/or exacerbated when people avoid thoughts of or actual encounters with the stimuli or situations associated with anxiety. However, not everyone develops an anxiety disorder simply because they have an encounter with a stressful or traumatic life event. Factors that make people vulnerable to develop clinically significant anxiety problems include a genetic predisposition (i.e., family history of anxiety), personality traits (e.g., neuroticism, the inability to tolerate uncertainty), being reared in an environment in which they had little control, and previous experiences with the feared stimulus or event. Moreover, things that happen during and after a stressful or traumatic life event can contribute to the degree to which a person has subsequent problems with anxiety. Specifically, people are more likely to develop clinically significant problems with anxiety when they have little control over a stressful or traumatic event, such as not being able to escape it; when they experience another stressful or traumatic event shortly thereafter; when they learn after the fact that the stressful or traumatic event was more dangerous than they originally perceived it to be; and when they mentally rehearse the stressful or traumatic event (Mineka & Zinbarg, 2006).","e":[63,53,-156,-3,72,56,58,25,60,-41,-27,21,81,50,3,-42,7,-12,-28,0,-45,-2,18,-8,-31,44,-13,-3,-9,22,62,-39,9,-56,-33,-59,20,77,23,-7,63,-10,13,-84,-36,-16,75,22,51,10,62,-61,23,-36,118,45,11,70,25,-63,101,40,-54,20,57,-4,-80,57,2,8,51,-31,21,33,-41,12,17,3,15,43,65,-25,65,-58,59,22,2,-6,-23,68,57,40,18,23,-76,53,-24,-31,-57,-46,-42,-9,-5,16,-10,-25,-19,-4,-11,27,-77,85,-18,-10,8,13,68,-30,13,33,-35,9,7,33,22,52,-6,12,58,-19,-11,-29,7,-13,15,54,-13,32,-12,41,68,30,-16,-23,-36,10,0,-33,-29,-19,-25,53,-28,36,38,-20,-41,24,61,15,65,13,-27,62,-28,-50,16,24,5,9,-9,-29,26,-2,59,27,79,-49,37,-50,25,-46,34,-2,15,-8,33,1,-53,-71,18,-1,-36,-2,-52,-78,38,-35,39,-40,-17,18,-6,-3,-25,57,-12,-35,-23,-74,32,-33,-33,-3,-11,-33,2,-41,-8,17,3,2,-34,9,5,20,-35,-29,5,19,-12,-76,73,22,8,50,-6,31,2,21,-1,22,54,57,-46,-2,-20,-44,-22,9,-10,9,13,-25,16,-53]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.27","t":"CASE EXAMPLES: CLAIRE AND KATE Claire and Kate have difficulties with anxiety in addition to their depression. Claire was in a plane crash in which she sustained major injuries, leading to the partial amputation of her leg. Thus, she had a direct experience with an unpredictable and uncontrollable traumatic event. Subsequently, she has experienced anxiety symptoms such as intrusive memories of the plane crash and an increased startle response. However, Claire’s anxiety did not develop into full-fledged posttraumatic stress disorder (PTSD). On the basis of Mineka and Zinbarg’s (2006) behavioral theory, it can be speculated that several factors “protected” her against the development of PTSD, including a family history free of anxiety problems, previous experiences with mastery and control over her environment, and no other experience with other traumas.","e":[82,-13,-170,-19,29,80,-14,34,20,0,-68,-23,76,36,-1,-28,-22,-6,-49,6,-54,-6,-63,21,29,73,-47,27,-96,41,60,-26,-26,-97,-42,-5,32,45,0,12,83,-10,5,-46,-32,-51,80,22,15,2,29,-38,18,-59,100,48,28,63,40,-43,69,14,-23,21,42,-15,-58,66,0,-46,56,8,-4,48,-45,23,-38,-1,-9,23,73,-27,21,-45,64,37,3,42,-23,54,38,40,36,17,-33,40,-4,-1,-76,-29,-38,-17,3,9,25,7,-29,-1,0,-20,-62,63,-28,2,49,-12,37,-65,-13,0,-50,1,1,20,49,60,-31,3,38,0,-47,-16,-7,25,19,38,-11,26,8,19,51,17,-44,-55,9,-11,23,10,-60,-22,6,30,9,27,13,3,-43,21,25,31,64,11,-12,70,-14,-35,21,48,20,30,-33,-53,3,-23,66,-9,54,-41,20,-46,24,-41,42,16,4,-34,-8,31,-86,-95,-29,19,-59,-18,-73,-68,55,0,21,-32,-28,20,-18,27,-37,57,14,-48,-11,-30,32,-26,-18,29,-12,-3,-15,-42,-26,-1,14,-8,-24,-14,-6,3,6,-19,-14,-36,-31,-67,60,-22,4,30,-60,31,-34,14,-8,42,7,18,-24,9,-34,-28,-12,40,-19,8,33,-11,33,-24]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.27","t":"In contrast, Kate reported having an increasing number of panic attacks in the time since she learned that her husband and her children left the state. Although she had the first panic attack when her mother broke the news to her, she has experienced subsequent panic attacks without warning. Behavioral approaches to anxiety would suggest that the first panic attack served as a powerful conditioning event for Kate, much like a traumatic event, and that similar external events (e.g., receiving a letter addressed to her husband at their address) or internal events (e.g., increased heart rate) would prompt future episodes of anxiety and panic (Bouton, Mineka, & Barlow, 2001). In addition, behavioral approaches to anxiety would suggest that Kate was vulnerable to develop anxiety problems because she had an introverted, anxious personality style, and she had little experience with mastery and control over her environment. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 15","e":[40,10,-175,-10,66,85,17,7,60,-19,-74,29,104,68,-15,-47,25,-12,-42,16,-56,-6,-35,-17,-10,54,-20,46,-44,23,73,-45,-10,-75,-40,-56,11,34,-17,-2,86,-12,35,-80,-34,-42,54,49,-3,23,32,-61,19,-60,108,39,28,39,41,-55,86,19,-45,18,55,-4,-93,72,-47,-18,49,-29,-6,34,-13,41,-28,-15,-14,44,54,-28,73,-53,79,-4,2,38,-21,51,23,26,13,42,-60,25,-35,-26,-48,-50,-48,-17,7,-1,2,-16,-31,-10,-5,-21,-47,55,-28,-11,-13,-17,37,-32,10,3,-29,-5,-1,30,7,72,-27,24,42,-41,-37,-1,13,21,18,36,-30,21,-7,25,46,37,-19,-28,0,-2,22,-12,-50,5,-11,24,-21,35,31,-27,-15,46,32,25,81,24,29,45,-25,-43,19,43,17,5,-31,-61,-2,-34,41,25,75,-55,34,-32,27,-42,33,7,11,-28,-4,5,-47,-77,-2,13,-65,-1,-63,-43,39,-24,21,-13,-20,47,-41,17,-44,71,21,-15,27,-66,56,-50,-22,-2,-23,-17,5,-29,-41,17,-8,13,-15,-22,-15,3,-9,-22,1,-24,-30,-56,64,8,-11,53,-34,8,-35,-1,6,22,41,49,-58,-6,-30,-9,-8,-1,-17,-3,26,-14,44,-48]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.28","t":"Integration of Cognitive and Behavioral Theory By now, it should be clear that both cognitive theory and behavioral theory are central to understanding the various manifestations of depression and anxiety that therapists see in their patients. Although we present these theories separately, in most instances, therapists will draw on their principles simultaneously in treatment because clinical strategies that are derived from them can work synergistically. As commonly observed in depressed Veterans, inactivity reinforces depression, both behaviorally and through its impact on cognitions. For example, continued inactivity may strengthen beliefs that a depressed Veteran may have that he is incompetent or that life is meaningless, which leads to further inactivity. Thoughts impact behaviors, Moreover, patients who develop strategies to modify cognitions and behaviors (or lack thereof) ultimately do things differently because they are no longer inhibited by impact thoughts! their maladaptive thoughts and beliefs. Once having done things differently, the new self-enhancing cognitions are strengthened. At the same time, patients who develop behavioral strategies to manage depression and anxiety learn that they can manage distress and adversity, which makes them more likely to engage in similar adaptive behavioral strategies in the future. Because of the interactional nature of cognitions and beliefs, as displayed in Figure 1.7, new cognitions reinforce new behaviors, and new behaviors strengthen and reinforce new cognitions. Simply put, thoughts impact behaviors, and behaviors (or lack thereof) impact thoughts!","e":[26,20,-147,-76,66,17,60,-14,31,-9,-31,21,51,68,-1,-14,-17,8,-46,41,-55,-11,-8,-51,13,78,-8,-1,-33,32,42,-14,2,-41,-47,-19,63,38,29,-15,11,27,16,-101,-27,-32,67,-6,60,4,32,-43,14,-35,101,23,27,18,20,-75,86,32,-43,42,33,-14,-39,60,-52,-4,44,-1,7,24,-44,40,22,-5,-29,-1,59,-59,43,-49,68,0,16,5,-37,69,-1,9,-5,61,-95,35,-16,-38,-35,-47,-72,-12,6,0,21,20,-28,-8,-2,61,-102,33,2,-22,16,-11,32,-26,-4,43,5,23,32,29,6,64,-19,-10,23,-20,4,-30,-10,18,6,4,-30,-19,-7,26,58,-13,-12,27,-38,-35,3,-20,-52,-16,8,35,3,22,57,-42,-53,18,60,-7,62,27,-3,47,-6,-44,11,30,21,32,-55,-26,-13,-19,71,39,65,-39,9,-21,7,-27,46,2,15,-19,33,2,-90,-59,-3,51,-16,11,-107,-60,40,-28,43,-44,-24,25,-1,-4,-19,63,-23,-14,-16,-27,24,-6,21,41,5,-4,-2,-45,-17,-7,20,-2,-7,35,37,0,-42,-5,-25,0,-24,-100,48,13,50,63,-8,21,21,54,25,40,45,36,-62,30,-14,-24,-21,41,7,44,-36,0,71,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.28","t":"Figure 1.7. General CBT Paradigm Situation Behavior Thought Emotion CBT Case Conceptualization Case conceptualization is the process by which therapists develop an individualized formulation of their cases in order to guide treatment planning and intervention • Case (Kuyken, Padesky, & Dudley, 2009; Persons, 2006). It is an essential component of conceptualization CBT and is an important factor that differentiates CBT from cognitive behavioral approaches or techniques that focus exclusively on teaching skills, often in a psychoeducational class format. In the case conceptualization process of CBT, therapists apply an empirical approach to each case, meaning they generate","e":[46,17,-130,-60,56,30,49,2,22,-33,4,-19,83,11,-22,-67,-29,-47,-38,31,-52,-14,0,-29,20,40,-38,26,-37,-8,13,-20,33,-17,-77,-73,71,10,-31,-30,47,19,12,-68,0,-3,62,4,-10,19,52,-50,50,-56,111,50,5,60,-24,-71,87,98,-70,67,6,-25,-64,50,-21,-42,34,-13,12,36,-35,-3,-38,5,8,38,84,-21,73,-59,52,14,-13,-2,-35,60,-12,31,-4,13,-88,11,-41,7,-31,-32,-67,-29,-9,-13,-7,51,-24,-22,20,30,-82,26,-48,22,2,15,54,-41,30,33,12,0,9,18,14,68,-60,-46,3,-52,5,-29,-7,-34,-20,44,31,-20,-13,44,58,1,-8,9,15,-3,9,-47,-35,14,10,50,20,-6,48,-18,-27,44,63,12,36,7,-44,28,-48,-30,16,24,12,-2,-40,-63,-8,38,73,54,73,-30,3,-18,-7,-16,19,28,42,-26,37,-2,-18,-37,33,44,-45,-13,-94,-61,33,-19,15,-48,7,24,-33,34,-43,38,2,28,-26,4,33,-40,3,25,-25,8,-16,-9,-57,-5,17,26,-7,16,0,30,-32,9,9,33,-40,-59,37,-16,22,50,-45,13,18,48,31,62,15,14,-43,13,17,-19,-7,43,-4,18,16,-36,65,0]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.29","t":"hypotheses about the cognitive, emotional, behavioral, and situational factors that contribute to, maintain, and exacerbate a patient’s mental health problems. For • Empirical example, early childhood experiences (e.g., parental divorce, conflict, abuse) or other approach formative experiences in adulthood may lead to the formation of particular core beliefs, conditional assumptions (i.e., intermediate beliefs), and compensatory strategies that impact present-day cognitive, emotional, and/or behavioral reactions to situations or circumstances in the patient’s present life.","e":[86,20,-164,-54,68,32,11,-17,33,-45,6,-2,62,73,13,-30,-16,-19,-3,43,-72,-13,-22,6,12,70,-20,-1,-24,19,-1,16,22,-70,-58,-51,40,50,29,-41,27,6,35,-92,-7,-8,42,-1,32,8,-7,-46,32,-21,103,35,41,76,29,-40,81,46,-57,38,39,-15,-66,63,-16,-17,37,-15,13,20,-44,8,8,22,22,39,74,0,79,-59,41,40,-22,11,7,69,4,10,0,11,-103,11,-38,12,-6,-26,-63,-35,17,-41,42,21,-16,11,-27,16,-84,59,-49,-33,23,-33,30,-15,18,44,-38,10,10,48,-12,40,-39,2,27,-25,26,-3,-21,-7,28,41,19,-6,-24,46,67,22,15,21,-8,-17,22,-20,-26,-4,-9,44,-23,23,10,-22,-58,-26,48,-24,38,18,-42,80,5,-35,18,51,10,68,-38,-59,8,9,108,40,94,-34,36,-28,27,-36,49,16,17,-25,25,-10,-101,-36,-19,30,-26,-13,-49,-76,5,-19,38,-36,-21,20,-26,26,-12,89,-10,-2,-26,-48,40,3,-29,29,-20,-5,-22,-17,-20,22,17,-6,0,11,2,5,-35,14,-3,34,-15,-90,90,13,37,19,-12,-12,28,41,-7,56,46,16,-40,-11,5,-51,-18,30,6,23,-12,-2,24,-35]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.29","t":"The information for the case conceptualization is obtained from an initial patient interview or assessment, the patient’s records, behavioral observation, and/or interviews with other care providers or family members. This information is then incorporated into a case conceptualization model that reflects the manner in which cognitive and behavioral theory can be applied in understanding the specific patient’s clinical presentation. The case conceptualization is modified over the course of treatment as new information is acquired and as specific hypotheses are verified or disconfirmed.","e":[58,21,-111,-38,75,26,4,8,24,-29,-5,-22,85,47,-26,-62,-37,-51,0,46,-62,7,-24,-20,-7,13,-23,21,-40,28,19,10,32,-48,-59,-99,45,-6,-19,-8,44,23,23,-67,12,10,48,2,0,8,28,-20,39,4,98,42,2,68,16,-70,104,97,-36,79,37,-29,-38,63,3,-46,35,16,26,-5,-40,32,-21,1,-11,50,117,-51,71,-60,57,30,-18,-6,-8,75,0,37,38,13,-76,26,-64,12,-29,-30,-64,-44,9,-9,23,73,-37,-19,4,29,-80,26,-56,28,4,-31,51,-22,8,11,-7,3,32,27,19,28,-42,-28,18,-31,-11,-26,-22,-3,6,33,17,-14,5,22,56,13,2,6,4,-13,19,-30,-21,34,-8,38,41,-6,50,-53,-24,21,35,16,90,-11,-42,69,-22,-60,12,14,0,-19,24,-49,15,33,81,35,73,-44,6,-12,-6,-43,-3,14,21,-58,56,6,-27,-38,5,20,-38,-14,-59,-46,25,-2,36,-39,-2,11,-33,39,-19,59,-16,-16,-46,26,9,-22,9,26,-31,22,-16,-18,-27,-20,29,-3,14,29,7,22,-49,32,-20,38,-38,-82,49,20,21,41,-51,17,42,22,-26,39,17,-3,-72,1,4,-34,-14,69,10,54,33,-16,62,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.29","t":"Figure 1.8 displays the commonly used Cognitive Conceptualization Diagram, as presented by J. S. Beck (1995). Therapists can use this form to record core beliefs, intermediate beliefs (i.e., conditional rules and assumptions), and compensatory strategies. Although the first box is labeled “Relevant Childhood Data,” it is our experience that many Veterans develop core beliefs and conditional assumptions through formative military experiences in young adulthood. Therapists working with • Cognitive Veteran patients can include such experiences in this box. In addition, the Cognitive Conceptualization Conceptualization Diagram allows therapists to record three problematic situations Diagram reported by patients and the associated automatic thoughts (and the meaning behind them), emotions, and behaviors. The completion of this form will help therapists organize relevant information about their patients and illustrate the manner in which maladaptive beliefs and compensatory strategies facilitate dysfunctional thoughts, emotions, and behaviors in actual situations encountered in patients’ lives.","e":[41,17,-155,-110,43,-11,43,-2,17,-20,-20,-16,66,51,15,-14,-36,-24,11,31,-54,-14,-35,-12,31,57,-12,15,-86,0,69,-6,13,-45,-73,-98,40,15,-10,-17,37,11,17,-93,-25,7,66,-23,45,12,12,-36,51,-27,101,13,1,41,16,-71,89,60,-53,59,30,-7,-60,51,-43,-38,50,-33,32,33,-54,29,-37,-12,2,61,64,-26,88,-36,65,37,20,23,-13,77,-28,19,4,11,-66,26,-43,3,-18,-6,-47,-44,-21,-46,8,41,-24,-19,-16,7,-87,36,-14,23,21,-17,51,-46,17,33,12,5,30,39,3,56,-61,-33,11,-26,-24,-18,-22,8,-6,45,7,-15,-20,44,50,7,-21,0,12,-17,12,-39,-21,13,-10,26,-14,18,41,-36,-12,11,31,23,38,40,-38,65,12,-56,26,34,23,13,-27,-51,2,-21,77,11,54,-23,21,-12,-26,2,35,26,7,-35,29,-7,-59,-24,14,34,-93,-2,-87,-69,15,-17,53,-60,11,17,-25,23,-47,63,-35,2,-34,-13,63,-3,8,54,-47,7,21,-14,-16,-6,13,4,17,12,-17,20,-57,3,17,14,-22,-94,41,32,57,16,-45,48,52,60,14,42,45,24,-86,15,-12,-49,-6,85,4,31,-8,-4,43,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.29","t":"J. S. Beck’s (1995) Cognitive Conceptualization Diagram heavily emphasizes the cognitive processes we present in the expanded cognitive model. Conceptualization of a case according to this model is especially useful when the primary intervention is cognitive in nature, such as cognitive restructuring or modification of core beliefs (see Part IV). However, there are other models for cognitive behavioral case conceptualization, and cognitive behavioral therapists can feel free to use whatever model with which they are most comfortable. For example, Wright, Basco, and Thase (2006) present a model for case conceptualization that takes into account diagnoses, formative influences, situational issues, biological/genetic/medical factors, and strengths/assets and allows for the therapist to evaluate the manner in which these domains influence the selection of treatment goals, patients’ schemas, and automatic thoughts, emotions, and behaviors associated with specific situations. This conceptualization might be especially useful in instances of comorbid diagnoses that are associated with different cognitive behavioral profiles, multiple pathways hypothesized to contribute to a patient’s clinical presentation (e.g., medical, cognitive, situational), and/or the use of more than one treatment modality (e.g., CBT and medications).","e":[34,38,-115,-48,42,7,48,12,19,-20,11,-23,92,45,-16,-41,-30,-35,7,39,-68,-16,-13,-9,4,49,-27,21,-57,5,48,5,13,-45,-76,-79,56,25,-11,6,38,28,17,-90,-2,-5,76,-6,39,-3,33,-35,38,-31,114,33,-5,61,12,-76,85,90,-47,53,31,-22,-41,66,-15,-48,35,-23,25,33,-34,30,-30,-16,11,40,80,-13,96,-37,55,54,-12,23,-23,65,-6,13,4,24,-65,30,-43,-17,-26,-27,-77,-19,20,-14,22,52,-21,-22,-3,37,-92,12,-40,24,-1,-17,43,-33,19,42,11,-6,37,18,3,57,-72,-44,7,-53,-17,-21,4,-1,-2,41,8,-25,-14,35,63,-10,0,22,0,-14,9,-27,-35,10,-7,44,-2,18,33,-34,-37,45,20,27,57,16,-32,54,-29,-57,30,10,8,18,-29,-56,1,10,76,20,69,-30,-2,-16,-13,-9,6,38,22,-42,41,11,-31,-37,38,23,-67,-17,-78,-72,41,-15,45,-55,-12,25,-36,42,-45,49,-20,-7,-32,-10,44,-22,8,23,-41,15,-22,0,-42,8,6,-6,17,15,2,1,-50,11,9,44,-16,-80,57,7,42,7,-52,24,33,57,38,56,28,-2,-59,-18,-18,-31,-5,92,0,57,22,-24,61,0]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.31","t":"We now turn to examples of case conceptualizations for the four Veteran patients described at the beginning of the manual. • Case conceptualization CASE EXAMPLE: JACK examples During his intake evaluation, Jack was diagnosed with major depressive disorder, moderate, recurrent, and alcohol dependence, in full remission. Although he was not assigned an Axis II diagnosis, the assessor noted that he exhibited features of paranoid personality disorder. During the point in the interview in which his psychosocial history was gathered, Jack admitted that he endured substantial physical abuse at the hands of his father. His father struggled with alcoholism and was unable to hold down a steady job. Consequently, the family had significant financial limitations, and Jack wore hand- me-downs and clothing bought from secondhand stores. Jack was often teased because of his appearance and, as a result, he kept to himself. As he got older, when he was teased or taunted by other children, he would strike back aggressively and usually win the fight. By the time Jack was in high school, he was known as a troublemaker who should be avoided. Jack was expelled from school for repeatedly fighting during his junior year. As soon as he was of age, he joined the military to start a new life and get out of the house. Although he ultimately was discharged honorably, he was disciplined several times for fighting and insubordination.","e":[69,3,-164,-56,0,43,-17,-12,53,-19,-51,-25,35,52,-20,-69,-8,-40,-24,-10,-54,3,-60,-23,67,25,-47,-18,-71,22,15,-24,-28,-26,-49,-48,48,44,22,-18,20,15,-11,-74,12,12,28,9,6,-14,51,-65,51,-44,101,31,-1,40,12,-46,62,35,-61,26,35,-21,-28,65,-27,-40,45,-38,-11,7,-34,60,-3,20,-8,48,61,-22,61,-64,57,16,14,43,-35,30,10,65,3,46,-56,16,-21,31,-14,-18,-39,-74,1,8,32,72,-3,23,8,-9,-61,25,-47,5,35,-10,50,-33,-2,15,-31,7,-29,29,3,30,-35,-10,40,-39,8,-31,-14,18,-8,32,36,-47,-31,-5,108,-14,-13,13,16,-43,-9,-46,-74,19,-4,47,27,27,21,-16,-40,28,23,50,31,-9,-20,64,-15,-28,6,71,5,37,-12,-80,5,-5,64,-14,79,-68,-27,3,23,-39,44,32,12,-11,44,2,-50,-54,-9,48,-69,-39,-67,-63,41,-3,-29,-34,14,-12,-2,38,-52,38,-8,30,-18,14,46,-40,-27,28,5,25,22,-12,-34,-1,-7,4,-8,-23,14,29,1,0,-62,-1,-55,-74,82,-12,-2,13,-45,45,34,8,-30,55,3,-13,-39,2,-25,-40,17,50,14,20,15,-21,42,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.31","t":"Jack’s therapist took all of this background information into account when she met him for his first session, and she recorded the key points of this information under Relevant Background Data. She developed the hypothesis that his most salient core belief is, Others will hurt me, when he rapidly listed the people in his life who have “screwed” him. The following is the line of questioning that the therapist used in order to more completely identify Jack’s core beliefs, intermediate beliefs, and compensatory strategies as she formulated her case conceptualization.","e":[67,21,-184,-74,26,44,2,-3,46,-16,-49,8,27,29,-10,-5,11,-21,1,36,-82,-39,-60,-28,28,21,-33,9,-36,28,52,-29,-37,-66,-57,-70,47,39,1,-16,-1,6,-12,-126,40,-29,52,38,35,20,6,-47,33,-32,112,41,8,42,22,-55,83,26,-78,28,25,-23,-41,53,-52,3,45,-17,21,17,-20,35,-4,33,21,35,54,-29,83,-34,40,23,-19,31,-17,88,27,-7,9,45,-88,16,-33,-19,-14,-18,-67,-38,8,-8,13,50,2,2,26,4,-34,13,-15,-24,-2,-31,81,-44,4,21,-43,29,-27,105,-5,62,-47,1,29,-4,-20,-48,-16,5,13,43,1,-25,-8,74,46,28,13,-17,0,-46,-7,-40,-55,28,19,40,-23,52,15,-40,-26,13,54,34,23,-4,32,48,10,-38,13,57,43,43,-16,-69,-3,-41,56,22,47,-47,36,-6,39,-44,42,31,5,-16,12,5,4,-49,-14,17,-59,2,-46,-84,42,-9,6,-27,-17,3,-50,24,-62,70,-8,10,-24,-20,53,-10,-25,55,-30,0,-11,1,-24,23,5,20,9,-19,6,14,-16,-18,-20,7,-57,-112,84,40,38,17,-4,38,26,13,-37,12,21,-10,-69,42,6,-55,11,65,-3,44,-22,18,37,-36]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.31","t":"Jack: I just knew my regional manager would do this to me. I knew it! And did the store manager do anything to defend me? No, of course not. And then, to make matters worse, things are awful at home. My wife doesn’t do anything to take care of the house or cook me dinner, but yet she expects me to give all of my money to the household so that she can keep her salary for whatever the hell she wants… Therapist: [gently intervening to de-escalate Jack’s anger] So, it sounds like one thing that brought you here is problems with some of the people you are closest to, both at home and at work. Jack: It’s their problem, not mine. That’s just the way people are. Hell, I’ve been going through this since I was two years old. If my dad wasn’t beating me, he was breaking promises left and right, leaving me and my two brothers to fend for ourselves. Therapist: It sounds like you’ve had a lot of tough experiences, Jack. I appreciate the fact that you’re willing to open up about them with me. Jack: [grunts] Therapist: You know, Jack, these kinds of experiences can make a big impact on people. What kind of an impact did they make on you? [Therapist asks this question to assess for additional core beliefs and intermediate beliefs] CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 19","e":[59,15,-176,-64,14,52,-3,-28,72,-37,-44,19,5,24,1,-15,32,-20,-25,21,-46,-47,-57,-30,25,27,-54,36,-67,51,52,-27,-44,-64,-64,-34,39,60,-1,-27,56,10,-23,-122,37,-61,51,54,15,-11,16,-119,11,4,91,-26,0,50,29,-59,78,14,-48,58,25,8,-35,54,-56,-27,43,-6,20,9,-56,54,-32,14,4,10,22,-10,54,-79,15,0,34,58,-13,90,20,25,5,52,-87,5,-43,-3,-12,-57,-50,-39,9,-18,33,50,20,7,16,-10,-49,22,-18,-13,16,7,63,-60,5,46,17,52,-43,10,28,39,-46,34,28,-11,-1,-23,13,16,-6,41,-3,-26,-5,11,81,13,-14,11,23,-47,-3,-16,-80,12,22,22,-28,41,25,-35,-37,14,50,62,31,-8,-11,26,44,-13,3,90,43,64,-43,-68,-5,-37,57,12,12,-30,-4,-33,52,-33,64,4,8,1,12,-31,-18,-68,2,48,-47,-16,-59,-55,61,-37,-2,-42,21,27,-13,33,-35,66,-35,2,-40,-38,47,-51,-20,26,-10,-8,11,19,-66,15,-7,19,14,-15,8,0,-17,-19,-29,8,-34,-97,73,21,-4,16,-28,30,31,43,15,23,31,33,-57,47,29,-50,24,17,34,8,11,-28,27,-61]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.32","t":"Jack: [lacking insight] I wouldn’t say that they did. I don’t let them get to me. I look out for #1. Therapist: What do you mean by that, looking out for #1? Jack: Just like it sounds. You can’t trust anybody, even your family. So, I’ll provide for them and do my duty as a father, husband, son, whatever. But the minute I see you do something to screw me over, that’s it. You don’t get another chance. Therapist: How has this attitude served you in your life? Jack: It’s the only way to get through war. Therapist: Yes, I can imagine that you have to look out for #1 during war. How has this attitude affected you at other times in your life? Jack: I don’t know; it hasn’t affected other areas of my life from my point of view, I guess. Therapist: What about from the points of view of others? Jack: I don’t know. I guess some people just don’t like the way that I am. They say that I complain a lot, that I’m always looking for the worst in people. But you know what? That’s their problem. It’s served me well. Therapist: [noting that Jack has changed from saying this attitude has not affected his life to saying that this attitude has served him well] In what way has it served you well? Jack: If anyone’s going to do the damage, it’s me, not them. I won’t let them get to me first. Therapist: So, you’ve been able to protect yourself throughout your life. [Jack nods] How does all of this play out with your family members? Do you use the same approach with your family members? Jack: [pauses] Well, yes and no. I mean, they’re family. It’s not like I want to do anything to hurt to them, even if my father was like that to me. But, I tell you, I’m not going to take it from them when they take advantage of me. I won’t stand for it! Therapist: And do you perceive that your family members take advantage of you from time to time? Jack: More than I’d like to admit.","e":[65,-10,-169,-47,58,54,-19,-15,70,-27,-54,3,-22,37,0,-20,47,-23,-9,20,-52,-19,-24,18,26,3,-31,10,-91,32,78,-37,-55,-44,-58,-50,27,85,6,-41,39,28,-17,-107,36,-91,67,33,53,-23,8,-97,-4,-2,95,4,-19,11,10,-55,75,24,-68,39,21,-1,-80,14,-33,-40,5,-10,18,-33,-28,43,-16,26,18,4,58,-12,39,-65,9,26,45,44,-1,92,32,23,4,41,-51,37,-43,-15,3,-35,-39,-10,-29,-32,51,21,28,33,33,-19,-38,12,-12,-33,-23,-2,58,-71,30,29,-14,41,-20,82,34,35,-63,40,-16,-20,-7,-13,14,9,-12,29,25,-46,3,-3,81,59,17,-28,45,-42,-30,-29,-68,-6,8,52,-38,44,17,-55,-31,11,48,55,35,18,-2,24,6,-19,9,79,35,35,4,-47,0,-60,41,-22,28,-45,-15,-22,39,-43,87,0,-9,-9,12,-15,-19,-62,13,30,-51,-2,-40,-28,48,-72,-5,-31,-8,-19,-13,35,-34,35,4,27,-25,-44,23,-46,-40,33,-19,-17,26,-2,-67,30,26,37,11,10,-14,18,-6,-26,-30,22,-47,-104,74,41,5,19,-23,43,37,67,-1,11,-10,7,-36,29,12,-38,25,10,19,26,28,-29,20,-71]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.32","t":"Notice that Jack’s therapist did not actively point out any of his core beliefs or intermediate beliefs. Because these beliefs are so central to people’s self-concept, particularly when they are experiencing acute symptoms of a mental disorder, it is often too threatening to verbally acknowledge them when the therapeutic relationship is in its infancy. Nevertheless, the therapist can ask targeted questions in order to generate hypotheses about core beliefs, intermediate beliefs, and compensatory behaviors, and she can revisit the conceptualization as more information is gathered • Self-concept in subsequent sessions. Jack’s therapist completed the case conceptualization form after meeting with him for the first time (Exhibit 1.1). The majority of the information that she recorded was specified directly by Jack throughout the session, supplemented by explicit examples that Jack provided to support some of these statements (as summarized in the situation thought emotion behavior sequence). However, notice that his therapist also proposed an additional core belief—“I don’t deserve love and care from others.” Although Jack did not verbally express thoughts or perceptions consistent with this core belief, she reasoned that many children who endure physical abuse and teasing from peers develop similar core beliefs, and she hypothesized that","e":[64,19,-152,-89,26,42,11,-6,45,-15,-39,-1,27,72,-18,8,10,-42,-4,54,-81,-33,-36,-25,26,33,-34,21,-49,21,54,-32,-3,-41,-44,-78,53,32,-20,-47,22,16,0,-131,31,-29,45,12,52,-7,37,-76,37,-26,136,37,-6,60,14,-87,87,46,-57,43,47,-25,-63,47,-70,-9,36,-5,-3,22,-26,28,-6,12,10,57,62,-43,69,-54,35,35,-9,47,-14,61,13,14,6,25,-76,-6,-27,10,8,-1,-69,-25,-6,-15,17,50,-24,22,3,13,-57,30,-50,-2,0,-22,89,-48,19,20,-46,39,-10,97,10,60,-24,-18,4,-24,-13,-42,-34,3,-5,22,27,-39,-5,42,50,34,7,-4,11,-59,-9,-48,-34,22,36,29,17,47,17,-28,-39,11,57,22,38,1,7,32,8,-27,8,48,20,30,-18,-53,2,5,77,20,66,-69,20,-20,21,-33,42,38,19,1,29,-8,-37,-45,-18,32,-85,-6,-44,-61,10,-12,-4,-34,6,9,-43,22,-64,55,-32,25,-10,-43,57,-39,-36,47,-30,20,-9,4,-56,28,-5,-15,6,9,-15,16,-43,-18,-28,11,-25,-120,80,28,22,42,-36,44,23,34,-25,25,22,16,-52,30,11,-38,4,54,-7,33,-13,-15,43,-30]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.33","t":"part of his anger is driven by a belief that he is unlovable. After the first session, the therapist requested Jack’s previous treatment records and saw that a previous therapist had made a similar speculation. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 21","e":[33,15,-175,-77,50,56,-3,-11,37,-25,-48,45,44,12,4,-7,21,-34,-22,24,-51,-48,-70,-57,35,55,-36,30,-45,36,47,-7,-27,-23,-41,-52,54,26,24,2,24,-7,13,-83,14,-5,66,83,44,-7,24,-94,23,-69,114,21,-10,24,-13,-59,73,27,-42,77,57,-32,-34,4,-42,-35,49,-17,39,31,-57,1,-38,-14,-28,14,54,-1,42,-70,77,-3,5,42,-21,51,6,27,4,48,-82,5,-35,-20,-33,-40,-70,-33,-19,-18,20,56,-9,2,-1,-23,-69,35,-16,-16,-2,20,61,-40,-3,38,17,13,-14,53,-5,21,-14,27,30,-10,-22,-15,-9,0,9,14,-15,-12,-45,28,64,-14,4,17,4,-32,-14,-28,-72,-9,23,35,9,7,24,-57,-51,33,28,20,25,-7,-18,23,17,-34,-14,54,35,42,-31,-57,-19,-30,77,18,41,-6,43,-43,45,-48,56,54,5,-7,11,-44,-41,-56,9,57,-61,-12,-45,-50,27,-10,7,-18,17,20,1,4,-70,49,-17,25,-9,-37,39,-60,-21,22,-12,3,32,-6,-50,16,35,34,-9,-24,-9,35,-17,-32,-22,-18,-34,-111,67,7,19,26,-4,51,3,48,-13,49,24,45,-67,19,-3,-57,23,32,-10,14,-2,-10,29,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.34","t":"Exhibit 1.1. Cognitive Conceptualization Diagram for Jack RELEVANT CHILDHOOD DATA Physically abused by father Financially poor childhood household Teased by other children Protected himself by fighting CORE BELIEF(S) Others will hurt me. Others are untrustworthy. [tentative] I don’t deserve love and care from others. CONDITIONAL ASSUMPTIONS/BELIEFS/RULES POSITIVE ASSUMPTION(S): If I get others before they get me, then I’ll be safe. NEGATIVE ASSUMPTION(S): If I let others get too close, then I’ll get hurt. COMPENSATORY STRATEGIES","e":[63,25,-156,-66,39,53,19,-10,12,-18,-42,2,40,63,8,-4,-11,8,21,45,-78,-11,-53,-7,51,32,-18,-1,-77,0,21,-20,-12,-76,-77,-62,52,34,19,-53,38,54,14,-94,28,-16,71,20,89,-10,17,-60,35,-29,117,26,26,-1,-8,-68,90,70,-58,31,66,3,-67,42,-35,-18,22,-19,23,0,-33,22,-31,14,9,60,51,3,79,-29,41,32,18,-9,-37,83,2,-13,14,23,-58,38,-44,11,-19,-19,-37,-26,-6,-52,2,49,-5,32,0,-5,-64,2,-36,-14,-7,-34,53,-42,30,38,2,15,10,83,-18,57,-52,12,11,-35,6,-17,-13,16,-18,51,0,-10,-16,51,58,63,-6,-20,0,-50,-10,-40,-51,8,-3,40,-11,35,6,-27,-2,19,30,14,59,9,-24,59,-13,-26,24,49,34,57,-29,-48,-4,-34,52,-23,20,-54,-1,-9,10,-45,75,36,-4,-46,29,26,-27,-44,10,18,-66,-25,-56,-90,27,9,33,-36,11,3,2,30,-48,56,-34,51,-11,-21,47,-20,-12,32,-30,-8,17,-12,-52,-6,-6,12,6,1,6,20,-12,-12,-28,15,-40,-120,59,33,24,41,16,35,26,10,-5,37,38,19,-52,9,-11,-50,-1,64,3,44,-4,-2,36,-30]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.34","t":"Looking out for “#1” at the expense of providing care and support to close others Interacting with others in a guarded manner Being aggressive when an injustice is perceived SITUATION #1 SITUATION #2 SITUATION #3 Wife out late with Fired from job girlfriends Car part doesn’t work AUTOMATIC THOUGHT AUTOMATIC THOUGHT AUTOMATIC THOUGHT They sold me this on They’re out to get me. She’s with another guy. purpose. MEANING OF A.T. MEANING OF A.T. MEANING OF A.T. People will screw you if I can’t trust anybody. I can’t trust her. they can. EMOTION EMOTION EMOTION Anger Anger, vengeance Anger","e":[39,-2,-162,-35,89,45,22,-12,-3,50,-24,58,81,9,23,-23,40,-10,-7,64,12,-60,-32,-17,27,15,-14,-10,-48,-54,-13,-30,-22,-57,-73,-75,31,54,25,-15,25,3,13,-43,-15,-38,19,67,53,-4,17,-75,-22,-39,110,33,53,48,-29,-18,63,40,-66,47,59,-35,-32,11,3,-36,71,-15,20,21,-28,-37,-45,24,30,54,64,-40,79,1,47,27,10,6,-20,99,-3,40,21,-2,-131,-2,-46,3,-25,-33,-57,-5,29,-6,54,38,-53,23,-9,27,-20,48,5,-17,-11,23,82,-45,20,27,41,45,-49,83,15,35,-61,-6,-9,-10,-11,-19,37,10,2,58,-8,-41,-22,44,82,-1,24,-5,-7,-58,-5,-55,-62,6,23,36,-39,-12,37,-17,-25,33,28,-2,21,27,-71,38,-45,3,-22,21,4,65,-46,-35,-8,-12,29,11,65,-2,-22,-51,51,-56,71,-10,-30,-56,6,-45,-24,-4,41,42,-36,26,-76,-53,26,4,-1,-23,-18,-15,-35,56,-14,68,1,15,-3,-32,18,0,-10,23,8,-24,11,-21,-62,-1,19,-5,-43,-7,-15,16,-6,14,-12,-14,-32,-103,50,9,27,-13,-9,25,4,70,-28,34,-9,17,-54,32,31,-19,18,53,-16,27,-14,4,33,-51]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.35","t":"The majority of Jack’s case conceptualization was centered on his perception of others or the world. At times, patients will present with many different core beliefs that drive different aspects of their clinical presentation, such that some core beliefs are associated primarily with one disorder (e.g., depression), whereas other core beliefs are associated primarily with another disorder (e.g., anxiety).","e":[46,16,-155,-69,21,59,6,-14,43,-30,11,8,58,67,-30,-24,-23,-10,-2,57,-78,-3,-51,-33,1,54,-44,-12,-41,48,26,-25,-19,-41,-45,-65,40,38,27,3,-11,15,-22,-97,24,-13,26,33,46,1,20,-67,28,-39,124,72,-17,87,14,-42,86,29,-41,45,46,-24,-55,50,-33,-17,46,-19,13,20,-31,39,-5,25,33,38,94,-36,61,-35,53,29,-7,18,-12,70,46,7,21,54,-90,11,-26,15,2,7,-79,-32,-3,0,18,48,-30,16,12,5,-44,25,-45,-27,12,-32,91,-36,-2,6,-24,5,7,87,9,42,-2,-22,16,-23,-4,-50,-28,7,-17,24,3,-11,-23,62,52,21,-17,0,15,-53,-9,-54,-51,18,31,36,10,38,-15,-44,-54,21,63,8,35,7,11,39,-3,-49,14,50,21,48,-18,-56,-14,4,97,29,60,-52,15,-11,1,-25,5,40,22,-11,42,-16,-30,-64,-2,7,-62,-1,-55,-62,9,-9,14,-45,5,2,-12,15,-60,64,7,18,-14,-22,40,-37,-49,27,-5,26,-18,-14,-37,20,-20,-8,-9,-19,10,16,-27,-16,-21,7,-34,-105,75,18,30,24,-25,28,47,10,-42,23,31,-7,-34,22,-23,-35,-4,58,-26,31,-19,-5,77,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.35","t":"CASE EXAMPLE: KATE Kate was diagnosed on Axis I with major depressive disorder, recurrent, severe, and provisionally with panic disorder, and on Axis II with dependent personality disorder. She indicated that she was the middle child in a family of seven children, two of whom had special needs. As a result, she received little attention from her parents or older siblings. Although she desperately wanted to fit in with her peers during her school years, she was a homely child and was often neglected. Whenever a new student was introduced to the school, she seized the opportunity to make a “best friend.” Unfortunately, the friendships often did not last as those friends expanded their social circle with other peers whom they regarded as more exciting. She spent most of her time on the playground reading on the steps while the other children played. Not only did these circumstances provide a context for Kate to develop a core belief about being unlovable, but they also deprived her of the opportunity to develop effective social problem-solving skills that are necessary for managing relationships. Thus, Kate also has little confidence in her ability to handle adversity, which often prompts anxiety.","e":[46,12,-156,-26,-7,101,-4,-1,29,-6,-77,-17,109,34,-16,-17,-26,-8,-60,50,-53,-8,-29,4,37,80,-27,1,-68,12,29,-23,12,-58,-56,-39,43,53,28,-1,62,25,9,-50,-49,-55,34,43,32,-3,30,-25,62,-46,101,73,7,37,0,-47,83,5,-81,31,47,-27,-64,65,-46,-61,76,-3,16,23,-8,14,-31,-5,-9,44,86,-19,30,-33,54,26,2,48,-21,26,26,48,-2,20,-42,17,-6,7,-58,-12,-30,-50,-16,10,31,26,-15,15,5,-12,-53,29,-61,-29,44,-31,23,-45,1,-11,-25,7,-11,63,37,49,-53,-3,37,-3,-23,-23,-21,29,-17,63,0,8,-36,12,51,18,-22,-28,16,-16,33,-30,-61,11,-8,26,-4,30,8,-26,3,31,36,-4,56,15,-34,72,-28,-22,47,60,7,21,-51,-74,2,-13,24,-21,79,-51,-1,-13,47,-43,34,2,-1,7,-3,-15,-39,-63,-8,10,-61,-10,-57,-44,42,-20,-10,-31,-17,16,-30,58,-48,28,9,3,36,-7,57,-26,-43,18,-17,0,-14,-38,-53,6,20,-23,-12,-3,31,28,-20,-3,-40,-7,-57,-70,84,8,-10,37,-70,4,-31,15,-49,30,-5,7,-25,16,-15,3,-13,64,-23,39,41,-24,76,8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.35","t":"Kate met her husband, Kevin, when he relocated to her school in their senior year of high school. This was Kate’s first boyfriend, and she was thrilled to finally engage in some of the same social activities as her peers. He had a strong personality, and she usually “followed his lead” in social circumstances. Although Kate was planning on attending college after high school, Kevin strongly encouraged her to get a job so they could move in together and start their life. She acquiesced and began working as a waitress. Approximately six months later, she learned that Kevin was cheating on her while she worked evening hours. She described herself as being so “mortified” about this betrayal that she joined the military to get away from him as fast as she could. When she returned home on leave a year later, Kevin claimed he had made a big mistake and begged her to marry him. They were married four months later.","e":[13,19,-171,-4,6,101,-47,-7,17,5,-132,23,87,23,-64,-8,35,-29,-37,32,-39,-37,-42,-44,11,-19,-43,19,-71,17,30,-4,9,-71,-33,-72,-14,-1,25,-73,52,27,-29,-55,35,-73,7,34,7,7,-35,-36,-28,-8,55,57,46,21,50,-78,105,23,-26,94,17,-13,-22,79,-30,-41,25,-33,11,16,19,33,34,-32,-15,12,75,-12,45,-13,7,27,18,30,-28,8,18,75,38,33,-57,-19,-45,-9,-29,-15,-23,-33,-11,52,44,60,-23,13,30,-3,-59,16,-34,-25,30,40,57,-27,49,47,-5,-2,-25,58,8,52,-25,13,16,6,13,-13,3,23,-3,64,0,-14,-22,21,68,9,-14,-35,-22,-7,0,-30,-26,23,10,18,-19,5,6,-31,-9,31,76,26,63,-4,33,15,12,-7,10,45,0,46,-69,-79,2,-67,23,7,46,-27,26,-3,54,-70,57,22,23,-15,-1,-15,-65,-73,-22,14,-66,-22,-46,4,44,21,-10,0,-3,-2,-49,46,-34,64,2,-8,-15,-3,24,-33,-60,20,3,3,3,-17,-79,33,6,22,-17,14,19,24,-28,-1,-45,4,-14,-34,52,36,-19,36,-29,54,-48,11,-24,2,17,3,-56,-6,24,-37,-34,39,39,13,27,36,35,-49]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.35","t":"Kate’s therapist developed hypotheses about Kate’s core beliefs, intermediate beliefs, and compensatory strategies in the first session as Kate described two major and recent disappointments—her husband leaving her and taking the kids to another state, and the unexpected loss of her job at the hospital. Notice that the therapist asked questions not only about the sequence of events associated with these problems, but also about the meaning these events had for her (to identify core beliefs and intermediate beliefs) and the manner in which she coped with them (to identify compensatory strategies).","e":[24,26,-173,-57,28,42,11,3,44,-3,-95,-42,91,66,7,-8,14,5,-27,53,-58,-27,-22,1,23,45,-32,37,-39,-3,45,-26,25,-68,-62,-56,77,29,-21,-57,50,-6,36,-119,10,-45,38,43,-9,4,9,-35,20,-11,94,36,29,43,26,-69,97,14,-48,44,33,-37,-62,84,-56,-32,49,-9,22,26,-32,7,-17,9,-13,37,56,-6,74,-19,8,36,-13,61,8,56,6,-8,17,20,-88,6,-29,-19,-11,-6,-63,-30,-8,-30,41,34,-25,-1,-5,18,-57,30,-40,-16,35,-25,57,-53,24,23,-30,26,-28,68,27,87,-74,6,-1,9,-2,-26,-32,44,23,33,18,-4,-2,37,43,21,-7,-17,7,-35,41,-30,-29,17,25,8,-14,55,35,-29,-39,19,49,-5,46,-5,6,57,10,0,23,61,10,27,-40,-80,7,-30,69,27,64,-41,9,-31,34,-4,50,15,31,-30,4,3,-63,-58,7,26,-58,1,-49,-64,22,-10,10,-30,0,28,-57,31,-34,81,-13,4,-11,-36,58,-29,-17,51,-22,7,0,-12,-33,10,15,-19,-11,21,5,18,-52,4,-14,-9,-30,-107,63,32,43,33,-23,11,18,44,-30,10,9,1,-61,36,19,-49,6,59,-13,28,-1,-17,49,-38]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.35","t":"Kate: ...And then when I came home, my mother picked me up from the base and told me that Kevin had moved with the kids out of state. [becomes tearful] Therapist: [gently] That sounds very hard. What did you do next? Kate: Nothing. Absolutely nothing. I went home, pulled down the blinds, and slept for three days. Therapist: Did you try to call Kevin or the kids on their cell phones? CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 23","e":[37,-25,-192,-57,31,66,-17,-13,22,-5,-85,5,49,20,-45,-52,7,-17,-33,19,-38,-21,-44,-40,36,37,5,77,-67,30,84,-22,-1,-63,-57,-13,26,28,-17,-40,43,-1,-25,-83,15,-65,68,41,-8,-44,-1,-42,-5,-17,73,-22,14,-10,23,-35,123,7,-38,70,46,-30,-67,79,-45,-49,47,-24,26,34,-42,11,-43,-19,-18,25,50,-2,30,-56,37,17,19,37,-8,71,-13,20,9,34,-44,6,-8,2,-32,-63,-53,-48,-48,-42,46,51,-11,-11,24,-26,-75,32,-5,-9,25,-2,46,-71,36,1,0,12,6,-2,39,62,-57,24,5,-13,-18,13,-20,28,-3,28,-11,-13,-10,12,56,-17,-23,-4,11,-8,30,-24,-21,-13,28,-10,-4,2,60,-72,-10,32,40,39,53,16,-26,26,26,-36,-22,67,25,27,-53,-90,0,-44,26,29,-1,-22,-9,-13,44,-28,63,18,-6,-34,-42,-55,-33,-73,2,33,-49,-7,-68,-23,51,-13,36,-31,17,37,-12,39,-55,49,-9,-1,-7,-19,47,-40,-7,38,-12,-21,13,-20,-58,15,-20,45,0,-3,24,18,-24,-10,-8,-2,-25,-94,40,15,3,62,-23,31,-12,44,30,27,43,10,-63,27,-6,-32,2,39,1,21,5,-3,48,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.36","t":"Kate: What’s the use? If they left, they probably don’t want to talk to me. Therapist: What do you think would happen if you tried to call them? Kate: I think they’d tell me they don’t need me…that they’re a lot happier without me. Therapist: [gently] What makes you think that? Kate: Because everyone would be better off without me. I’m boring. I never really say or do anything. Therapist: Is that why you think they left? Because you don’t contribute anything meaningful to their lives? Kate: [crying out loud] Yeah. I used to just try not to make waves, thinking that they wouldn’t leave me if I didn’t cause them problems. But after I was deployed, they probably saw that life is even better without me. Therapist: [Later in the session, when Kate was describing the unexpected loss of her job] When did you find out about the loss of your job? Kate: Well, I realized that I could not stay in bed forever and that the hospital would be expecting me. So I went to the hospital administrator’s office to let her know that I’m back and wanted to start taking shifts. Therapist: What happened then? Kate: She looked surprised to see me. She said they had filled my position six months ago. [looks down at her hands] Therapist: I can imagine that this would be quite a shock for you. Kate: Well, yeah! She told me that they did not hold the position for me because I volunteered to stay longer. But that’s not true at all. I was told that I had to stay longer. I didn’t volunteer for anything! Therapist: Did you try to explain this to the hospital administrator? Kate: [shyly] No. Therapist: What prevented you from clarifying with her what had happened? Kate: I just couldn’t. I can never tell my side of the story. I just get too tongue-tied and emotional. Therapist: So then what did you do? Kate: Nothing. I just said “Thank you” and left her office. Therapist: Do you have a new job lined up? Kate: [tightly wadding up a tissue in her hand] No, I can’t find one. Therapist: This sounds like a difficult situation, and I’m sensing that there is a lot running through your mind right now. What are you thinking? Kate: [crying] I can’t deal with this! There are already bills that are piling up, and I have no money to pay them! Therapist: Might it be useful for us to put together a game plan for addressing some of these stressors that are piling up? Kate: What’s the use? I’ve never been able to deal with stress! Therapist: How have you dealt with stress in the past? Kate: I don’t think I’ve ever dealt with it. I just try to ignore it. Therapist: Are you doing that now? Kate: [pauses] Yeah. I’m not even trying to make any form of payment on any of the bills, even the small ones. And I’m not even really sure how to go about finding a new job, since there is only one hospital in town. I’m stuck. I’m such a failure.","e":[27,-11,-153,-68,34,77,-36,-6,48,-29,-112,-4,27,23,23,-26,33,-29,-86,29,-18,-56,15,-3,1,47,-25,57,-94,37,97,-18,46,-52,-66,-21,32,64,-49,-25,71,-13,3,-105,1,-98,93,59,-10,-32,-1,-62,-53,58,61,-37,33,-2,1,-32,98,-13,-41,80,46,-31,-65,56,-43,-72,16,18,-5,40,-56,77,-42,-14,23,3,55,-16,29,-32,29,49,40,19,1,70,-42,11,12,3,-54,30,6,-20,-5,-61,-31,-52,-34,-39,68,40,-28,-32,42,-23,-22,36,-22,-26,9,-19,36,-89,31,-4,-22,23,-22,-9,67,51,-48,23,8,11,-13,11,-30,40,5,43,9,-70,20,4,89,-6,0,-26,2,-6,49,-6,-40,39,7,7,-31,33,56,-42,3,28,20,15,49,-5,-31,37,53,-8,-6,47,9,11,-1,-60,17,-22,26,36,25,-25,-22,-25,83,-20,62,-26,9,7,-25,1,-21,-74,12,25,-51,12,-53,-1,45,-55,-4,-12,3,3,-44,21,-30,-6,-14,-12,-24,-44,57,-11,-32,31,-9,-15,34,-14,-73,32,4,8,35,13,13,-9,-43,14,-31,-28,-35,-74,38,20,-18,38,-31,61,-14,36,5,9,-9,7,-49,8,7,-35,30,38,23,-11,52,-33,45,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.37","t":"Notice that Kate’s therapist alternated between asking her how she handled events in the sequence (e.g., “So then what did you do?”) to identify compensatory strategies with asking her about her perceptions of the events (e.g., “What makes you think that?”). Exhibit 1.2 displays the case conceptualization that Kate’s therapist completed after meeting with her for the first time. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 25","e":[19,-7,-169,-63,68,33,41,-24,35,4,-64,-7,87,65,7,-35,-18,-47,-30,48,-47,-20,-40,-14,36,37,-33,67,-45,-16,48,-3,10,-47,-63,-50,62,27,-30,-25,58,-6,19,-97,0,-39,80,39,-9,-30,18,-30,23,-37,106,0,30,35,10,-55,105,28,-56,57,35,-41,-58,78,-72,-27,38,4,35,33,-54,14,-30,7,-35,25,58,-29,76,-49,50,6,2,37,-3,58,6,15,27,48,-77,9,-19,-18,-15,-55,-63,-11,5,-36,38,62,-16,-10,-6,-25,-73,15,-26,1,12,-7,49,-49,2,37,-13,-12,-19,13,3,59,-55,10,14,-23,5,-23,-28,35,1,18,-7,-13,-11,10,51,-8,-32,-4,7,-18,2,-15,-39,-10,13,26,8,22,69,-62,-21,25,26,17,53,3,-23,62,16,-5,19,43,33,22,-57,-87,-11,-36,74,28,42,-31,10,-15,28,-35,46,26,-2,-51,8,-19,-52,-42,-3,42,-56,-16,-81,-44,46,-11,26,-51,0,55,-50,39,-62,75,-16,-4,-11,-27,59,-34,-5,29,-44,11,12,-1,-50,11,20,6,-22,-1,-4,9,-38,-5,-10,0,-21,-86,33,-7,30,43,-27,44,13,51,4,14,44,19,-55,47,11,-26,23,46,-3,10,12,-6,53,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.38","t":"Exhibit 1.2. Cognitive Conceptualization Diagram for Kate RELEVANT CHILDHOOD DATA Neglected by parents Neglected by peers Lonely childhood Boyfriend cheated on her CORE BELIEF(S) I’m unlovable. I don’t deserve love and attention from others. Others will leave me when they find someone better. I can’t cope with adversity. I’m a failure. CONDITIONAL ASSUMPTIONS/BELIEFS/RULES POSITIVE ASSUMPTION(S): My relationships will be fine as long as I don’t make waves. NEGATIVE ASSUMPTION(S): If I don’t do what others want, they will leave me for somebody better.","e":[23,16,-133,-67,32,83,14,-8,4,-6,-56,12,73,79,-25,6,-20,-17,-6,83,-57,-13,-46,0,39,64,-23,-10,-106,8,16,-14,7,-62,-96,-55,32,17,49,-54,52,56,14,-64,24,-42,78,24,82,13,21,-35,60,-10,87,38,26,0,-6,-61,85,53,-47,102,51,-9,-67,44,-47,-62,27,-6,9,4,-42,29,-36,-13,11,51,58,-13,75,-10,47,44,42,-7,-37,59,-16,9,18,-10,-41,27,-51,-16,-45,-11,-32,-29,-27,-42,26,61,-26,26,-11,-6,-62,7,-48,-21,-22,-47,31,-47,24,32,22,7,40,81,-4,41,-43,0,-5,-22,-1,-8,-29,27,-25,64,0,-5,-25,44,59,33,-9,-11,-10,-37,17,-41,-41,18,-6,28,-14,-6,-5,-40,3,22,27,-35,71,15,-51,57,-11,-24,32,27,34,44,-24,-35,-7,-31,39,-16,26,-24,15,-4,21,-22,57,23,-3,-28,16,18,-49,-42,22,4,-56,-3,-48,-73,15,18,42,-29,3,5,10,48,-49,24,-20,46,-19,-16,50,-29,-27,24,-39,0,13,-30,-64,6,9,9,23,18,13,24,-34,0,-16,-5,-39,-127,72,44,30,50,-15,35,-13,26,-23,56,14,34,-50,7,-1,-16,2,74,3,59,26,7,51,2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.38","t":"COMPENSATORY STRATEGIES Lack of assertiveness Allowing others to make decisions Relying on others to help solve her problems Giving in during arguments or conflicts SITUATION #1 SITUATION #2 SITUATION #3 Husband took children Learned that she lost her Finally talked to children and moved out of state job at the hospital on telephone AUTOMATIC THOUGHT AUTOMATIC THOUGHT AUTOMATIC THOUGHT They sound happy without I caused this. I can’t pay my bills. me. MEANING OF A.T. MEANING OF A.T. MEANING OF A.T. I don’t deserve to have a I don’t have the ability to My children would be “normal” family. deal with this problem. better off without me. EMOTION EMOTION EMOTION Despair Panic Depression","e":[66,4,-171,-55,50,49,15,-9,11,15,-65,5,78,54,39,-9,5,9,-28,65,-4,-32,-18,2,55,22,-10,14,-44,-50,-12,-41,30,-46,-87,-18,70,46,-6,-16,46,-5,14,-51,-15,-20,39,65,40,-11,39,-86,-24,-33,110,-5,21,29,-46,-22,89,42,-47,30,72,-35,-35,54,-8,-31,55,-28,5,6,-33,-24,-58,12,10,36,58,-26,93,3,66,23,20,-16,10,96,-11,38,12,0,-92,21,-23,18,-19,-49,-41,19,-1,-33,52,34,-28,22,-12,32,-41,41,-24,-18,5,-14,61,-59,27,21,1,49,-22,49,12,79,-58,11,24,10,17,-30,18,-2,0,26,-25,-49,-13,48,59,14,19,-20,-16,-31,4,-83,-43,-26,18,28,-37,25,60,-26,-13,24,-12,-19,28,19,-77,66,-39,-3,6,46,11,66,-34,-38,6,-17,41,24,68,-9,-32,-55,35,-23,58,11,-12,-35,21,-12,-32,-25,40,60,-21,-14,-81,-64,21,9,13,-32,5,-10,-19,2,-21,40,-33,7,14,-21,28,-6,-28,25,-13,-18,10,-32,-66,-13,12,-32,-22,32,8,-7,-15,24,-29,-7,-7,-109,73,8,17,25,-9,22,12,71,-10,24,28,-1,-71,34,6,-37,3,28,-9,31,-9,-44,37,-25]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.39","t":"The case conceptualization helped Kate’s therapist to identify the hypothesized cognitive and behavioral sources of her depression and anxiety. Kate experienced depression when beliefs about being unworthy of love were activated, but she experienced anxiety when beliefs about an inability to cope were activated. Both her depression and anxiety were also associated with the belief that she is a failure. Behaviors that maintained Kate’s depression included ungratifying interactions with others, such as times when she would appease the other person at the expense of getting her own needs met. In contrast, behaviors that maintained Kate’s anxiety were avoidance of solving problems and making decisions, which reinforced her belief that she was unable to cope with adversity. Both of these cognitive and behavioral profiles contributed to her Axis II presentation of dependent personality disorder.","e":[59,15,-145,-56,28,83,7,5,10,-11,-71,-2,120,52,-3,0,2,12,-48,62,-71,-2,-28,-19,23,69,-24,-6,-39,20,23,-35,6,-77,-45,-39,48,45,31,-12,38,10,14,-72,-51,-36,58,45,-7,26,48,-34,69,-50,112,42,9,43,15,-61,91,21,-33,40,58,-41,-73,85,-75,-28,55,-8,4,29,-11,39,-3,-3,18,31,90,-28,45,-48,78,42,-9,26,-16,40,9,5,10,25,-64,24,-23,-12,-48,-9,-70,-26,-22,5,20,32,-24,2,3,35,-61,46,-41,-30,30,-42,29,-51,2,-3,-19,5,23,63,18,57,-25,5,23,-23,-17,-40,-24,42,-9,33,-6,4,-52,14,42,18,-28,-32,-10,-15,38,-37,-46,-7,-1,6,-22,16,33,-36,-19,25,53,-17,70,15,3,54,-9,-28,49,36,7,17,-49,-63,-13,-20,64,28,65,-41,20,-34,43,-16,25,19,20,-20,27,-10,-60,-82,0,15,-61,0,-75,-61,37,-21,27,-27,-4,21,-11,29,-64,47,-3,-7,13,-26,24,-28,-20,17,-19,4,-13,-32,-40,-11,12,-2,4,25,11,39,-51,-17,0,-34,-30,-101,59,-3,9,43,-68,11,-35,10,-29,40,25,26,-46,15,-28,0,-9,55,-27,4,5,-23,83,1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.39","t":"CASE EXAMPLE: MICHAEL Michael’s clinical presentation is different from Jack’s and Kate’s because Michael experienced a dramatic change in his beliefs and behaviors after he returned from service. Prior to his deployment, he was an ambitious, driven young man who hoped to go to law school and one day get into politics. Michael was reared as an only child by a single mother who worked two jobs to “make ends meet.” Despite the fact that she was not around much of the time, the two had a close relationship, and she instilled many strong values in him. She often told him that he could do anything he set his mind to and that education and hard work were the keys to living a better life than she did.","e":[36,3,-164,0,3,86,-10,-21,78,-9,-41,-20,110,69,-51,-40,8,-39,-6,55,-68,-25,-53,6,42,9,-5,-1,-86,45,91,-25,3,-38,-62,-46,14,69,9,-44,15,-18,-24,-89,27,-56,8,27,1,-34,26,-23,37,-16,106,29,19,42,24,-68,94,16,-53,50,16,-20,-41,35,-25,-53,49,-25,-2,-2,16,34,-14,-4,-13,22,68,7,42,-7,27,33,61,21,-2,67,13,59,-11,42,-76,10,-22,12,-5,-1,-35,-68,-5,21,55,83,17,-1,7,-14,-55,13,-64,-1,20,-27,49,-56,26,25,-11,-20,-13,49,7,55,-35,10,16,-6,4,-37,-19,16,-5,37,31,-29,-17,14,92,14,-26,7,-16,-9,33,-6,-27,36,11,61,11,62,7,-48,-29,22,23,31,41,-10,-17,33,-20,-47,0,66,-6,4,-10,-89,4,-12,70,-27,64,-37,-1,-12,25,-35,5,15,5,-16,27,13,-63,-51,-28,32,-57,-37,-56,-48,36,-5,-1,-37,-26,-3,-23,67,-58,60,0,28,12,-13,55,-25,-25,-10,-7,6,-1,-27,-52,22,-35,11,-10,2,9,4,-4,-12,-58,4,-28,-47,83,45,-7,14,-35,34,28,30,-44,27,30,-34,-36,2,37,-8,5,64,28,20,24,10,38,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.39","t":"Michael and his mother lived in a bad section of the city, where there were street gangs and poor-quality schools. Nevertheless, Michael excelled in school—his intelligence and abilities were quickly recognized by his teachers, and they took him “under their wings” to ensure that he stayed away from deviant crowds and achieved the milestones necessary for him to be admitted to a good university. Michael was often teased by his peers, who called him a “teacher’s pet” and said that he was trying to be “too White.” These comments generally did not bother Michael because his focus was on doing more with his life than he saw others around him doing. Michael was admitted to the flagship state university to study political science. When he realized that he and his mother would have trouble covering expenses, he joined the National Guard to pay for his tuition, with the idea that it was unlikely that he would be called to duty. However, he was called upon to serve in Iraq during his senior year of college.","e":[-12,35,-180,-15,57,102,-15,22,53,13,-24,1,93,50,-47,-67,20,-33,5,1,-77,-30,-18,6,85,-26,-37,-39,-54,30,48,-30,-30,-19,-26,-27,-11,51,23,-25,25,-2,-34,-80,47,-6,-5,-19,33,-32,5,-23,25,-22,60,-18,17,-25,51,-30,129,42,-86,28,12,-4,-31,54,-20,-1,35,-49,2,24,21,25,27,-21,6,18,40,0,47,5,25,10,23,-6,-19,66,-30,60,27,40,-49,32,-18,2,7,-24,0,-56,3,21,84,88,20,-16,5,0,-69,36,-50,2,9,38,31,-69,52,57,-8,7,-47,67,-7,28,-2,12,6,1,-10,-76,-5,-26,-43,77,8,-49,-32,11,79,15,-28,-10,0,-14,-9,-25,-36,-8,-12,51,-5,29,38,-32,-4,17,69,38,41,-25,4,19,1,-69,24,42,-5,3,-27,-36,38,-22,50,-48,13,-40,-1,-29,36,-59,26,10,-13,-11,29,21,-75,-36,-45,45,-26,-42,-36,-15,60,3,-11,-8,-58,-22,-21,17,-31,66,-10,24,-12,-10,34,-44,-20,11,-4,8,1,-37,-52,41,-31,3,-8,20,22,28,-59,3,-27,16,3,-54,104,25,-7,38,1,14,20,-2,-34,35,31,-53,-54,-13,45,-15,12,46,9,14,9,44,16,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.39","t":"At the time of his intake evaluation, Michael’s diagnosis was major depressive disorder, single episode, severe. The assessor noted that he endorsed persistent suicide ideation with a desire to kill himself, although he denied having a specific plan to do so. He was not assigned a diagnosis on Axis II. The following dialogue illustrates the manner in which Michael’s therapist identified his core beliefs, intermediate beliefs, and compensatory strategies that operated before his time in service and since his return.","e":[57,-19,-157,-33,14,36,16,29,26,-27,-25,18,78,8,13,-28,-15,-45,-26,43,-73,-43,-50,-9,75,84,-5,9,-48,34,70,-5,-6,-7,-47,-56,15,96,38,-9,-17,-25,0,-101,-6,21,6,33,6,-62,50,-41,48,-38,83,13,-30,28,30,-90,65,33,-7,9,65,-38,-75,45,-37,-46,95,-34,33,27,-17,38,-1,-12,18,15,38,-19,68,-11,27,50,14,35,4,56,-6,29,-2,58,-79,16,-21,34,-40,-12,-40,-14,-27,-14,64,73,17,-22,17,13,-44,34,-49,-28,54,-12,67,-78,15,44,-39,-11,-10,87,2,19,9,0,11,-18,-24,-55,-23,23,-26,45,10,-34,-64,-17,73,20,-11,3,-5,-21,52,-12,-33,-3,6,58,5,5,16,-54,-44,10,26,10,19,-5,-25,41,7,-68,23,82,33,-2,-32,-74,30,-12,89,8,41,-11,16,-20,29,13,31,23,-2,-26,44,-14,-54,-31,8,53,-35,-17,-41,-25,43,-35,14,-27,-7,20,-36,30,-82,37,-4,-14,12,-12,50,-61,-6,-3,-27,5,-24,-19,-30,28,29,-13,3,8,16,29,-60,-12,5,-31,-6,-80,98,19,-3,4,-25,23,14,44,-39,47,21,2,-52,15,11,-1,24,13,-38,1,-22,28,49,7]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.39","t":"Therapist: Let me summarize what you’ve just told me to make sure I understand what you have experienced. You were in your senior year at the university, applying to law schools, and working part-time in a law firm where you hoped to eventually be employed. Unexpectedly, you were sent to Iraq. You were told that you would be there for a year, but you ended up being there for almost a year and a half. Is this correct? CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 27","e":[17,-21,-180,-79,63,47,26,5,37,-24,-41,35,36,-45,24,-71,16,-36,-31,-8,-63,-34,-49,-33,28,44,-41,60,-68,17,52,-13,15,-33,-16,-57,21,52,12,-25,37,-38,16,-81,30,-48,93,29,11,-35,24,-57,-14,1,84,-42,-36,-12,-5,-34,137,2,-67,81,37,-23,-46,38,-24,-44,60,-8,28,48,-66,-10,-57,12,-30,14,62,-3,32,-52,34,17,-4,-5,2,75,-23,14,-10,68,-56,-14,-27,11,-20,-28,-33,-36,6,5,34,45,-16,-40,3,-47,-90,61,-15,-4,-1,31,41,-29,19,33,7,0,7,8,4,34,-24,23,23,-6,-6,-9,-6,54,-13,38,-1,-34,-30,27,74,-39,-12,8,-10,-8,2,-17,-57,3,4,62,-15,32,56,-58,-29,21,34,11,31,30,-11,40,11,-17,-52,53,29,4,-50,-61,19,-14,62,6,28,8,-2,-26,18,-58,33,18,-22,-20,28,-44,-53,-37,4,42,-37,14,-104,-19,74,-40,9,-2,5,42,-23,12,-42,68,-16,6,-28,-32,50,-49,19,15,-1,-18,14,18,-44,19,23,25,8,-7,27,27,-49,-9,4,11,8,-75,51,3,2,22,1,26,20,26,35,19,30,35,-95,32,9,-45,25,32,2,11,1,32,29,-44]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.40","t":"Michael: [dejected] Yeah. Therapist: Have you made plans to take classes and get your degree? Michael: I’m not going to finish. Therapist: What is behind the decision not to finish? Michael: [angry] Everything’s changed, that’s why! I can’t do it anymore. I tried to go back to the law firm when I came back to the States, and all that happened was that I made lots of mistakes and couldn’t keep up. When they first told me that I had mild brain injury after the explosion, I didn’t think it would really affect me. I used to be able to do anything I set my mind to. But now all of the abilities I had that were important to me are gone. I’m going to rot in the ‘hood, just like everyone I went to school with! Therapist: [gently] How had you hoped your life would have gone? Michael: I had dreams, man. All my life I was different, but I didn’t care because I knew I was going somewhere. I was gonna go to law school, maybe even go into politics someday. I was gonna get my mom out of the inner city so that she could actually have a house somewhere. With a real yard. You know, not having to worry about living paycheck to paycheck. Therapist: [gently] And that’s not possible now? Michael: [laughs sarcastically] Do you know any successful lawyers that are brain damaged? Everything I used to be able to do—focus no matter what else was going on, be organized, think on my feet—it was loud and clear to me when I went back to the law firm that those days are long gone. Therapist: So what I’m hearing is that, before, you were on an academic and career track that was very meaningful to you, which seemed to contribute to your view of yourself as a competent, successful person. Now that you’re seeing that the mild brain injury has affected some of your ability to perform on this track, you no longer view yourself as competent or successful. Michael. Yeah. That’s exactly it.","e":[60,10,-141,-12,12,80,29,43,63,-45,-59,0,39,23,5,-22,-4,-68,-66,22,-60,-54,-42,0,38,24,-41,24,-89,77,85,-13,-8,-34,-79,-26,44,77,32,-44,60,-31,-28,-102,49,-40,53,-26,11,-36,39,-54,10,6,70,-2,36,6,22,-60,79,10,-25,91,-10,-44,-72,22,-24,-62,38,0,5,50,-24,44,-10,3,-1,6,1,-19,35,-5,-14,5,20,20,-6,104,-6,46,-24,23,-61,-17,-13,1,-1,-43,-55,-50,0,-7,102,48,-8,-63,0,20,-41,24,-37,-13,-50,14,69,-64,-5,34,-34,-38,9,24,37,82,-31,16,18,22,-20,-32,2,65,22,82,41,-22,-8,-7,87,-21,-9,-11,-13,-17,33,-10,-31,11,9,34,16,45,50,-39,-11,0,55,4,10,-24,2,42,12,-24,1,67,14,3,-11,-71,30,-23,64,-4,0,-11,-43,-29,59,1,43,-13,28,28,-1,17,-23,-35,12,29,-70,-32,-39,-36,51,-5,2,-27,-8,24,-61,23,-23,42,7,-14,-48,-1,52,-42,-23,8,-15,2,-5,-19,-39,44,2,13,8,8,36,-5,-32,-5,-30,-12,-15,-70,65,41,28,26,5,26,21,80,-10,57,7,-41,-39,0,35,-11,16,41,65,25,28,23,25,1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.40","t":"Michael’s therapist noticed many examples of unhelpful or maladaptive thinking, such as his perceptions that he is no longer competent or successful and that his life was destined to be one in which he “rots in the ‘hood.” However, she noted these beliefs on his cognitive case conceptualization (see Exhibit 1.3) and decided to revisit these cognitions using cognitive strategies in the middle phase of treatment (see Part IV). Michael’s therapist also suspected that some of the cognitive deficits he reported could also be explained by depression, rather than his brain injury, and that he might see some improvement as his depressive symptoms improved. She was sure to communicate this to Michael in the initial phase of treatment in order to motivate him for treatment by explaining some potential benefits of CBT (see Part III).","e":[51,14,-139,-60,70,15,33,37,65,-16,-27,7,77,52,-11,-9,-22,-55,-7,47,-78,-12,-50,-25,21,57,-37,31,-32,31,92,-19,-39,-32,-79,-20,71,59,37,-22,22,-21,-5,-95,8,1,44,19,-2,-22,73,-55,64,-56,108,22,11,11,30,-68,105,34,-21,34,13,-23,-52,45,-63,-14,63,-17,9,28,-38,25,-23,6,-9,24,39,-24,46,-24,37,30,20,11,-23,71,-17,-1,-15,49,-79,29,-45,-30,-41,-15,-72,-22,18,-6,35,115,-7,-32,-14,17,-84,28,-26,-37,-1,25,55,-44,17,49,-8,23,-17,28,21,92,-25,-8,33,7,-27,-40,-5,13,4,74,36,-8,-33,28,65,-12,-1,0,-8,-39,23,-7,-47,-5,-31,34,27,15,47,-54,-56,3,36,20,41,7,-15,28,5,-46,37,49,19,10,-35,-61,1,-6,97,6,56,-10,-12,-25,28,9,16,27,24,-6,35,14,-73,-34,1,49,-60,-8,-75,-38,43,-20,23,-35,-8,8,-29,25,-88,55,-5,9,-13,-13,41,-23,16,7,-61,10,-17,-11,-34,14,12,-6,-25,0,27,29,-44,-21,-4,-6,-14,-76,80,28,23,25,-23,3,28,89,-7,60,8,-5,-54,-3,15,-49,14,51,-5,56,9,10,43,2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.41","t":"Exhibit 1.3. Cognitive Conceptualization Diagram for Michael RELEVANT CHILDHOOD DATA Reared by a single mother who worked two jobs and strongly promoted education Excelled in school; teachers often took him “under their wings” Berated by other Black children for being “too White” CORE BELIEF(S) Before service: I’m competent. After service: I’m incompetent; I am damaged beyond repair. Before service: I’m going places in life. After service: I’m going nowhere in life; life is unfair. CONDITIONAL ASSUMPTIONS/BELIEFS/RULES POSITIVE ASSUMPTION BEFORE SERVICE: With hard work and perseverance, I can achieve anything.","e":[18,-2,-183,-72,39,61,71,7,24,-4,-25,10,47,76,9,-16,-8,-50,-3,45,-65,-13,-19,-22,50,39,-37,-11,-66,-1,45,-31,10,-47,-59,-46,36,31,57,-72,36,9,8,-91,19,1,55,-16,48,-36,17,-24,51,7,112,20,34,6,-29,-19,89,55,-52,87,17,-8,-37,80,-59,-37,20,-44,-19,41,-34,28,-17,30,1,24,49,31,74,6,38,28,33,-7,-61,84,-12,21,-7,12,-52,0,-42,9,6,-10,-24,-79,-30,-57,34,72,1,-12,-6,-13,-62,23,-32,14,-34,-26,56,-59,23,1,2,-16,32,67,-14,63,-41,2,6,-12,11,-21,-34,17,-34,53,2,-22,-24,45,56,30,-9,2,0,-42,12,-55,-3,22,-22,55,-3,27,8,-26,-13,10,19,-13,59,-9,-40,51,19,-48,6,43,-5,27,-5,-54,16,-37,54,-32,40,-25,-16,-15,1,-2,44,49,-15,-43,31,28,-64,-36,-10,29,-46,-14,-58,-64,36,9,28,-71,1,-15,-35,55,-29,60,-7,21,-20,12,66,10,-1,11,10,8,4,-25,-33,17,-37,-16,28,5,18,14,-27,-27,-33,22,-20,-91,64,24,10,16,-14,22,28,34,2,55,45,-11,-47,10,29,-32,-5,67,12,15,-10,-3,22,-24]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.41","t":"NEGATIVE ASSUMPTION AFTER SERVICE: All the hard work in the world won’t get me anywhere. COMPENSATORY STRATEGIES (AFTER SERVICE) Putting in little effort Making excuses SITUATION #1 SITUATION #2 SITUATION #3 Argument with girlfriend Difficulty performing Received results from adequately at former job neuropsychological testing AUTOMATIC THOUGHT AUTOMATIC THOUGHT AUTOMATIC THOUGHT She’s putting too much pressure on me. I might as well quit. I’m dumb now. MEANING OF A.T. MEANING OF A.T. MEANING OF A.T. She thinks I’m someone I don’t have the ability to My life will not be what I who I no longer am. do worthwhile work. hoped it would be. EMOTION EMOTION EMOTION Depression Depression Despair","e":[37,-24,-185,-49,54,75,47,-29,12,16,-69,31,70,27,52,-24,22,-22,-45,37,2,-55,-22,-33,41,42,-33,15,-35,-18,-5,-45,3,-34,-77,-35,39,56,14,-12,36,-24,11,-46,0,-19,42,58,33,-28,54,-55,-9,-2,109,-8,45,9,-30,-39,66,20,-55,56,71,-66,-27,42,-15,-40,44,-1,-6,38,-47,-19,-40,20,5,44,36,-32,89,7,64,17,32,6,-14,111,-5,49,21,13,-102,28,-35,12,-30,-49,-37,-6,-4,-46,53,76,-52,8,2,11,-31,58,-19,-23,-19,-17,52,-54,5,6,39,26,-33,51,-11,47,-65,24,19,-1,18,-27,-12,26,-4,38,-49,-64,-16,50,68,-14,11,3,-21,-56,8,-67,-37,-1,10,40,-7,3,50,-15,-28,33,1,-18,61,-14,-64,54,-28,16,0,43,12,65,-37,-49,-1,-29,43,23,59,-27,-36,-14,28,-29,40,9,-10,-75,17,-11,-46,-26,39,46,-24,9,-98,-39,28,-3,19,-24,22,11,-31,40,-20,50,-5,12,-25,-32,40,-9,-5,6,8,-20,22,-14,-59,1,-2,-36,-16,5,2,16,-18,22,-34,-12,-16,-83,55,-6,31,17,-4,27,-2,43,-29,20,17,4,-79,36,3,-3,23,32,-11,27,-32,-24,59,-30]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.42","t":"After reviewing Michael’s case conceptualization, his therapist realized an unspoken belief that likely drove his current perceptions of incompetence and his life not going anywhere—that a life worth living is one characterized by high achievement, such as having a high-status job with a high salary. If Michael no longer had the opportunity to attain this level of achievement (which was a hypothesis in and of itself that still needed to be tested), then he would have to radically redefine the components of a meaningful life. Michael’s therapist speculated that his suicide ideation was related to his perception that he no longer has reasons for living.","e":[59,29,-161,-16,44,74,13,47,51,10,-80,-5,79,48,-29,-4,1,-70,-14,41,-68,-45,-60,6,30,32,-12,-18,-50,36,40,-24,-19,-16,-72,-19,56,107,77,-57,-29,-34,-4,-79,28,8,40,14,31,-34,48,-61,27,24,102,36,27,24,-1,-86,81,66,-19,41,47,-11,-26,42,-43,-35,41,-28,-34,36,-34,85,-9,29,14,34,52,-22,72,1,20,26,41,-11,-24,79,-9,41,20,28,-98,7,-20,30,-13,9,-60,-53,-5,-15,54,85,0,-19,-13,42,-41,25,-52,-44,14,3,89,-72,0,48,-13,21,17,46,-12,61,2,5,-12,-15,18,-41,-19,46,4,58,29,-27,-37,10,80,4,-7,22,-17,-49,20,-14,-56,10,1,49,4,19,-11,-44,-54,5,55,-14,17,3,-27,43,7,-40,4,22,-13,4,-14,-65,40,-13,79,-40,33,3,-31,-41,19,-30,42,9,6,-18,36,-11,-58,-36,3,47,-26,-14,-26,-55,65,-16,8,-37,-7,14,-37,29,-64,64,-19,-4,-34,-7,35,-41,-40,15,-18,17,-32,8,-27,16,3,-5,7,11,24,20,-88,-23,-5,17,4,-65,76,11,-20,25,-24,17,27,74,-25,23,-16,-17,-38,19,27,-41,-13,40,1,16,19,7,28,3]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.42","t":"CASE EXAMPLE: CLAIRE Claire, like Michael, was faced with major life adjustments after she returned to the U.S. following her injury. She was unsure whether she would be medically cleared to resume her position as a pilot. The possibility of not flying was exceptionally threatening for Claire, as she had dreamed of becoming a pilot since she was a child and had directed her entire academic and professional career toward achieving this goal. Because Claire was so focused on professional success, she had done little to develop other aspects of her life, such as close relationships and interests outside of work. Thus, she had very little to do while she was awaiting the results of her medical review, and she spent most of her time ruminating over “what if’s” and frequently checking on the status of her medical board.","e":[59,-2,-168,4,9,76,-16,-16,55,-34,-49,-16,97,69,7,-34,-25,-67,-17,-36,-44,-41,-72,36,34,30,-4,3,-104,22,34,8,-11,-91,-39,-15,-20,75,31,-15,32,-29,-14,-73,19,1,70,2,10,-44,36,-14,-5,12,96,29,50,38,34,-48,85,2,-30,59,11,-62,-45,38,2,-29,49,-25,-23,56,-57,45,-24,12,-7,2,54,-40,37,-3,24,40,29,-14,-37,60,24,58,17,8,-41,5,5,16,-49,-21,-19,-53,12,32,28,37,-7,-2,19,-11,-43,28,-46,-3,15,-2,57,-60,-8,37,-23,2,-8,36,22,67,-68,-1,38,9,-3,-33,-9,62,5,33,11,-24,2,11,81,-33,-13,-20,-4,-43,46,3,-34,7,-17,29,27,36,25,-16,-36,41,23,-10,75,13,-18,49,-40,-21,-6,40,19,49,-38,-74,33,-27,97,-25,68,-18,-31,-34,24,-57,8,12,-2,-27,39,21,-73,-77,-29,24,-73,-36,-85,-55,46,0,-5,-33,-16,12,-9,56,-60,37,28,-37,-24,-3,32,-15,-21,42,-19,-6,-22,-24,-23,27,14,-41,-17,-20,20,18,-18,-14,-24,-23,-7,-69,74,12,-13,2,-39,47,16,25,-33,49,13,-38,-24,2,4,7,-11,67,-3,22,44,34,7,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.42","t":"Claire’s anxiety spanned across a number of anxiety disorder diagnoses—she worried excessively about professional success; she compulsively checked the status of her medical board; she demonstrated perfectionistic behavior; she worried about whether others judged her as a success; and she had occasional intrusive memories and nightmares of the plane crash. At the intake interview, Claire was given a diagnosis of anxiety disorder not otherwise specified. A diagnosis on Axis II was deferred.","e":[93,-9,-167,6,31,37,-7,9,18,-21,-59,23,104,40,37,-21,-20,-14,-34,-21,-50,-29,-58,9,33,85,-31,-20,-59,39,69,-9,-24,-86,-21,-49,-24,69,36,46,62,2,0,-84,-39,29,55,20,26,-31,17,-46,7,-12,102,53,4,74,49,-58,72,-4,-13,28,43,-47,-58,53,-1,-22,78,-26,40,48,-50,17,7,-8,14,9,59,-34,23,-11,31,82,15,24,-14,62,36,22,13,50,-40,41,15,14,-102,-22,-56,-16,-15,5,31,-8,-8,-18,4,-8,-36,51,-17,-16,38,-22,58,-44,27,5,-17,-16,2,44,20,29,-23,-4,24,-8,-29,-27,-11,40,-21,45,-16,2,-23,4,27,25,-16,-51,-4,-22,50,7,-44,-41,-3,21,-5,18,11,-6,-40,44,33,41,65,9,-2,53,-43,-52,22,62,22,50,-26,-34,12,-15,74,-4,58,-29,26,-52,32,-23,25,13,-8,-32,41,-13,-53,-77,2,17,-46,-14,-53,-37,34,-29,7,-32,-13,26,-6,28,-53,55,11,-71,-7,-22,48,-41,-11,34,12,-33,-11,-56,-10,29,3,-24,0,-17,-3,21,-15,-21,17,-47,-5,-91,63,8,14,21,-49,36,-14,27,-41,49,24,-12,-43,5,-36,5,-20,32,-23,-20,30,28,37,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.42","t":"Claire revealed information about her background that was relevant to understanding her anxiety problems during the portion of the intake interview that focused on her psychosocial history. Claire’s parents are successful and well-to-do—her father is a well- respected ophthalmologist who owns his own practice, and her mother is a partner at a prominent law firm. They had pushed Claire and her brother to succeed throughout their childhood. Claire did not disappoint her parents, as she graduated in the top 2% of her class from a private high school and attended a prestigious university on an Air Force ROTC scholarship to prepare her to become a pilot. Despite these achievements, Claire often worried that she would under-perform on her examinations and that she would somehow achieve less than was expected of her. As a result, she studied excessively for examinations and participated in extracurricular activities not because she enjoyed them, but because she thought they would help her reach her academic and professional goals.","e":[36,6,-167,7,36,61,-9,-25,44,0,-67,14,97,64,3,-1,-22,-21,5,-39,-77,-32,-34,20,64,21,-48,-48,-92,57,62,-13,-37,-91,-22,-4,-23,82,25,13,57,5,-12,-90,-28,-13,64,-3,41,-33,-1,-20,-17,22,79,39,1,49,54,-44,111,34,-47,62,21,4,-17,45,20,21,39,-44,23,22,-53,-2,-3,-17,-25,3,74,-42,17,3,25,40,38,1,-11,85,40,78,22,42,-32,56,14,2,-42,-43,-47,-48,14,24,47,37,27,-15,-23,-3,-57,48,-58,-33,-8,-22,30,-49,28,23,-29,18,-4,32,21,48,-35,-8,42,27,-4,-40,-25,3,2,55,-32,15,12,7,41,41,-13,-44,7,-51,25,13,-48,-55,-10,29,-7,18,-4,-20,-28,-2,46,61,94,25,-10,42,-50,-50,-23,45,16,52,3,-27,6,-42,74,-53,50,-20,7,-39,37,-74,23,7,-5,-16,16,9,-87,-67,-9,5,-42,-27,-82,-58,29,-49,11,-16,-23,4,11,34,-35,67,14,-52,-17,-12,28,-51,-21,44,10,-35,0,-56,-38,53,-3,-1,12,-8,-10,16,5,-11,5,-6,3,-66,71,13,15,24,-35,62,-5,43,-35,14,24,-27,-25,5,4,8,-28,32,30,11,34,30,-13,-52]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.42","t":"The following dialogue is a discussion between Claire and her therapist at Claire’s first visit. At this point in the conversation, Claire had been expressing frustration and agitation about the length of time it was taking to receive the results of her medical board. Therapist: I’m sorry to hear that this process has taken so much time. What have you been doing with yourself in the meantime? CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 30","e":[57,6,-169,-74,69,26,39,-36,28,-14,-58,35,35,25,23,-61,0,-70,-45,5,-55,-33,-82,-19,30,48,-32,60,-66,29,46,-16,6,-39,-33,-48,20,49,14,8,69,9,17,-106,0,-29,86,12,-23,-66,21,-42,-14,-9,89,0,-3,36,11,-63,121,24,-51,84,70,-46,-37,28,-26,-16,44,-16,41,52,-49,0,-34,-21,-32,-2,34,-23,58,-62,40,29,10,31,-10,76,-2,14,-14,33,-89,-6,-8,5,-47,-41,-62,-22,1,-22,29,55,-7,-28,-18,-26,-82,21,-15,-14,-5,-5,36,-44,1,19,-8,1,-5,25,0,54,-55,11,35,36,-22,-1,-2,19,-14,26,-4,-19,-12,22,50,-36,-21,-5,-5,-34,39,-5,-31,-19,20,27,13,14,48,-35,-28,37,20,15,43,22,-58,38,0,-24,-9,38,43,15,-51,-69,-19,-16,86,10,41,-28,-23,-43,20,-50,24,26,-2,-4,2,-59,-32,-78,-29,38,-53,-20,-57,-28,49,-20,24,-39,-17,42,-12,42,-50,56,-22,-28,-44,-29,49,-27,-10,36,-32,-23,-14,0,-18,31,30,-21,1,-11,11,5,-21,-14,-17,-8,-19,-82,37,8,2,25,-41,37,-4,52,13,43,47,43,-66,17,10,5,6,45,3,3,17,28,33,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.43","t":"Claire: Just getting ready to get back in the air. You know, reading up on the next stage of training. Also doing a bit of searching on the Internet about accomplishments of other people who have had leg injuries. Therapist: Claire, do you have a plan in place for what you will do in the event that the conclusion of your medical review is that you can no longer fly? Claire: [looks stunned] That’s not going to happen. It can’t! It just can’t. [slows down and speaks more softly] Not flying, that’s really just not an option for me. Therapist: [gently] Why not? Claire: Because I’ve been preparing my entire life to be a pilot. That’s what I’ve been telling everybody ever since I was a little girl. [becomes tearful] Everything I’ve worked for, it would all just go down the drain. And everyone else would think I’m a failure. Therapist: Would you think you’re a failure? Claire: Oh yes, without a doubt. Therapist: Even if you could no longer fly due to circumstances beyond your control? Even if you take into consideration all of the accomplishments you’ve had at such a young age? Claire: It doesn’t matter. I didn’t do what I said I was going to do. I came up short. Therapist: It sounds like you get a lot of your self-esteem from flying. [Claire nods] What else contributes to your self-esteem? Claire: Nothing. Just flying. Therapist: [making another attempt to identify other areas in which Claire has the potential to view herself as successful] Well, tell me about some other aspects of your life, like your friends or your interests outside of work. Claire: I don’t really have a life outside of work. Ever since I graduated from college, it’s just been work and preparing to get to the next level in my career. I was hoping to do more than any other woman ever had in the Air Force. Therapist: It sounds like your work and the accomplishments and promotions you get through your work are what you value most. Claire: Yeah. I’ve always viewed other things—hanging around doing nothing with other people, meaningless hobbies—as a waste of time.","e":[44,19,-168,-22,19,74,-3,-20,38,-54,-65,-9,52,46,55,-5,-13,-99,-37,-37,-49,-80,-47,15,30,12,-68,13,-127,19,64,-25,-8,-68,-21,-3,-8,90,6,-11,22,-32,0,-77,9,-55,118,-14,2,-11,11,-47,-35,38,71,-19,37,7,24,-69,85,8,-44,97,12,-35,-81,15,-21,-47,54,-26,23,59,-81,52,-41,-10,21,-7,25,-4,29,-27,37,43,34,9,-33,93,36,46,12,5,-34,-21,19,-8,-41,-77,-32,-9,-22,10,40,16,25,-28,5,-22,-34,43,-41,-17,-26,-8,51,-85,-18,9,-15,-10,29,8,39,69,-60,3,10,17,-19,-9,-23,61,8,47,6,-43,2,1,56,-14,-15,-34,9,-44,35,26,-34,-2,-13,37,4,9,55,-33,-5,5,39,23,66,6,-8,33,-7,-5,-22,48,39,44,-28,-40,28,-28,79,-35,24,-9,-75,-55,61,-29,21,10,5,10,15,21,-59,-71,-12,30,-51,-20,-73,-34,61,-53,-10,-11,7,11,-39,26,-19,32,2,-39,-31,-3,69,-28,-11,46,-3,-39,1,-35,-47,45,29,-28,4,-11,-13,16,-27,-17,-5,-26,-2,-78,35,-3,3,6,-32,61,17,69,0,40,20,-14,-55,31,4,-14,-8,40,41,38,23,27,-1,2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.43","t":"Through this conversation, Claire’s therapist hypothesized that Claire’s core beliefs center on themes of success vs. failure (see Exhibit 1.4). It appeared that Claire had a rigid definition of failure, such that anything less than a 100% match between her expectations and actual accomplishments was defined as a failure, as well as a rigid definition of success, such that only pre-determined professional accomplishments could contribute to her perception of success. As a result, she spent most of her time engaged in work activities and over-preparing for various duties at work at the expense of other activities that had the potential to enhance her emotional well-being, such as developing close relationships with others. At the time she met with her therapist, Claire’s primary symptom was anxiety because she was coping with the ambiguity of whether or not the results of her medical board would support her reinstatement as a pilot. However, Claire’s therapist predicted that Claire would also exhibit symptoms of depression in the event that she was told that she could no longer","e":[74,3,-171,-41,34,29,16,-18,22,-8,-70,-6,93,71,12,7,0,-45,-15,16,-72,-40,-67,8,25,71,-38,-15,-69,19,28,-14,-10,-81,-46,-26,-25,92,60,-3,3,14,10,-79,-27,-28,45,6,22,-19,17,-59,-3,-7,112,62,-1,53,46,-65,79,36,-26,59,31,-34,-42,31,-16,-35,52,-47,23,35,-33,28,-3,-18,14,-14,43,-64,42,4,64,63,12,23,-29,81,25,35,1,28,-80,-7,0,-19,-46,-5,-55,-43,-5,-7,31,23,2,5,6,8,-49,73,-38,-46,28,-21,66,-47,22,21,1,-10,2,62,12,33,-33,-14,23,27,-16,-19,-50,37,4,45,7,-3,-25,25,28,-12,-19,-22,-23,-73,47,30,-36,-8,-8,39,-20,18,0,-13,-43,18,19,3,69,31,-15,24,-31,-55,-21,38,21,70,-32,-36,-10,16,94,-1,75,16,-21,-57,36,-36,26,19,7,4,48,-13,-70,-82,-21,36,-37,3,-61,-45,22,-37,14,-50,-26,32,8,46,-64,57,-8,-56,-16,0,37,-36,-30,40,0,-22,-20,-19,-14,40,-1,-8,-11,-12,-1,17,-21,-29,10,-35,3,-77,63,19,26,35,-57,28,-10,52,-21,6,-2,-9,-63,27,-10,-7,-28,42,9,19,31,26,35,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.45","t":"Exhibit 1.4. Cognitive Conceptualization Diagram for Claire RELEVANT CHILDHOOD DATA Successful parents who pushed her to achieve Had many academic and professional successes at a young age Little experience with failure and life not going as planned CORE BELIEF(S) Failure (anything less than 100% success) is unacceptable. Success is defined by my professional achievements. CONDITIONAL ASSUMPTIONS/BELIEFS/RULES POSITIVE ASSUMPTION(S): I am successful as long as I am excelling professionally. NEGATIVE ASSUMPTION(S): I am a failure if I am not excelling professionally. COMPENSATORY STRATEGIES","e":[46,17,-154,-31,25,45,48,-16,4,0,-45,-13,89,74,15,13,-11,-42,18,44,-77,-22,-58,9,64,57,-42,-42,-78,1,1,-3,7,-77,-73,-31,12,39,66,-67,27,36,41,-80,1,-6,56,-3,62,-28,-4,-65,40,-5,93,43,13,28,-8,-60,83,49,-23,65,48,-13,-38,55,-19,-32,24,-36,18,16,-43,9,-33,-30,-6,45,41,-54,81,8,55,30,41,-1,-53,79,6,40,11,29,-69,26,-21,2,-23,17,-25,-53,-14,-38,23,68,6,-7,-13,-9,-60,36,-39,-42,-6,-27,55,-40,26,22,14,-15,36,49,-17,32,-60,-22,29,3,0,-2,-39,33,-4,71,9,3,-10,45,33,30,3,-4,-14,-81,39,-7,-26,19,-15,40,0,9,-1,-20,-14,17,22,-23,80,22,-65,30,-25,-25,5,39,26,73,-7,-33,-8,-27,72,-45,41,6,-14,-34,0,-19,25,33,2,-17,53,19,-57,-29,20,4,-42,-2,-68,-86,16,0,42,-42,20,30,0,37,-46,44,-13,-4,-18,22,51,-21,-28,42,-10,-30,-4,-5,-31,8,-20,-2,6,5,12,24,-37,6,-10,14,-11,-93,44,19,40,40,-31,22,18,46,-23,30,0,6,-70,15,-21,-27,-24,72,30,30,22,5,25,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.45","t":"Over-preparing for professional responsibilities Spending free time on professional responsibilities at the expense of close relationships Responding aggressively in circumstances that threaten professional success SITUATION #1 SITUATION #2 SITUATION #3 Waiting for results of A man held the door open Received news that medical board for her at the hospital. former classmate won an award AUTOMATIC THOUGHT AUTOMATIC THOUGHT AUTOMATIC THOUGHT I’m not going to be He thinks I can’t do this Everyone else is achieving reinstated. on my own. professional success but me.","e":[24,38,-163,1,18,34,44,-45,45,2,-36,11,34,54,74,-18,44,-68,-39,-12,-39,-65,-34,6,31,47,1,-60,-61,-16,-21,11,25,-45,-55,-62,60,11,26,-22,26,-2,44,-91,28,-12,38,52,62,-8,42,-72,-17,2,87,7,46,32,-6,-64,79,20,-42,63,53,-31,2,39,-5,-29,23,-11,18,21,-27,-8,-44,21,41,52,45,-1,74,-10,35,19,9,-15,-49,67,10,-2,-1,17,-108,38,-16,-3,-47,-36,-39,-51,3,-15,35,39,6,1,-2,29,0,90,-30,-32,-1,-6,59,-21,26,53,23,-24,-22,71,-30,101,-49,12,44,10,19,-28,-10,33,-18,87,-30,-17,7,9,56,14,11,-25,-20,-52,27,-33,-56,19,11,15,-39,38,32,24,-28,39,50,0,32,-8,-92,-1,-50,-14,38,49,-3,61,-29,-83,46,-24,60,1,72,-48,-13,-51,37,-49,44,1,3,-22,23,16,-34,-10,34,35,0,-52,-91,-26,19,17,3,-44,21,6,-48,33,-23,71,-4,6,-2,-18,55,9,-53,-4,14,-32,6,-10,-49,31,1,-39,-16,-31,-7,-1,-27,7,-34,29,2,-92,46,33,19,-9,-15,75,1,48,-5,19,-12,-5,-62,24,7,-21,-33,29,1,38,9,-6,25,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.46","t":"The case conceptualization provides a means for applying cognitive behavioral theory to understanding patients’ clinical presentations. It helps therapists to identify the particular “lens” through which their patients view the world. In addition, the case conceptualization forms the basis of treatment and can serve as a guide to help therapists select particular interventions.","e":[54,42,-97,-62,67,23,46,22,12,-31,10,-30,83,53,-31,-68,-46,-44,-6,41,-58,18,-27,-23,6,44,-3,33,-34,27,12,16,19,-36,-57,-76,62,11,-34,-26,18,28,37,-70,10,-7,34,-17,2,24,35,-38,66,-16,120,35,10,78,-13,-48,95,92,-37,76,28,-51,-48,44,-3,-62,32,-6,30,12,-49,24,-27,7,0,37,89,-62,49,-66,61,34,-7,-15,-21,58,5,34,6,11,-61,15,-36,13,-29,-20,-72,2,7,1,0,67,-37,-13,5,45,-78,28,-55,2,10,-16,54,-49,30,14,17,0,32,4,28,44,-56,-49,18,-54,2,-29,-30,-14,-12,53,25,-46,-7,49,59,11,1,10,-4,-11,11,-51,-16,18,-13,48,34,-14,65,-34,-18,15,31,3,47,4,-34,48,-44,-50,31,18,-17,-9,-13,-39,21,34,71,33,48,-47,-13,-16,-19,-23,2,24,34,-34,61,4,-22,-16,17,15,-46,3,-82,-56,10,14,31,-69,-11,12,-40,31,-40,48,-16,-5,-56,12,26,-48,22,16,-42,27,-25,-25,-52,0,9,16,13,38,-3,35,-49,31,3,32,-53,-63,37,10,30,23,-51,11,46,52,9,51,20,-1,-42,13,-16,-18,-25,60,2,48,20,-32,71,14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.46","t":"CASE EXAMPLES: JACK AND CLAIRE Jack views the world as one in which others will hurt him if they get the chance. A useful focus of treatment with him would be to develop (a) cognitive strategies to consider alternative explanations for people’s behavior toward him and (b) behavioral skills for interacting with others more effectively than he does now. Claire, on the other hand, views the world in terms of rigid conceptualizations of success vs. failure. A focus of treatment with her would be to develop (a) cognitive strategies to redefine her view of success and failure and to see the “shades of gray” in between, and (b) behavioral skills to expand the repertoire of meaningful activities in which she engages.","e":[44,-4,-152,-35,40,45,-3,-49,47,19,-10,-15,79,78,3,-26,-14,-34,-14,20,-82,-12,-49,5,16,31,-49,10,-82,25,4,-1,-69,-62,-31,-13,49,36,4,-19,-13,33,9,-96,41,-49,78,-1,46,-25,33,-40,20,-27,147,57,7,41,13,-59,86,50,-40,34,36,-30,-44,46,-42,-20,39,-20,28,10,-28,32,7,-13,13,36,30,-70,53,-55,40,31,34,28,-46,57,43,46,24,46,-71,12,-29,-27,1,33,-61,-36,30,-8,16,48,1,47,-12,-11,-57,26,-38,-3,-8,-22,47,-36,26,28,-9,1,-1,34,20,50,-91,-25,37,-10,-20,-17,-15,28,2,79,20,-22,-1,31,54,-11,-18,14,-17,-53,-6,-12,-43,0,-3,49,38,46,21,-32,-55,14,21,10,55,-6,-20,38,-19,-34,37,34,21,57,-33,-52,-17,11,96,-1,76,-30,-22,-17,22,-50,13,48,5,-13,44,9,-52,-82,-13,25,-46,-8,-63,-64,23,-20,-1,-47,-37,-2,-11,59,-67,51,17,14,-26,-22,39,-27,-13,27,-29,-3,-35,-13,-65,26,-4,21,-11,-27,18,11,-28,-10,-11,7,-43,-90,47,13,2,16,-10,41,13,43,-28,62,-11,-12,-28,20,4,-23,-11,66,6,30,19,-17,23,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.46","t":"As illustrated in Figure 1.9, we view the timeline of CBT as having three distinct phases: (a) the initial phase, (b) the middle phase, and (c) the later phase. During the initial phase of treatment, the therapist focuses on clinical assessment, motivational enhancement, and socialization to the CBT approach. Following the initial phase of treatment, the case conceptualization is developed and specific treatment goals are established. On the basis of the case conceptualization, specific cognitive and behavioral strategies are selected and implemented during the middle phase of treatment. During the later phase of treatment, therapists focus on relapse prevention and work collaboratively with their patients to develop a plan for termination.","e":[34,0,-143,-27,51,-16,50,-10,33,-10,-36,11,65,13,-6,-79,-5,-52,-16,34,-64,-17,-45,-43,-13,58,-31,23,-36,10,65,10,16,-37,-43,-72,50,11,-45,-40,51,5,20,-92,-5,-38,58,22,-18,7,44,18,1,-52,93,40,-17,32,3,-54,115,75,-57,85,45,-43,-34,36,-64,-43,30,-10,31,24,-31,9,-38,-26,7,30,46,-21,53,-42,27,24,-5,7,-54,61,-11,15,2,35,-106,-3,-29,2,-6,-27,-78,-35,37,-27,14,42,-5,-28,-1,0,-93,12,-26,14,-16,32,61,-41,22,39,8,-23,6,23,-4,79,-73,-37,34,-5,-3,-4,-12,6,-1,70,22,-6,-14,22,34,-33,-3,19,9,-6,18,-30,-19,3,0,24,25,27,44,-48,-20,-9,45,31,23,-26,-22,49,-25,-37,27,-2,40,12,-16,-50,-45,23,93,44,61,-7,12,-14,23,-5,-11,59,28,-25,24,-18,-40,-45,40,42,-59,-8,-84,-23,38,-24,0,-51,0,13,-65,50,-69,79,-10,29,-50,1,54,-6,-7,20,-75,14,-19,-11,-30,34,22,17,-6,-39,4,34,-47,-7,0,3,-30,-70,28,3,15,22,-7,-6,11,72,-11,41,63,19,-70,22,22,-35,10,50,9,26,21,9,46,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.47","t":"The manner in which the case conceptualization influences particular intervention strategies is illustrated at length in Parts III through V of this manual. We also note that the selection and implementation of specific CBT strategies derived from the case conceptualization are specifically tailored to the Veteran in light of his or her cognitive, physical, and/or social limitations. Before discussing these strategies, we first describe the basic CBT session structure, which applies to all phases of treatment, in the next part. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 35","e":[36,4,-147,-60,70,38,35,-27,19,-32,-9,-30,43,6,-6,-69,-26,-49,-11,23,-48,-17,-48,-33,36,50,-20,37,-34,21,39,3,26,-23,-41,-54,46,31,-21,-22,27,0,24,-80,-6,-20,84,11,-11,-10,62,-49,23,-65,104,-21,-14,36,-2,-59,123,59,-77,64,13,-42,-60,56,-31,-47,46,-5,23,16,-65,16,-47,-2,-19,27,56,-30,62,-76,50,9,-1,-3,-24,54,-12,27,14,47,-94,8,-25,9,-3,-33,-47,-31,11,-17,9,65,-4,-16,-1,0,-90,9,-33,17,-18,-3,52,-37,5,43,4,-9,29,5,14,45,-74,-20,37,-48,1,-17,-11,-16,5,12,-10,-41,-8,16,51,0,-12,22,-8,-16,0,-27,-49,-7,4,44,23,25,57,-50,-32,38,24,24,36,9,-50,43,0,-27,-2,29,22,12,-33,-77,-37,18,106,26,63,-36,-6,-13,-7,-30,7,32,1,-27,33,-18,-55,-41,21,58,-35,-35,-94,-52,63,-2,24,-41,11,42,-25,31,-49,53,-14,22,-22,-21,48,-30,18,29,-41,19,-5,-5,-49,-4,18,25,-27,9,-4,12,-40,3,20,5,-32,-73,33,-24,-1,23,-30,5,20,51,32,37,52,21,-66,32,-10,-37,1,51,-6,22,2,-23,48,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.51","t":"CBT follows a session structure in order to make efficient use of time, ensure that • CBT session goals are achieved in each session, and maintain a thread across sessions so that structure progress is made toward longer-term goals. The components of CBT session structure include (a) a brief mood check, (b) a bridge from the previous session, (c) the setting of an agenda, (d) a review of the previous session’s homework assignment, (e) a discussion of agenda items, (f) periodic summaries, (g) a homework □ Mood Check assignment, and (h) a final summary and feedback. Our experience is that □ Bridge from Previous Session this structure models for patients an adaptive problem-solving approach and □ Agenda Setting communicates hope that their problems can be addressed in a systematic □ Review of Previous Session manner. Of course, sound clinical judgment might point to an alternative Homework course of action during a session that should be pursued in specific □ Discussion of Agenda Items situations, such as in response to crises or when patients report or display □ Periodic Summaries behaviors that suggest a specific action should be taken to assess or address □ Homework Assignment potential suicide risk. Throughout this section, examples are provided in which the session structure proceeds as described and in which the therapist □ Final Summary & Feedback encounters obstacles in implementing the session structure.","e":[35,-16,-152,-75,36,-42,63,-19,44,-33,1,-13,56,15,4,-79,-21,-41,-36,8,-33,-11,-19,-7,-9,89,-44,36,-11,-12,56,-22,27,-30,-73,-48,72,33,-47,-29,51,-1,-21,-100,34,-49,112,-6,-12,-15,13,-30,-15,-41,125,42,10,43,44,-56,99,40,-40,68,32,-26,-50,58,-36,4,39,16,42,28,-41,0,-44,8,-13,35,39,-2,65,-42,44,8,-7,32,-35,67,-9,-38,41,28,-89,14,-17,11,-25,-22,-76,-22,17,-23,-5,44,-27,-18,-14,-8,-73,27,-44,21,1,10,78,-26,21,39,-3,-41,-2,37,9,61,-43,-8,50,-6,3,-9,-14,26,27,41,-11,-30,5,1,24,-1,-4,23,19,-25,45,-51,-34,14,23,-7,8,38,45,-38,-9,-12,50,45,46,-12,-84,21,-43,-48,16,52,24,30,-41,-65,-14,8,62,31,67,-19,26,-39,34,9,25,39,-1,-8,15,-66,-4,-29,41,35,-34,-18,-67,-49,26,-27,-1,-29,10,34,-51,35,-42,72,-31,14,-25,-50,83,27,-22,7,-58,14,-3,-15,-41,24,20,-26,13,-55,-12,31,-19,-20,0,34,-62,-54,-2,-17,40,40,-5,23,1,54,19,33,54,1,-69,13,6,-37,-8,55,-1,-20,3,14,28,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.51","t":"We strongly encourage cognitive behavioral therapists to be cognizant of the therapeutic relationship as they structure the session. We remind you that CBT is fundamentally a collaborative enterprise between the therapist and patient. Patients are active participants in all aspects of therapy and contribute to the structure of therapy as much as is possible (e.g., helping to set the agenda, developing homework assignments). We find that many patients welcome CBT session structure so that expectations for what will be accomplished and their roles in treatment are clear. However, some patients have an adverse reaction to the session structure. Jack, for example, believed that therapy is a time to “vent CBT is fundamentally a frustrations” and found it offensive that his therapist wanted to “take collaborative enterprise between care of business” before letting him “get things off of his chest.” For the therapist and patient. this reason, early socialization to CBT and discussion of the therapy process are important. Furthermore, in some instances, such as that with Jack, we encourage therapists to be creative in modifying session structure to respond to the preferences of patients in order to foster a strong, collaborative therapeutic relationship, which should always take precedence. In Jack’s case, he and his therapist agreed that he could spend the first 10 to 15 minutes of each session “venting” about the previous week, and then they would move onto the other CBT session components (see J. S. Beck, 2005).","e":[25,46,-148,-54,45,-21,59,-18,32,-17,-28,-2,26,26,18,-74,-18,-34,-38,30,-58,-23,-7,2,2,72,-46,32,-14,-6,93,6,13,-25,-91,-46,55,17,-45,-13,42,14,1,-130,25,-36,80,12,16,5,26,-48,-10,-31,131,13,-12,66,-15,-82,85,25,-33,84,40,-12,-49,64,-32,-9,35,-6,76,44,-19,0,-30,-25,-16,17,60,-27,41,-40,34,-2,15,10,-9,81,11,-34,24,43,-74,3,-38,-34,-41,-15,-70,16,-10,-4,-22,24,-16,-8,-7,7,-64,20,-39,16,-1,7,64,-52,21,25,23,-19,-32,26,2,78,-57,-12,46,-25,-34,-3,-1,-3,-9,48,-16,-27,-11,41,29,10,3,28,40,-29,24,-34,-33,30,17,10,2,45,16,-50,-34,-21,30,50,46,9,-40,-17,-37,-47,19,53,22,13,-45,-57,-23,4,61,37,50,-1,1,-31,8,1,11,23,18,20,11,-34,-14,-51,48,29,-58,7,-63,-54,24,1,22,-31,-24,30,-28,44,-62,73,-40,2,-50,-52,64,-24,-27,25,-61,-20,8,-4,-64,52,30,-12,4,-34,-9,-8,-29,-11,-7,35,-43,-47,19,16,25,42,-25,14,8,74,36,32,34,13,-72,28,7,-54,-5,25,-12,-10,18,-29,46,6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.51","t":"Brief Mood Check At the beginning of each session, the therapist briefly assesses patients’ mood in the time since the previous session. The purpose of the brief mood check is to track patients’ progress over time and to make this progress explicit so that it instills hope • Brief mood and builds momentum. It also alerts the therapist to symptoms that require immediate check attention in session (e.g., a patient who endorses suicide ideation accompanied by a plan in the time since the previous session). One way to facilitate the brief mood check is to have patients arrive 5 to 10 minutes before their sessions and complete a standardized self-report inventory. The therapist can scan patients’ responses to such","e":[22,-2,-194,-65,5,-14,73,-10,-1,-42,11,61,58,27,-2,-24,35,-49,-23,17,-36,-27,-71,-19,-6,82,40,25,-41,23,35,-7,-2,-45,-55,-76,46,47,6,-8,22,-7,11,-82,20,-20,66,-4,-9,-54,-33,-70,7,-21,104,31,-2,21,47,-33,94,10,-22,68,55,-30,-3,-17,-4,5,27,-1,8,39,-6,36,-8,-9,12,-16,54,-23,49,-45,46,7,-35,22,-24,75,32,8,35,45,-117,28,-8,14,-5,-23,-44,-12,-49,-33,24,32,-45,28,6,-23,-48,59,-10,-7,22,9,54,-28,10,40,-39,14,22,62,31,35,-27,9,9,12,-25,-11,-59,8,16,45,15,-3,-22,12,29,12,-11,-12,-24,-8,18,-33,-36,33,-7,-18,25,15,46,-29,-16,4,53,23,65,26,-47,54,-20,-47,41,33,1,8,-41,-47,2,-27,40,48,69,-30,54,-45,40,-47,57,14,-19,-44,42,-83,-51,-45,27,13,-77,-12,-68,-22,9,-31,4,-12,-28,4,-26,28,-61,63,24,-18,-16,-46,44,-6,1,-9,-22,23,-21,10,-1,24,53,8,11,-31,20,25,-60,-11,-40,4,-52,-57,-8,12,14,11,-8,36,4,45,-3,24,58,67,-102,-14,-12,-42,-3,35,1,-13,19,1,31,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.52","t":"The most commonly used self-report inventory for this purpose is the Beck • Beck Depression Depression Inventory-II (BDI; A. T. Beck, Steer, & Brown, 1996). It is a 21-item Inventory self-report instrument developed to measure severity of depression in adults and older adults in the previous one or two weeks. The measure assumes that the respondent is able to read at an 8th grade reading level; for patients who cannot read at this level, therapists can administer the measure orally. Each item consists of four statements reflecting increasing levels of severity of a particular symptom of \u0002 Mood Check depression. The score for each individual item ranges from 0 to 3. The total □ Bridge from Previous Session score ranges from 0 to 63 and is achieved by adding the 21 ratings. If more □ Agenda Setting than one statement for an item is endorsed, then the statement with the □ Review of Previous Session highest score is selected for that item. The BDI manual (A. T. Beck et al., Homework 1996) provides interpretation guidelines on the severity of depression based □ Discussion of Agenda Items on total BDI score: 0–13 (minimal), 14–19 (mild), 20–28 (moderate), and □ Periodic Summaries 29–63 (severe). These scoring guidelines were established for adult patients □ Homework Assignment who were seeking outpatient mental health services; therefore, therapists are □ Final Summary & Feedback cautioned to interpret these scores with respect to the clinical sample and setting in which the measure is used.","e":[45,24,-191,-62,-2,4,47,-11,-5,-25,13,31,57,-24,32,-49,-22,-51,-14,25,-50,-33,-81,3,68,61,3,14,-59,51,14,11,23,-15,-66,-26,52,38,38,55,-21,-10,16,-83,29,-21,84,15,57,-41,33,-39,54,-17,76,9,-47,-2,-9,-8,77,13,-23,36,66,-24,-27,37,-23,-27,81,-15,49,37,-42,13,-59,-43,17,4,38,-1,57,-55,77,16,-2,38,-17,41,41,-13,13,67,-61,31,-22,36,-24,-33,-10,3,-32,0,44,11,-8,-9,-5,-14,-37,38,-11,-49,47,5,52,-46,-59,67,-30,-15,54,23,28,-2,-39,58,21,-18,-21,1,-12,-6,15,44,-9,-1,-55,13,64,-5,-16,1,-10,-5,53,-28,-60,36,-10,-7,14,-19,6,-54,-35,49,30,30,16,24,-39,69,16,-50,4,59,39,81,-38,-75,-10,-47,21,2,46,-17,53,-25,37,-56,40,11,-21,-32,48,-48,8,-23,31,31,-45,-32,-75,-19,32,-14,57,-28,-17,24,-28,-4,-63,58,21,16,11,-42,72,-32,20,-11,-32,-4,-50,-3,9,-18,-5,-20,36,-11,53,32,-36,-3,12,4,-11,-101,8,-3,17,6,-10,29,33,17,-18,-7,4,30,-62,35,-29,-18,27,27,-38,-6,-17,7,66,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.52","t":"Although, in general, higher total BDI scores are associated with increased risk of suicide, special attention should be paid to two particular items. If the patient endorses a 1 or higher on the suicide item (Item 9) or a 2 or higher on the hopelessness item (Item 2), then further assessment of suicide risk may be warranted. Thus, the completion and evaluation of the BDI at each therapy session provides the therapist with one strategy for monitoring ongoing suicide risk. The following is an example of a straightforward mood check with Kate.","e":[49,38,-168,-13,60,37,29,28,6,-7,-44,52,94,16,3,-28,7,-58,-6,30,-94,-70,-61,-9,21,85,-7,45,-74,53,27,6,14,-29,-77,-22,76,81,19,-1,11,-7,-5,-80,-2,-19,116,34,74,-12,31,-41,31,-3,95,29,-38,-8,-25,-50,37,5,-41,3,86,-7,-51,16,-41,-14,60,15,38,25,-37,36,-21,-28,5,52,35,0,64,-25,50,34,29,38,-16,73,34,26,32,71,-96,31,-16,30,-37,-9,-46,16,-7,-4,6,5,-2,-12,-22,10,-60,6,-55,-57,53,9,43,-64,-38,47,-25,-28,29,70,-4,20,-52,37,27,-30,-14,-32,-36,8,9,53,-16,4,-31,-4,37,19,3,-4,-1,-41,57,8,-56,-10,6,9,0,-38,-14,-70,-40,34,43,16,47,33,-32,64,-5,-34,8,26,7,54,-45,-68,24,-47,48,-11,30,-15,67,-56,27,-60,64,5,-3,-54,31,-16,-52,-1,21,34,-49,-26,-56,-20,52,-5,41,-8,-60,43,-54,-8,-62,75,-14,29,-36,-60,52,-32,-9,-8,-10,-7,-15,-17,-47,11,5,-10,11,-24,25,33,-63,-41,15,-2,-7,-75,31,-22,-12,28,-3,6,-1,30,-19,16,21,20,-52,48,-33,-26,7,46,-29,1,4,21,38,8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.52","t":"Therapist: Hi, Kate, come on in. It’s good to see you today. Kate: Thanks. It’s good to be here. Therapist: Did you have a chance to fill out the Beck Depression Inventory in the waiting room? [Kate hands her paperwork to her therapist] Good. Let me take a second to look this over. [Therapist quickly reviews Kate’s responses and sees that her overall score on the inventory is similar to the previous week’s score, although her sleep disturbance had improved] It looks like you’re still feeling pretty down, although you haven’t been sleeping as much this week as you had in previous weeks. Is that right? Kate: Yes, that’s right. I’m still not feeling like myself at all. But, I’m trying to stay up and do things even if I just feel like crawling back into bed.","e":[-6,-4,-163,-36,-9,52,27,-9,31,-33,-62,13,61,15,-4,0,34,-61,-34,41,-32,-32,-76,-16,19,77,-16,38,-77,27,63,1,8,-55,-70,-28,48,51,-10,-2,64,20,5,-97,0,-73,77,13,16,-60,-5,-51,-19,16,81,35,53,-1,19,-28,105,10,-12,81,57,-11,-43,72,-67,-37,72,17,30,25,-65,41,-34,-44,17,17,42,-14,49,-42,27,25,-3,45,-12,66,28,-9,6,43,-51,33,6,24,-75,-71,-51,6,-31,-19,59,45,-30,-28,-37,-34,-47,19,-12,-31,10,-17,48,-102,-8,37,-9,13,4,6,35,47,-43,30,17,-4,7,-33,-51,46,-7,38,22,-4,-19,-21,74,27,-13,-28,-15,-30,29,0,-39,17,13,-24,11,6,37,-71,-5,24,51,49,55,-7,-17,42,19,-27,-11,58,23,31,-30,-72,-18,-43,14,-3,40,-25,21,-49,83,-5,50,-21,-7,-34,-3,-42,-42,-59,27,14,-57,0,-52,-27,36,-18,38,-15,-15,28,-43,8,-26,67,17,-22,4,-59,64,-31,9,19,-19,8,-6,-19,-62,23,10,17,-13,9,22,8,-54,14,-32,-16,-39,-89,4,9,30,36,-29,47,0,49,3,39,7,17,-67,52,4,-3,9,46,9,17,26,-5,74,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.52","t":"A few patients find the completion of weekly self-report inventories aversive, or they have difficulty organizing their lives in order to arrive to their sessions early enough to complete the forms. In these cases, the brief mood check can be done verbally, such as by asking patients to rate their moods in the past week on a scale of 0 to 10 (0 = not depressed; 10 = the most depressed I have ever felt). At this time, the therapist CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 38","e":[22,-1,-208,-89,44,-1,47,-33,12,-47,6,33,40,16,-6,-14,13,-62,-9,22,-31,-17,-66,-34,26,78,-11,16,-32,28,19,8,-7,-33,-63,-49,35,46,28,14,58,-11,17,-82,14,-2,88,42,20,-36,-5,-76,24,-31,87,0,-40,12,30,-13,84,8,-35,100,49,-4,-34,20,-34,-27,45,-15,24,44,-51,31,-33,-36,3,7,52,-9,65,-46,85,-15,-1,23,0,89,-5,-2,30,42,-90,39,-8,13,-31,-59,-37,-16,-47,-47,13,33,-23,-21,15,-24,-76,54,-4,-20,22,18,51,-41,-25,56,-10,13,25,46,6,22,-19,30,22,-28,-13,-24,-39,-4,3,43,-12,-5,-5,14,58,8,-23,27,-14,-35,8,-28,-44,10,9,-15,37,11,15,-59,-18,45,38,6,61,13,-35,49,13,-53,0,67,20,4,-58,-48,-5,-27,41,20,45,-8,39,-46,53,-30,54,16,0,-33,22,-53,-40,-32,22,43,-64,-31,-67,-32,17,-12,-4,-41,-9,40,2,22,-81,55,6,-15,-4,-56,38,-40,-16,2,-26,16,-7,12,-34,21,39,11,24,-18,30,30,-38,-12,-8,-14,-10,-98,26,-21,-14,31,-20,27,22,58,55,37,46,35,-97,9,-42,-20,21,48,-13,0,0,2,40,1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.53","t":"can also ask specifically about other symptoms that had been particularly problematic in the past, such as concentration difficulties, anxiety, or suicide ideation. The following is an example of the manner in which Michael’s therapist modified his mood check when he complained about completing the BDI.","e":[49,23,-156,-18,40,11,44,6,57,-31,8,43,70,59,-27,-21,4,-87,-13,40,-76,-39,-55,-4,12,66,9,21,-50,48,63,-7,4,-40,-68,-17,54,69,18,33,64,-25,-15,-118,22,-10,72,26,19,-38,49,-52,28,-40,91,37,8,31,22,-58,58,9,-21,39,65,-48,-38,38,-49,-11,73,9,37,42,-42,30,-12,-17,1,26,21,-3,57,-29,71,30,8,45,5,94,2,13,18,47,-91,15,-13,14,-28,-35,-46,5,-12,-17,18,41,12,-23,0,22,-75,36,-14,-13,52,5,29,-64,-30,46,-43,-13,6,40,23,24,-36,6,24,-23,-17,-37,-25,29,-9,26,10,-4,-28,-23,92,0,-21,13,-7,-31,33,-16,-63,6,-22,21,5,-5,35,-43,-68,36,62,8,28,6,-30,67,19,-67,28,83,13,43,-53,-56,17,-11,75,41,46,-24,69,-51,20,-54,32,9,-3,-50,49,-21,-57,-26,-12,50,-37,-39,-57,-46,47,-32,25,-27,-31,18,-28,4,-36,74,-10,10,-22,-35,42,-51,12,-16,-34,5,-4,-12,-5,37,-18,-28,-16,-9,41,19,-50,-27,-14,-7,-3,-83,68,14,9,16,-42,3,11,51,-19,37,41,28,-59,20,-4,-20,4,22,-20,4,5,12,32,-9]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.53","t":"Therapist: Hi, Michael, come on in. Good to see you today. Michael: [grunts] Therapist: Did you have an opportunity to complete the Beck Depression Inventory in the waiting room? Michael: [hands the therapist a blank form] I think this form is really dumb. It’s just asking the same thing over and over again. Half of the questions don’t even apply to me. Therapist: It sounds like filling out these forms is aversive to you, Michael. Michael: Yeah. Therapist: I understand that it seems like these forms ask the same things over and over—you’re not the first person to say that to me. [makes one more attempt to solicit Michael’s agreement to complete the inventories] Believe it or not, these forms really do provide us with important information, as they give a fairly comprehensive picture of how therapy is working for you. Michael: I can tell you how therapy is working for me right now. Things still suck. Therapist: I’m sorry to hear that. I’m hopeful that, as therapy continues, we’ll be able to turn that around. [pause] I have an idea. How about, instead of filling out the forms, I just ask you to rate your depression on a scale of 0 to 10, with 0 being no depression and 10 being the most depression you’ve ever experienced. Would you be willing to give that a try? Michael: Why is this important again? Therapist: So that I can track how therapy is working for you and see if what we are doing is helping your depression. Michael: OK, I guess so. Therapist: Good. How would you rate your mood over the past week on that 0 to 10 scale? Michael: A 10. Maybe a little bit of 9, but mostly a 10. Therapist: OK, Michael, this is helpful for me to know. We’ll be sure to continue to address depression in today’s session. The other thing that has been causing you problems recently is your suicidal thoughts. Have you continued to have suicidal thoughts in the past week? Michael: They’re about the same as before. Therapist: [goes on to conduct a suicide risk assessment]","e":[21,9,-133,-73,41,7,48,-1,21,-56,-50,-12,50,16,-22,-9,35,-96,-36,61,-51,-54,-60,-11,-1,58,-14,18,-97,27,78,8,-12,-8,-92,-21,43,92,-12,18,65,4,-16,-103,15,-53,76,3,16,-62,52,-54,17,5,62,9,2,-1,47,-36,89,38,-28,69,45,-6,-32,34,-54,-25,62,3,42,38,-45,68,-38,-37,50,12,10,-2,41,-37,17,4,25,42,-9,83,-10,2,-10,39,-57,31,-26,-3,-56,-43,-52,16,-25,-13,34,50,4,-48,-9,-13,-49,34,-22,-14,8,4,52,-88,14,46,-18,19,7,-15,31,17,-11,46,8,-20,-12,-41,-51,17,-14,46,18,-36,-21,-13,69,12,-24,-22,17,-26,5,-8,-27,-3,6,-17,26,24,40,-72,-28,-3,54,56,47,22,-24,38,39,-27,27,45,4,20,-1,-66,-13,-31,36,28,54,2,28,-30,62,-3,59,-24,5,-24,39,-34,-14,-57,26,18,-30,-7,-35,-9,42,-47,8,-4,-38,30,-31,-10,-67,66,18,-3,-15,-49,61,-62,17,39,-44,14,3,-10,-43,18,22,17,17,0,11,37,-65,-1,-12,-6,-35,-68,32,7,-4,24,-39,18,2,82,3,47,37,29,-61,5,-3,10,27,54,-7,23,-4,4,53,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.53","t":"By making this adjustment, the therapist demonstrates to Michael that CBT is a collaborative enterprise and that his opinions and wishes are important. Another common obstacle that therapists encounter in conducting the brief mood check is that patients immediately launch into their problems or how bad they feel, which often escalates their agitation and hopelessness. In these instances, the therapist gently intervenes, validates their experience, and invites them to place the items on CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 39","e":[12,16,-174,-58,62,25,56,-13,20,-29,5,22,29,12,12,-19,20,-40,-17,20,-39,-34,-54,-23,4,71,4,35,-39,13,63,-5,7,-42,-72,-61,59,62,-9,25,48,-6,9,-105,6,-18,79,31,6,-41,22,-97,34,-56,98,11,-12,36,23,-66,70,29,-39,74,53,-31,-33,22,-31,-8,45,-4,45,72,-51,32,-29,-18,-11,-3,57,-12,45,-61,49,-12,5,15,-19,78,26,5,21,44,-94,31,-15,-5,-26,-48,-57,-10,-33,-14,5,35,-1,-1,5,-20,-84,42,-14,-11,18,12,60,-35,-1,51,-1,14,-2,35,9,38,-38,-5,28,-22,-25,-24,-8,-24,-3,26,-21,-3,-27,5,47,11,-15,14,-2,-15,4,-5,-52,4,12,7,17,15,47,-25,-12,32,45,27,48,17,-54,35,4,-21,24,58,29,27,-62,-69,-8,-13,74,52,50,-8,33,-54,33,-33,50,12,-6,-27,18,-72,-52,-61,28,38,-59,-16,-80,-46,32,-21,29,-28,-9,35,-11,39,-72,67,-11,-9,-30,-68,64,-39,2,3,-52,18,8,9,-34,26,36,13,7,-21,-10,5,-63,-27,-12,0,-9,-79,27,10,15,33,-19,14,9,67,33,37,58,49,-81,18,3,-39,14,30,2,-16,0,-6,25,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.54","t":"the agenda for the session. On many such occasions, the brief mood check and agenda setting are accomplished simultaneously. Claire, for example, was extremely frustrated that she had not heard any news in the time since the previous session regarding the reinstatement of her position in the Air Force. During the mood check, she ignored her therapist’s questions about her mood and produced a litany of complaints against the military. Below is an example of the manner in which her therapist handled this.","e":[62,-26,-195,-41,22,20,20,-36,28,-28,18,26,63,71,48,-9,7,-46,-20,-14,-16,-34,-62,-10,28,72,21,-13,-73,17,28,-10,10,-38,-27,-96,20,67,-15,26,17,5,-5,-97,6,-18,65,23,9,-82,2,-52,-27,-41,111,17,33,56,57,-35,96,-1,-10,91,21,-8,-39,23,-28,-21,44,0,11,11,-29,25,-5,-21,-9,-6,51,-45,86,-18,63,41,11,26,-28,76,30,6,26,20,-81,35,20,20,-43,-11,-51,-16,-40,-8,35,-1,-26,9,5,-23,-63,50,-16,10,27,-8,57,-53,13,32,-31,-20,4,35,26,12,-31,-8,5,-7,-24,-22,-25,32,18,13,-12,-31,8,-15,36,4,-33,-22,-25,-39,53,-17,-34,15,-4,-17,21,19,44,-29,-21,27,35,32,84,3,-50,42,-13,-25,26,73,15,16,-50,-46,-11,-19,78,48,74,-36,39,-39,26,-29,11,0,-14,-51,26,-44,-67,-45,-32,35,-36,-6,-57,-39,13,-28,13,-9,-24,-3,-19,26,-57,78,26,-32,-8,-49,64,2,1,-4,2,8,-4,-7,-17,25,39,-19,9,-33,14,17,-33,-16,-27,5,-32,-103,11,23,18,25,-22,60,-1,24,-28,29,47,12,-72,20,-13,-20,-16,43,2,-21,13,7,28,-38]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.54","t":"Therapist: Hi Claire, good to see you today. Claire: I’m glad my appointment is today because I really need it. Therapist: Well, then I’m glad to be of service. Did you have a chance to complete the Beck Depression Inventory in the waiting room? Claire: No, I was late. Therapist: Then, why don’t you just tell me right now how your mood has been in the past week. Any changes from last week? Claire: I’ve still not heard anything about the results of my medical exams despite putting in several calls. They never get back to me. I’m just sitting here, doing nothing, while the fate of my professional career is in the hands of bureaucrats. Just because I’m an amputee doesn’t mean that I can’t function. I mean, it’s… [becomes increasing agitated] Therapist: [gently] Claire, let me jump in here to make sure I’m understanding everything you’re saying. Clearly, it seems that the problems you’ve been experiencing in the time we’ve worked together have not been solved. That sounds very frustrating. Let’s be sure to make this a high priority agenda item. What I’m wondering about is the effects of all of this on your mood. Claire: Well, if they would just acknowledge that I exist, I would feel a lot better. Therapist: [noting that Claire still did not provide a direct response to this question] So, on a scale of 0 to 10, with 0 being no anxiety and 10 being the most anxious that you’ve ever been, how would you rate your mood? Claire: I don’t know that I would call this anxiety. So I can’t answer that. Therapist: What would you call what you’ve been experiencing emotionally? Claire: I don’t know—frustration, I guess. Exasperation. I’m at my wit’s end! Therapist: OK, frustration, exasperation. Are you more frustrated and exasperated than when I saw you last week, or less frustrated and exasperated? Claire: Oh, God, definitely more! This is probably the most frustration and exasperation I’ve ever felt in my life. Therapist: Have the frustration and exasperation been causing problems for you? Claire: [slows down a bit] I hate to admit it, but yeah. I think I’m coming across as really pissed in my phone messages, and I wonder if that’s going to hurt me in the long run. And my mother says she can’t even talk to me right now because I just go off at the littlest things. Therapist: So, in addition to addressing your problems getting reinstated, should we also put on the agenda ways to manage your frustration and","e":[61,-7,-135,-75,35,3,27,9,60,-18,-47,19,17,21,45,-20,29,-67,-69,16,-41,-44,-63,6,-2,92,-38,26,-89,62,52,-21,-7,-42,-90,2,28,92,-3,31,88,-9,11,-90,-30,-71,94,19,-9,-63,17,-54,-31,22,84,7,36,53,52,-37,100,12,-26,89,52,-11,-34,22,-19,-46,61,8,32,47,-39,41,-28,-28,11,-14,11,-26,38,-61,34,22,13,51,-9,93,10,13,-7,15,-71,-3,16,-14,-71,-70,-54,15,-33,-23,8,32,-10,-38,-14,-18,-43,47,-4,-26,-13,2,52,-85,5,5,5,28,-14,3,65,32,-11,31,12,32,-36,-13,-21,27,-31,48,27,-25,6,19,61,-19,-14,-33,-4,-16,40,15,-41,1,0,-13,18,11,46,-17,-26,26,34,19,44,11,-51,40,35,-28,13,58,29,34,-9,-58,-29,-16,32,18,61,-19,2,-48,45,-8,48,-23,-19,-11,22,-31,-26,-81,-5,28,-46,6,-30,-33,56,-73,6,-11,-23,18,7,12,-41,28,25,-62,-9,-38,50,-39,-5,53,-26,-28,7,-37,-9,34,35,-45,0,10,-17,33,-29,18,-13,-18,-25,-86,47,17,16,32,-55,19,-26,75,-4,47,23,50,-78,24,3,20,11,34,8,1,24,-2,56,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.55","t":"Although the brief mood check focuses mainly on symptoms patients experienced in the time since the previous session, the therapist uses this opportunity to check in on other important issues as well. For example, many Veterans who are in psychotherapy are also taking psychotropic medication, or they struggle with medical problems that require ongoing monitoring. Thus, during the brief mood check, the therapist also assesses these patients’ adherence to other treatment regimes and whether they are attending other scheduled appointments. If patients report problems in these areas, the therapist likely would suggest that they include this as an agenda item to be covered in session. Patients who have a history of alcohol or substance use (or who are actively using alcohol or other substances) should be asked about their substance use in the time since the previous session.","e":[15,-13,-181,-51,8,-6,52,-19,20,-40,50,40,39,19,-21,-30,24,-49,-14,8,-48,-26,-59,-35,-13,76,32,20,-33,2,31,4,4,-49,-55,-72,49,75,12,20,24,21,2,-99,11,-12,52,15,-25,-31,1,-79,3,-25,108,10,8,33,66,-52,92,3,-31,67,33,-30,-16,-1,-16,-13,34,-4,24,41,-28,45,8,-24,12,-11,47,-29,55,-34,52,26,-16,30,-10,85,40,13,36,38,-115,33,-9,-11,13,-24,-38,-2,-43,-22,41,13,-30,33,-6,-14,-50,64,14,-15,12,-3,36,-44,4,39,-36,7,26,67,26,22,-33,-14,3,15,-9,-28,-51,0,24,33,27,-2,-14,-8,48,9,-12,3,-23,-8,24,-42,-28,23,-3,-3,30,5,56,-28,-30,14,54,19,57,22,-33,54,-2,-45,38,41,3,3,-45,-39,9,-39,81,53,74,-52,72,-33,26,-39,23,-4,-11,-37,38,-93,-59,-26,-3,22,-57,-16,-79,-61,-7,-31,2,-15,-38,18,-33,37,-56,71,-5,-40,-30,-63,74,-9,28,-13,-50,15,-15,5,-13,31,51,21,33,-34,8,19,-64,4,-20,8,-26,-90,2,21,33,23,-29,21,16,41,1,31,56,56,-82,5,-28,-33,-5,43,-3,-12,17,8,25,-35]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.55","t":"Bridge from Previous Session The bridge from the previous session is a very brief strategy to ensure that patients remember the work completed in the previous session and to follow \u0002 Mood Check up on relevant issues. It is helpful to bridge from the previous session so that \u0002 Bridge from Previous Session coherent themes across the course of treatment will be evident, and goals □ Agenda Setting established at the beginning of treatment are met. It also provides an □ Review of Previous Session opportunity for the therapist to identify any negative reactions that patients Homework","e":[23,-11,-164,-105,19,-14,45,8,24,-9,-15,27,33,7,0,-20,2,-46,-31,3,-24,12,-23,-2,-19,48,4,18,-48,-18,68,-25,16,-46,-55,-24,31,2,-3,-55,49,19,-14,-106,49,-43,95,3,-11,-37,-22,2,-33,-32,99,53,29,46,35,-21,74,41,-15,64,28,-39,-63,42,6,-12,19,30,35,19,-19,-7,-13,-22,3,18,12,-30,66,-20,74,40,-17,26,-54,73,0,5,27,18,-135,33,-44,-14,-68,-31,-44,-27,37,-25,8,62,-7,18,-21,-19,-24,42,-4,-1,-4,-12,40,-47,6,-4,-21,-58,5,0,38,68,-57,-5,52,-8,-35,-39,-47,29,42,22,31,-39,28,-19,53,8,-18,-2,-20,-18,47,-69,-9,43,-11,-3,9,60,48,-52,-17,-18,26,27,44,-5,-3,18,-36,-71,28,26,18,21,-38,-50,9,-37,75,31,60,-40,28,-37,11,-31,38,15,-61,-13,4,-33,-20,-25,4,38,-49,-50,-65,-72,38,-3,34,-46,-5,59,-67,60,-39,66,-14,-30,-28,-17,42,41,27,-24,-41,-11,-1,-23,-24,28,11,26,14,-17,22,25,-22,-6,-41,18,-62,-61,-44,-9,64,-7,8,46,-23,83,1,56,-4,-4,-88,44,-1,-48,7,31,38,10,2,-5,14,-56]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.55","t":"might have had to the previous session. Below we summarize questions that □ Discussion of Agenda Items the therapist can ask to bridge from the previous session. □ Periodic Summaries □ Homework Assignment □ Final Summary & Feedback Strategies for Bridging from the Previous Session What did we cover in the previous session that you found helpful? What did we cover in the previous session that you did not find helpful? What did you learn from the previous session? • Bridge from What stood out for you about our last session? previous What message did you take home from the previous session? session Are there things from the previous session on which we need to follow up in this session? Was there anything that bothered you from our previous session?","e":[48,-36,-135,-97,18,-11,48,-26,43,-13,-46,9,52,42,-11,-52,15,-57,-20,12,-29,-14,-21,3,-10,50,-5,19,-57,-22,65,-61,20,-22,-51,-25,57,19,-26,-52,70,31,-49,-96,61,-55,91,-3,10,-38,15,-1,-33,-9,92,19,59,14,71,-30,74,26,-19,65,14,-47,-55,53,-43,-21,55,27,45,4,-56,-2,-13,-26,-6,4,10,-4,74,-19,38,48,-15,45,-21,98,-13,9,22,26,-86,7,-32,-5,-62,-47,-48,1,65,-32,45,52,-4,-22,-18,-9,-45,40,-36,7,4,-17,58,-33,23,45,-35,-41,-9,13,25,62,-33,-24,47,-17,-2,-46,-25,55,24,38,9,-47,44,2,97,-30,-16,13,-5,-28,50,-56,-26,20,0,15,9,46,42,-56,-23,-19,26,17,29,-31,-31,13,-11,-26,22,30,15,37,-23,-46,11,-42,46,55,48,-36,9,-20,27,-8,45,8,-37,-29,-5,-19,-5,-6,-26,64,-14,-64,-65,-84,50,-8,20,-47,-1,54,-50,58,-48,51,-38,-20,-20,-10,53,10,-2,23,-57,8,9,-25,-23,44,-20,-18,4,-25,20,38,-4,-20,-44,44,-63,-128,-6,-8,60,8,0,32,-16,74,22,30,36,-27,-70,56,5,-8,34,57,36,16,17,50,1,-42]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.55","t":"When patients have done their homework and have thought about therapy in the time between sessions, the bridge from the previous session runs smoothly and usually takes only a minute or two. It is undoubtedly frustrating for therapists to have patients who claim not to remember what was covered in the previous session, but it will happen. When this occurs, it is important for therapists to monitor their own automatic thoughts, which could lead to counterproductive therapeutic responses, and quickly restructure these thoughts. For some patients, like Michael, memory problems are secondary to CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 41","e":[67,14,-172,-77,52,-21,77,0,38,-10,-45,28,14,15,-5,-42,11,-65,-41,12,-29,-3,-36,-29,-21,75,-48,17,-40,28,97,-18,-21,-56,-61,-38,44,34,0,-13,41,-15,16,-107,43,-27,92,22,7,-37,33,-37,-17,-25,100,10,11,37,25,-42,105,21,-47,70,25,-29,-61,46,-21,-8,23,3,31,43,-36,-9,-30,19,-8,26,36,-11,42,-33,75,18,-12,18,-25,126,-11,-23,4,44,-93,20,-22,-1,-66,-15,-69,-7,13,-43,33,42,13,-13,-21,-6,-68,40,-12,11,-1,-4,47,-48,2,9,-21,-33,2,20,20,79,-15,-2,54,1,-41,-20,-20,38,10,32,18,-40,-22,-8,43,-18,-2,5,-14,-30,15,-41,-56,12,3,6,-7,42,64,-27,-27,-9,74,24,39,3,-44,29,-7,-51,12,48,9,-10,-51,-66,3,-14,70,36,50,-17,35,-20,6,-38,9,20,-10,-23,-15,-27,-43,-36,30,29,-39,-17,-89,-48,60,-26,44,-40,3,45,-34,34,-51,73,-24,-18,-45,-45,68,35,2,17,-43,-26,-17,-10,-28,41,17,1,30,-52,3,-3,-22,-11,-14,34,-14,-77,24,8,31,29,-25,30,16,90,43,57,27,38,-87,15,23,-40,-3,16,7,2,-13,4,23,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.56","t":"traumatic brain injury. Others, like Jack, are not fully invested in therapy and have negative attitudes about treatment that prevent them from taking it seriously. Moreover, concentration difficulties (and often disorganization) often co-occur with depression, which could affect the degree to which patients like Kate can bridge from the previous session. It often is important for patients to write down key points that emerge from sessions so that they can consult those notes in their daily lives. In Part III, strategies for motivating patients to invest fully in CBT are presented. However, in the initial phase of treatment, therapists can also take the lead and provide a summary of the previous session. The following is an example of the manner in which Jack’s therapist handled the bridge from his first to second session.","e":[36,41,-167,-44,48,56,24,31,51,-1,-49,-7,26,-1,3,-43,-21,-40,-41,46,-68,-2,-23,-13,-2,52,-46,44,-54,34,73,-34,-30,-57,-56,-18,47,12,-12,-11,39,-26,1,-113,14,-39,105,35,10,-9,42,-58,-5,-45,148,60,5,32,14,-52,66,23,-17,46,51,-25,-89,67,-39,-22,36,5,65,29,-21,27,-23,-17,-1,46,26,2,64,-59,57,32,-1,23,-27,77,15,2,28,46,-92,23,-46,-19,-43,-38,-72,-18,15,-15,17,39,-9,-4,2,-16,-58,8,-18,-37,-7,5,37,-36,-28,-11,-2,-13,-14,30,11,86,-50,5,64,-14,-53,-24,-3,11,29,55,5,-31,-8,16,49,13,-9,10,16,-34,14,-24,-39,6,1,21,7,23,42,-47,-11,-13,47,33,57,-3,-14,36,5,-42,15,45,48,29,-30,-80,-7,-22,73,32,35,-19,13,-19,23,-37,17,12,-11,8,-14,-1,-28,-41,27,25,-45,-35,-63,-64,69,14,9,-16,-12,42,-52,29,-48,91,-18,26,-30,-48,40,2,-32,2,-67,-24,-2,-30,-65,27,2,19,-23,-38,6,-1,-20,-18,-23,-7,-42,-62,31,2,39,22,-10,20,-1,65,-2,55,18,-9,-53,30,-3,-32,3,29,-8,11,17,-24,25,-7]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.56","t":"Therapist: [finishing the brief mood check] Well, I’m sorry to hear that things continue to be tough for you. Perhaps as we continue to work together and address these problems we will make some headway. What did we cover in the previous session that you found to be the most helpful? Jack: [grunts] I don’t know. All we did was get to know each other. Therapist: You’re right. The first session is geared a bit more toward learning more about one another. Let’s see…last session, we talked about how you felt about being laid off from your job. You were feeling angry toward your manager and upset about your financial situation. We also talked about the communication problems with your wife and how you tend to not discuss problems that you’re having with her. I also recall that toward the end of the session, we were discussing some things you could be doing to improve your mood and how you could begin to open up with your wife. Is there anything that you would like to add? Jack: [pause] You make it sound like I am the one with the problem. Therapist: I understand how you may think I see you as the problem. I’m glad you can share this with me, but I just want you to know that I don’t blame or judge you for the problems that you’re having. I also understand that dealing with a job loss and family problems can be very difficult, and I hope that we can put our heads together and figure out ways to improve things for you. Jack: [pause] OK. I appreciate that. Therapist: Is there anything else that we talked about during the last session that was important? Jack: Not really…just the problems that I’m having in managing my diabetes. Therapist: Yes, and that you were having some concerns about sticking to the diet that your doctor had recommended. Jack: Yeah, but it’s been less of an issue for me this week. Therapist: That’s good. So now that we have covered the most important issues from the last session, I thought we could talk about the homework from last week and set an agenda for today’s session. Would that be OK? Jack: Sure. Therapist: [goes on to work with Jack to formulate the remainder of the agenda]","e":[62,-6,-149,-74,-20,7,12,-52,28,-53,-1,29,9,45,14,23,58,-61,-61,36,-26,-44,-28,-9,-7,75,-40,30,-48,42,55,-39,-6,-34,-74,-29,63,82,-12,-6,66,-4,-1,-139,34,-70,63,19,-11,-24,31,-74,-32,7,94,24,11,39,25,-66,95,12,-56,63,27,-37,-19,21,-63,1,51,-1,47,31,-41,38,4,-18,24,-19,14,-6,70,-64,17,24,8,42,-10,106,32,17,10,41,-57,30,-7,0,-15,-53,-53,-7,-20,-16,31,45,-37,-20,-1,11,-60,14,-12,-2,14,-12,57,-62,27,45,-40,22,-6,23,65,46,-32,21,13,12,-1,-17,-8,46,-8,41,16,-26,-1,-17,74,29,-14,-22,16,-10,2,-37,-57,16,26,-19,3,30,43,-52,-36,-2,63,35,56,-15,-24,19,50,-17,36,74,24,55,-24,-82,-2,-19,38,57,62,-27,5,-30,84,-10,58,-10,15,-14,18,-53,-27,-47,-6,17,-45,-8,-25,-28,55,-75,-23,-17,-6,29,-15,17,-57,59,13,-15,-38,-40,41,-32,-11,34,-13,-20,12,20,-55,9,8,-12,12,-15,13,17,-34,-14,-54,21,-62,-107,31,0,7,15,-42,15,0,88,0,35,42,5,-83,37,9,-24,21,31,35,-3,40,-16,54,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.57","t":"Agenda Setting Agenda setting is a collaborative process between the patient and therapist in which they identify the topics to be addressed during the therapy session. Agenda setting • Agenda Setting also facilitates the prioritization of the most important problems, which are usually related to the treatment goals. It occurs near the beginning of the session, usually after the brief mood check and bridge from the previous session. This process allows for the most efficacious use of time and facilitates goal setting and skill acquisition. Moreover, it models to patients a systematic approach to organizing their life problems.","e":[54,40,-170,-57,10,2,35,-29,26,35,11,10,65,41,21,-21,-9,-38,-66,6,-21,-21,-55,-14,13,67,17,-16,-34,-13,31,-16,0,-12,-36,-81,71,36,-20,-1,16,-4,10,-116,4,-37,65,-2,-9,-51,18,-24,-46,-50,90,27,11,91,39,-39,130,64,-51,85,43,-24,-20,29,-26,5,20,16,52,5,-30,13,-8,-26,-3,10,27,-37,78,-41,25,32,18,25,-31,73,16,13,-23,-9,-100,52,-25,2,-50,-31,-62,-1,-14,-7,2,20,7,3,-14,9,-37,29,-40,8,28,-26,97,-26,38,10,4,-65,11,27,16,70,-63,-28,28,20,-27,-32,-6,28,1,52,-12,-40,20,-4,42,7,-25,-37,2,-11,50,-32,-28,30,-7,29,11,28,24,-43,-28,-7,29,16,75,20,-48,36,-25,-23,40,51,14,14,-44,-64,-2,-5,73,50,77,-26,32,-15,24,-45,10,19,-39,-11,25,-36,-33,-53,-11,40,-29,-34,-63,-15,44,-31,47,-33,-36,8,-73,30,-47,84,29,-1,-11,-22,41,-6,19,-9,-20,0,-9,8,-4,41,16,-38,-18,-1,37,-15,-55,-8,-42,30,-44,-80,17,13,28,10,-34,44,19,75,-25,31,17,9,-63,37,29,-36,-42,40,5,-10,8,-2,26,-47]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.57","t":"Many patients find that the agenda setting process is quite different than the usual manner in which they address problems in their lives. Thus, it is \u0002 Mood Check important for therapists to socialize patients into the agenda setting process \u0002 Bridge from Previous Session early in the course of treatment. In the first session, patients are educated \u0002 Agenda Setting","e":[23,25,-168,-42,29,38,29,-4,46,2,15,18,64,53,11,-30,14,-47,-40,2,-31,-30,-62,-13,-9,59,-8,-11,-36,7,47,1,9,-19,-40,-72,62,33,13,14,31,1,-3,-107,5,-25,55,11,21,-62,14,-53,-39,-21,116,50,-1,101,47,-54,103,32,-40,59,23,-4,-28,24,-42,24,25,0,39,6,-10,33,10,-27,-12,16,31,-24,86,-45,50,40,15,15,-29,88,39,-28,-18,9,-121,35,-39,0,-13,-35,-59,-10,-19,-11,20,-6,-1,2,-10,-13,-33,37,-21,0,13,8,84,-28,28,13,-2,-20,23,44,40,55,-27,-33,21,-5,-24,-31,-12,20,4,47,4,-55,19,-31,49,30,-17,-29,-16,-5,42,-39,-30,25,-20,9,21,40,35,-41,-16,25,58,24,78,-9,-40,24,-10,-46,51,50,-3,1,-46,-38,9,-18,60,40,62,-42,55,-28,3,-54,-11,-10,-14,-23,28,-54,-41,-44,-17,51,-42,-13,-53,-40,24,-20,13,-11,-39,29,-59,4,-84,72,39,-10,-42,-58,45,-20,-4,-11,-28,6,-2,9,-9,46,34,-27,7,-24,28,-1,-63,-5,-27,33,-47,-89,20,24,40,-7,-25,20,34,42,-15,32,42,37,-49,10,18,-33,-30,27,11,7,-3,22,12,-44]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.57","t":"about what agenda setting involves and its purpose, as well as the □ Review of Previous Session Homework expectation that both parties will contribute to agenda setting at the beginning of each subsequent session. The therapist, then, takes care to □ Discussion of Agenda Items follow through on this. Not only do the patient and therapist identify the □ Periodic Summaries items to place on the agenda, but they may also allocate an approximate □ Homework Assignment amount of time to devote to each agenda item. Many therapists find it □ Final Summary & Feedback helpful to write down the agenda and keep it in a location so that both the therapist and patient can refer to it throughout the session.","e":[49,20,-145,-62,4,2,23,-19,41,12,-18,7,65,56,-5,-35,-2,-38,-33,2,-14,-29,-68,-11,-10,72,19,-15,-32,-6,50,-14,-28,-18,-22,-79,74,40,-31,-13,10,18,-25,-107,25,-42,57,-30,11,-59,38,-30,-38,3,112,35,26,54,72,-28,119,47,-61,78,27,-32,-21,36,-36,20,48,24,68,-4,-48,15,11,-6,-10,23,17,-7,92,-23,42,44,8,35,-21,89,12,-1,14,19,-80,19,-3,16,-48,-15,-62,7,35,-20,54,11,-3,16,-18,9,-30,41,-52,18,21,-2,103,-35,54,59,-18,-48,14,39,6,63,-20,-38,14,10,-18,-37,-21,28,19,51,-30,-52,21,3,45,5,-17,-21,-23,-11,47,-51,-36,31,-3,26,-11,7,53,-41,-23,-10,43,34,51,-11,-57,56,-19,-11,23,28,-4,15,-9,-46,2,-1,61,43,65,-13,28,-24,16,-34,17,-3,-20,-30,16,-46,-39,-20,4,63,0,-14,-49,-39,32,-23,1,-34,-35,6,-48,13,-53,80,14,-12,-26,-35,59,-2,-8,47,-25,5,-37,-10,-29,27,7,-37,6,-40,7,28,-48,-21,-32,37,-48,-97,29,11,47,8,3,48,12,58,-28,20,69,-8,-71,37,25,-39,-39,48,29,-3,0,39,14,-43]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.57","t":"It is important for the therapist to strike a balance between ensuring that items on the agenda will help patients achieve the goals they established at the beginning of treatment and the items that patients deem important (whether or not they are related to treatment goals) are given attention. We encourage therapists to be flexible during agenda setting. It may be necessary to deviate from what the therapist believes is most important in order to maintain the therapeutic alliance and to help the patient with immediate issues that may have arisen in the time since the previous session.","e":[16,40,-140,-38,34,8,26,-15,65,11,-21,-19,59,38,40,2,-4,-54,-22,40,-25,-30,-56,-16,-26,67,25,-13,-54,11,35,7,-8,-29,-35,-86,71,47,-1,-19,0,5,-28,-100,24,-44,43,2,4,-48,20,-31,-34,-34,129,11,10,74,28,-65,116,34,-78,69,25,-28,-32,1,-55,1,46,4,77,25,-29,18,-3,-14,-32,0,24,-18,75,-28,22,49,44,21,-15,80,24,-11,-8,26,-112,36,-25,8,-32,-8,-64,12,4,-16,21,-3,21,11,-24,-18,-25,35,-32,0,0,-1,77,-46,35,24,-1,-44,19,46,11,33,-32,-54,30,6,-12,-38,-24,16,-6,45,23,-46,30,4,40,25,-15,-38,-30,-24,51,-13,-31,22,-19,32,-1,62,25,-62,-2,12,25,1,72,5,-30,19,-14,-30,29,31,-10,11,-20,-34,1,-27,86,24,74,-24,37,-35,-11,-22,-25,3,-37,3,38,-40,-36,-19,23,66,-46,-5,-61,-33,48,-30,27,-22,-34,14,-54,31,-64,62,16,15,-20,-71,79,-15,-11,30,-41,-6,-15,11,-17,65,32,-6,18,-21,-4,-12,-49,-24,-28,30,-27,-82,29,71,64,-6,-6,41,40,53,-8,11,46,10,-73,43,30,-56,-31,25,25,10,9,34,5,-53]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.57","t":"A straightforward manner to commence agenda setting is to ask the patient, “What items would you like to place on the agenda for today’s session?” However, some patients find the use of the term “agenda” aversive. In these cases, the therapist can ask, “What topics do you think are important to discuss today?” or “What would you like to have accomplished by the end of today’s session?” to obtain the same information. Some patients find more informal language easier to digest, such as using the term “game plan” rather than “agenda.”","e":[9,34,-141,-67,29,32,7,-57,32,18,1,-3,71,79,17,-30,3,-93,-31,20,-10,-27,-58,-4,15,30,8,-8,-38,3,19,3,16,-16,-20,-106,44,46,-35,-59,30,-11,-10,-121,48,-31,68,25,10,-85,11,-14,-26,-43,67,28,32,64,64,-26,116,37,-39,65,49,-15,-46,61,-19,-7,54,16,66,16,-27,15,-14,-41,4,20,0,-31,84,-49,36,34,18,22,14,67,15,-8,5,20,-99,36,-36,-3,-37,-29,-60,-10,18,-28,32,35,-5,7,-15,-14,-13,40,-40,11,14,7,93,-7,53,34,-13,-20,30,28,28,62,-56,-19,32,4,-19,-14,-9,12,3,54,16,-45,53,-22,34,-19,-24,-28,-17,-22,46,-24,-8,37,3,22,20,30,65,-67,-12,-3,35,15,79,9,-75,55,-17,-16,24,46,0,6,-26,-47,-6,-7,74,37,67,-19,17,-47,27,-34,10,-3,-52,-20,17,-44,-22,-30,-29,42,-31,-19,-63,-19,56,-14,10,-24,-37,31,-37,27,-58,67,24,11,3,-44,81,-24,-25,16,-40,12,13,13,-41,63,13,-26,-33,-2,28,6,-34,3,-41,33,-36,-108,8,-2,58,12,-21,57,13,49,-26,20,78,11,-84,15,28,-27,-14,41,10,13,30,11,29,-45]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.57","t":"The following is an example of agenda setting with Kate, who has easily acclimated to this process. This transcript occurred in the same session as the brief mood check illustrated previously. It begins after Kate summarized the take-home message from the previous session—to combat depression, it is necessary for her to re-engage with activities that used to give her pleasure. Therapist: A few moments ago, we talked about discussing your increased depression. What else would you like to put on the agenda for today? CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 43","e":[16,6,-167,-62,28,55,4,-36,49,4,-36,27,85,59,15,-15,-17,-32,-49,26,-12,-21,-64,-25,7,73,9,27,-61,32,21,-25,-3,-31,-28,-54,67,45,-21,-13,45,0,1,-80,17,-53,87,34,-5,-58,12,-73,16,-63,92,-6,12,27,12,-55,119,14,-44,76,33,-17,-57,57,-83,-16,63,12,16,9,-28,8,-23,-42,-9,16,48,-19,64,-62,64,23,22,27,-2,43,45,6,-11,34,-58,33,-16,0,-28,-29,-81,-28,0,-21,20,33,-7,-6,-19,-21,-49,19,-30,-11,20,6,53,-41,7,29,-3,-18,29,32,29,52,-50,-10,36,-14,-1,-14,-14,48,15,19,-20,-13,0,6,51,9,-33,-2,-8,-7,32,-8,-47,5,-9,1,18,25,42,-49,-23,19,29,17,82,16,-53,42,7,9,13,41,15,31,-62,-84,-36,-43,57,22,73,-31,12,-37,39,-43,29,25,-28,-35,-5,-37,-42,-47,-20,35,-40,-25,-84,-37,58,-18,11,-19,-7,34,-28,27,-48,67,16,-9,12,-69,76,-10,-3,-11,-11,21,11,10,-36,14,11,-8,-9,-20,26,18,-27,-27,-21,10,-19,-106,18,-7,35,37,-27,47,-11,46,2,33,57,36,-61,28,10,-28,-12,41,9,-12,15,10,58,-44]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.58","t":"Kate: I would like to talk about some ways to deal with feeling irritable and tense at times. I’d also like to talk more about figuring out how to start seeing my children again. I mean, my husband isn’t even returning my phone and text messages. Therapist: That sounds frustrating. Let’s put these issues on the agenda. Anything else that’s important to cover in today’s session? Kate: I don’t think so—those are the main issues. Therapist: Do you see any problems about other issues that might arise in between now and the next time that I see you? Kate: Um, I don’t think so. [pause] Unless you count the fact that I still don’t have a job and that I don’t know how I’m going to pay my bills this month. Therapist: Those are some pressing financial concerns. Should we leave some time to address this issue as well? Kate: Yes, we probably should. Therapist: So, we’ve identified three topics—finding ways for combating depression, re-connecting with your children, and addressing your financial concerns. All three of those are big topics. How should we allocate our time in session to make sure that we get to all of them? Kate: I’m not sure. Therapist: Which of the three is the most important to you to cover? Kate: Definitely getting in contact with my kids. Therapist: OK, why don’t we spend the most amount of our time on that topic? Kate: Yeah, but how about dealing with my tension first? Therapist: How’s this for a plan, then? Let’s go over some strategies for improving your tension and mood first. Then, we can spend the majority of our time on your difficulties resuming contact with your children. After that, we can spend the last part of the session talking about the financial problems. At the end of session, we can review what we’ve accomplished, set a new homework assignment if we haven’t already done so, and get feedback on the session. How does that sound to you? Kate: That sounds fine.","e":[53,26,-141,-54,14,24,-13,-52,37,-21,-56,-19,23,65,-13,25,26,-44,-72,59,-36,-37,-19,16,3,89,-9,23,-47,30,64,-46,4,-39,-106,-9,73,79,-31,-64,96,-19,18,-102,0,-100,56,23,-15,-20,21,-73,-31,6,68,15,27,43,9,-61,128,11,-53,83,25,-23,-62,54,-27,-41,51,3,56,3,-44,18,-17,-29,11,9,43,-13,33,-63,30,16,26,18,4,75,-4,14,-12,8,-35,33,5,-4,-33,-57,-78,-13,-14,-19,11,30,-32,-20,-3,-3,-55,26,-18,-28,17,-7,31,-54,26,9,-22,-16,19,-1,64,68,-55,28,20,12,-4,-13,-22,7,-2,50,1,-23,-9,17,70,22,-26,-24,11,-3,28,-28,-4,4,-4,-19,-12,21,73,-46,-16,-18,71,8,23,-6,-38,35,36,-4,11,57,24,15,-29,-68,-8,-41,27,39,81,-34,-9,-32,44,-39,54,-15,-17,28,-5,-46,-26,-30,-6,23,-53,-3,-38,-53,72,-43,-4,-30,10,16,-30,20,-37,64,2,-21,-12,-38,70,-27,-2,37,-23,-19,40,-28,-63,16,7,-22,3,14,19,-2,-37,14,-41,10,-67,-92,18,31,28,39,-42,22,-34,65,13,34,39,16,-67,44,19,-7,-16,13,13,-5,44,-20,66,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.58","t":"The identification of issues to be discussed in therapy should be something that the patient thinks about during the period between sessions. When patients come prepared for each session, agenda setting proceeds smoothly and in a straightforward manner, allowing for maximal time to engage in the therapeutic process. Thinking about agenda items in between sessions also keeps patients focused on growth in between sessions, maximizing the potential for change. Although it is optimal for patients to come prepared with items to place on the agenda, there are many instances when this does not occur. In fact, many of the patients who have difficulty remembering what had occurred in the previous session also have difficulty with agenda setting. When asked what they would like to put on the agenda, they respond with “I don’t know.” In these instances, the therapist takes a more active lead in agenda setting with the intention of modeling the process to patients.","e":[30,32,-152,-58,28,8,34,-13,45,8,-10,15,57,50,10,-34,3,-83,-32,23,-17,-9,-56,-14,-31,69,2,-14,-30,18,53,-8,3,-7,-35,-91,64,55,-11,-23,30,-12,-4,-124,11,-31,70,7,-17,-81,31,-23,-35,-18,105,34,26,86,47,-43,128,19,-63,70,46,-19,-36,31,-13,10,39,19,40,24,-22,27,-1,-19,-15,12,25,-12,79,-36,39,62,38,15,-9,97,2,-13,8,22,-109,58,-20,7,-58,-14,-55,1,12,-22,18,33,5,5,-12,-3,-51,34,-47,10,11,-37,83,-36,60,16,-9,-39,13,25,35,62,-29,-40,38,0,-25,-12,-26,25,25,53,24,-54,22,-5,39,10,-23,-25,-14,-23,45,-36,-34,35,-20,23,9,43,49,-49,-16,-21,38,6,70,-4,-35,25,-31,-26,43,34,19,-8,-17,-49,9,-5,74,39,90,-25,17,-27,-5,-50,-15,-7,-29,-24,40,-21,-32,-48,-1,43,-34,-13,-62,-45,67,-38,8,-22,-23,8,-60,19,-55,66,21,-4,-10,-38,73,-6,-18,32,-25,-11,-14,11,-23,49,33,-22,-18,-14,22,-9,-37,0,-45,42,-49,-83,35,19,40,0,-26,22,15,60,-20,26,43,17,-70,18,21,-39,-43,46,11,10,6,-5,34,-45]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.59","t":"Therapist: What would you like to put on the agenda for today’s session, Michael? Michael: I have no idea. Therapist: What issues or problems do you feel are important for us to cover today? Michael: I don’t know. Nothing. Everything. My life’s a mess. Therapist: Yes, in getting to know you over the past couple of weeks, it’s clear that you have a lot on your plate. It often is helpful to choose a subset of two or three issues to work on in session so that our time together is meaningful and you’ll leave with ways to deal with each issue. You may even see positive changes in your life over the upcoming weeks. Are there any issues that stand out as more important to address than others? Michael: No. They’re all weighing on me right now. Therapist: Fair enough. Why don’t we decide, together then, how we might prioritize these problems? One thing that concerned me when I saw you last is that you were pretty hopeless about the future and wondered if your life was worth living. Michael: [slight nod] Therapist: That is one issue I’d like to put on the agenda. Perhaps we can figure out one or two ways to manage that hopelessness. Would that be agreeable to you? Michael: OK. Therapist: Why don’t I supply you with some choices for the remainder of the agenda for today’s session, and you can tell me what is most important to you from this list. Michael: I guess so. Therapist: OK, when we first started treatment, you had mentioned problems in many areas of your life. One [holds up one finger] was that your relationship with your girlfriend is strained. Two [holds up two fingers], you’re also having trouble deciding on a direction for your life career-wise, such as deciding whether you will finish school and what you should do after that. And finally, three [holds up three fingers], you were concerned about the results from neuropsychological testing, saying that you had mild brain injury. Of those three things, has anything happened in the past week that would indicate that we should focus on it in today’s session? Michael: I don’t know…I guess the thing with my girlfriend. We’ve had a lot of fights this week. Therapist: That sounds very frustrating, Michael. We’ll be sure to talk about that. How about we spend half of the session on ways to address your hopelessness and the lack of meaning in your life, and the other half of the session on the relationship with your girlfriend and ways to improve that? Michael: Sounds like a plan.","e":[31,15,-118,-57,25,50,11,-24,49,-12,-16,-13,25,50,-11,-11,-4,-67,-79,39,-17,-55,-38,23,-6,56,-7,13,-61,40,78,-18,-12,-16,-68,-40,44,81,12,-53,52,-19,-13,-142,13,-71,61,4,-27,-38,42,-22,23,13,74,29,37,28,32,-64,125,26,-50,77,39,-53,-56,20,-25,-29,64,-5,74,35,-44,42,-1,-15,28,-4,1,-9,66,-50,-8,29,35,33,3,87,13,54,-29,1,-64,13,-19,-18,-37,-25,-66,22,-13,-8,44,60,-12,-14,-34,3,-52,32,-21,4,11,-23,66,-79,29,26,-16,-7,3,21,52,42,-35,-6,27,19,-29,-38,1,29,-12,66,54,-39,-22,5,82,0,-43,-6,27,-3,28,-25,-45,11,12,23,-3,17,69,-41,-23,-30,53,7,29,2,-46,30,17,-19,52,49,9,26,7,-70,5,-25,63,46,56,-12,7,-22,59,2,23,-39,-30,17,11,-32,-11,-26,-9,19,-33,2,-22,-33,68,-63,-4,-6,-43,29,-30,44,-56,61,22,8,-30,-42,72,-49,8,37,-48,-28,16,-7,-49,47,26,-16,-7,-10,12,30,-33,-15,-40,-5,-44,-81,51,21,24,12,-31,23,10,93,-12,61,38,-12,-59,7,25,-14,-2,36,11,-1,32,1,33,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.59","t":"Michael’s therapist was patient with him, realizing that two factors were potentially interfering with his ability to remember the contents of the previous session and his ability to organize an agenda—his severe depressive symptoms and his mild brain CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 45","e":[27,11,-164,-54,52,32,35,-12,36,-30,-37,-2,48,15,3,-24,-2,-56,-15,27,-48,-25,-64,-31,30,73,-13,33,-40,25,90,-12,-17,-27,-53,-44,30,81,14,14,25,-25,-15,-117,-21,-6,39,30,-20,-49,42,-54,37,-67,105,2,8,24,49,-36,121,29,-51,60,28,-37,-67,43,-43,-23,78,-27,30,50,-26,16,-32,-6,-19,-4,45,6,60,-19,53,4,7,41,6,85,-14,13,-2,57,-77,27,-24,-4,-39,-36,-38,-7,0,-8,49,57,15,-35,-6,-12,-86,36,-35,-13,28,8,48,-51,17,38,-13,-16,-12,33,2,46,-21,20,34,-22,-18,-39,-6,7,10,30,3,-11,-19,-8,67,-4,-23,8,-7,-19,28,-15,-58,-10,12,37,-9,35,45,-51,-37,5,44,34,31,13,-22,41,26,-58,28,73,12,11,-34,-78,-4,-14,97,41,34,5,31,-28,13,-6,13,11,-26,-23,18,-25,-57,-32,-12,51,-42,-31,-54,-72,52,-25,14,-32,-29,31,-11,20,-58,59,-13,-3,-8,-38,36,-39,1,7,-44,4,-14,-13,-41,27,6,6,-18,5,5,12,-44,-14,-2,-2,-12,-55,82,32,10,15,-26,16,18,67,-3,53,47,-1,-74,6,2,-52,26,35,-15,22,-11,31,19,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.60","t":"injury. She took the lead in establishing one agenda item—his suicidal thoughts— because she judged that these symptoms were of high priority in order to keep him safe. However, to model the agenda setting process and involve him in the collaborative venture, she gave him a “menu” of three choices to add to the agenda. On the basis of information she obtained from his psychological evaluation, she knew that problems in his relationship with his girlfriend contributed to his depression and suicide ideation, so she reasoned that discussion of this topic would be consistent with Michael’s treatment goals of reducing depression and suicidal thoughts.","e":[47,15,-145,-36,68,73,1,3,32,-1,-51,-3,84,86,-20,12,-12,-40,-30,37,-59,-61,-104,-19,33,57,-4,0,-43,60,46,-23,-42,-33,-58,-52,33,83,22,-17,0,1,-22,-117,-4,-37,33,20,32,-55,49,-17,45,-68,71,38,26,44,54,-62,79,25,-14,39,64,-22,-44,24,-27,20,66,-10,27,22,-25,51,13,-7,11,15,25,-31,56,-18,21,39,53,9,-33,52,-3,36,-11,38,-81,29,-43,-18,-9,6,-70,-13,15,10,25,47,-3,0,26,27,-43,2,-33,-29,53,-3,83,-72,29,47,-26,-20,5,47,7,12,-11,12,11,-17,-28,-49,8,26,9,42,3,-40,-35,-3,57,38,-57,-29,-15,-31,35,11,-61,-4,2,23,1,8,5,-58,-40,4,29,3,50,11,-20,34,2,-22,58,43,16,35,-26,-82,-3,-9,78,14,56,-33,34,-26,31,-33,26,23,-4,-31,32,-28,-65,-33,-22,47,-43,-19,-41,-21,75,-29,11,6,-55,9,-40,11,-70,89,19,7,10,-46,31,-26,-3,-15,-38,-7,-10,-13,-23,25,-5,9,-41,-16,24,23,-54,-44,-31,-40,-11,-59,63,3,-20,7,-30,8,-21,44,-27,25,60,14,-48,17,15,-19,-15,55,-7,6,-34,36,42,-24]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.60","t":"Patients who have difficulty contributing to the agenda often benefit from a homework assignment designed to facilitate the agenda setting process. A simple but straightforward homework assignment is to have patients jot down possible agenda items as they think of them in the time between sessions. A more advanced • Homework assignment homework assignment is to have patients not only jot down potential agenda items, but also prioritize them before they present for session. In fact, therapists could construct a worksheet that would serve as a place to record potential agenda items and provide tangible instructions for how to organize them. As patients progress through therapy, they take more and more responsibility for determining the agenda.","e":[50,25,-148,-60,23,-5,13,9,36,16,-2,-2,83,53,-7,5,10,-48,-34,6,15,-27,-71,1,9,39,-21,-44,-54,38,7,-10,-22,-19,-19,-55,73,34,-26,4,-4,-21,-2,-95,35,-20,57,-11,34,-33,11,-56,-13,20,101,23,19,33,61,-11,104,63,-56,72,31,-20,-12,41,-38,23,39,22,68,7,-58,17,-10,-20,11,9,51,-31,90,-27,76,36,6,35,-17,91,-1,13,14,3,-82,40,3,26,-67,-26,-66,-2,25,-18,20,8,8,5,-4,11,-25,53,-44,8,51,13,79,-32,67,44,-4,-47,0,37,12,75,-37,-13,41,-6,-24,-21,-35,19,2,45,-26,-50,29,-20,48,18,-17,-7,-30,1,18,-20,-50,51,-16,-8,32,6,54,-31,-12,-16,20,24,59,-10,-77,58,-14,-24,32,59,1,34,-19,-57,28,23,49,34,50,-8,34,-16,21,-29,-1,-8,-20,-23,13,-17,-51,-32,12,51,10,-24,-74,-30,48,-26,3,-21,-40,5,-32,14,-61,86,6,-33,8,-39,53,3,-7,12,-21,-1,-44,-2,-38,-3,20,-40,22,-25,32,21,-49,-7,-56,34,-39,-78,40,8,53,-7,-16,32,16,71,-34,5,51,-3,-80,35,30,-59,-35,42,14,-13,1,10,8,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.60","t":"At times, therapists encounter a problem with agenda setting that is opposite of what Michael’s therapist experienced—patients launch into excessive detail and identify too many problems than can reasonably be covered in one session (i.e., the “Chatty Cathy” problem). When patients launch into excessive detail, therapists gently intervene and model naming the problem before going into a detailed description of the problem. When patients identify an array of problems, therapists identify an underlying theme that unifies many of the problems.","e":[65,68,-178,-49,-4,34,15,-2,36,21,-24,-19,78,60,-11,-35,-9,-53,-30,22,-37,-1,13,-1,-23,38,-3,26,-25,13,63,-17,-18,-30,-70,-58,69,34,-33,43,49,2,-10,-93,-29,-45,34,47,-8,-44,63,-37,-14,-32,110,43,15,56,54,-56,94,4,-57,76,24,-24,-45,42,-36,-31,37,-20,52,3,-29,19,-8,-6,-5,38,28,1,62,-61,33,16,37,60,-18,55,7,-10,10,9,-88,29,-2,0,-50,-42,-62,14,3,2,9,44,-6,7,-15,15,-27,41,-14,-35,0,1,79,-36,17,3,1,-48,-35,37,29,58,-20,8,16,11,-32,-45,0,-17,18,29,15,-30,9,24,51,24,-12,-17,-9,6,40,-21,-20,8,-14,38,-21,-4,32,-26,-27,21,41,3,35,-12,-64,32,7,-24,26,48,-48,30,-34,-64,7,-11,41,50,68,-29,55,-39,15,-36,24,1,2,12,16,-48,-22,-35,-9,60,-20,-27,-33,-68,72,-7,4,-44,-14,-7,-49,23,-73,68,-14,30,-42,-59,63,-5,-2,51,-57,-12,12,13,-30,26,14,-23,-5,-22,31,-14,-39,-9,-11,22,-19,-86,80,15,32,-15,-26,50,12,42,-18,37,32,-9,-62,8,13,-30,-8,49,-14,-4,17,-11,20,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.60","t":"CASE EXAMPLE: JACK When Jack was asked to contribute to the agenda, he mentioned frustrations with his wife, his son, his daughter, and a former co-worker whom he believes said negative things about him to his supervisor. His therapist regarded these issues as “problems with close relationships” and anticipated that many strategies to deal with one of these relationships would generalize to other relationships.","e":[67,13,-147,-62,-5,64,-25,-53,46,22,-65,-2,40,70,-30,-14,22,-39,-45,10,-20,-19,-65,1,30,31,-32,-19,-50,5,31,2,-32,-44,-68,-46,50,35,8,-9,46,-10,-32,-112,31,-69,23,71,47,-36,29,-24,17,-20,101,56,23,67,21,-46,54,34,-57,57,55,-33,-9,39,-30,-10,39,-18,44,11,-41,38,-2,-5,-2,19,38,-14,81,-36,36,35,22,33,-16,61,24,43,15,-1,-86,42,-32,-22,-28,-24,-39,-36,13,-8,8,36,-13,37,17,17,-44,37,-38,-9,46,-22,67,-75,24,37,-37,5,-52,47,-6,43,-54,1,11,-37,-19,-42,6,8,-8,35,24,-41,7,8,95,7,-16,15,9,-21,23,-39,-81,28,1,28,-5,51,24,-26,-58,4,40,-8,38,-19,-22,48,-25,-20,31,71,7,54,-35,-83,-13,-12,64,22,85,-40,19,4,21,-30,47,10,10,-16,34,-44,-31,-64,-14,37,-35,-24,-61,-79,40,-17,-9,-33,-12,-7,-4,44,-56,34,-6,5,7,-26,34,-48,-12,43,-29,-15,-1,28,-48,16,-12,-10,-15,-23,34,12,-25,-10,-85,22,-62,-103,86,37,14,-1,-25,41,5,56,-38,26,2,10,-54,32,16,-36,16,49,25,30,14,-14,41,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.60","t":"If there are truly a large number of disparate problems with no unifying theme, then therapists can work collaboratively with patients to prioritize the agenda items. For example, patients can rate the importance of each agenda item on a scale of 0 to 10 (0 = very low priority; 10 = very high priority), and the agenda would then unfold on the basis of these ratings.","e":[31,55,-162,-68,40,19,10,-1,33,10,-32,8,59,35,3,1,-3,-67,-35,20,-11,-32,-48,-34,9,60,14,-50,-74,19,33,-7,-1,-63,-42,-52,51,47,-4,12,30,11,18,-109,2,-17,55,37,33,-31,33,-23,-15,-8,66,34,-1,48,60,-15,101,41,-59,64,60,2,-34,36,-42,2,-5,-34,64,17,-52,36,2,-19,1,12,34,-25,89,-10,16,10,28,30,-14,113,23,16,-5,19,-93,46,-16,-19,-35,-50,-72,18,-4,-35,13,8,12,25,-4,-6,-32,26,-46,-6,27,-27,94,-59,-8,27,13,-45,26,60,-1,40,-31,8,14,-6,-35,-22,-8,-3,-14,78,13,-23,32,6,39,33,-17,-12,1,-36,33,-10,-32,28,-10,14,6,27,13,-45,-22,-7,38,-11,66,18,-30,42,9,-39,34,39,-3,55,-35,-46,25,-15,77,22,46,-1,31,-33,23,-25,4,1,-29,-8,39,-25,-22,-36,10,63,-22,-28,-53,-20,51,-32,18,-46,-29,5,-27,35,-88,68,1,22,-25,-71,46,-42,-24,29,-46,-8,-46,0,-41,53,14,-9,9,-25,16,-5,-63,-17,-36,15,-1,-86,50,20,14,14,-17,29,19,80,-5,13,37,11,-56,11,2,-26,-23,55,-7,-3,6,11,6,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.60","t":"Sometimes, patients suggest trivial items for the agenda, avoiding more meaningful topics that the therapist predicts would result in the greatest therapeutic change. In these instances, the therapist takes a more active role and gently suggests agenda items. If patients object to placing these items on the agenda, the therapist can ask them to identify the pros and cons of addressing the topic. During such an exercise, it is often found that patients fear that their symptoms will escalate if they talk about difficult topics. Many patients indicate that they do not want to “fall apart” during the session and then have to go back and resume “normal life” at their jobs or with their families. Therapists can take the opportunity to use the cognitive strategies described","e":[29,54,-129,-64,38,39,29,-23,56,2,-9,-16,45,62,0,-12,-6,-74,-40,19,-25,-25,-48,-24,-19,49,2,-6,-35,30,55,-5,-11,-23,-54,-56,76,58,-9,-22,38,-13,12,-100,30,-33,80,9,17,-43,36,-59,2,-17,94,22,19,58,59,-43,109,31,-74,62,58,-10,-46,47,-30,16,56,3,59,19,-45,25,7,-40,-5,15,20,-41,82,-60,36,41,44,33,11,83,6,-1,16,32,-105,43,-19,-48,-46,-40,-53,13,-2,-17,12,12,-1,16,-9,8,-31,49,-64,-17,31,3,91,-55,51,46,-9,-25,13,50,24,69,-55,-36,36,-11,-38,-31,-34,4,15,53,1,-35,56,-5,53,21,-7,-17,-19,-39,24,-11,-30,20,0,15,15,30,56,-47,-1,19,26,1,65,20,-40,42,-8,-19,30,43,2,40,-8,-51,13,8,89,22,52,-8,29,-58,7,-22,-10,-2,-10,-16,28,-5,-20,-40,-22,44,-33,-21,-62,-56,57,-32,34,-33,-23,-2,-31,23,-64,50,7,-8,-45,-62,78,-15,-21,28,-47,-12,-4,10,-30,54,18,-31,-20,-17,31,-10,-35,9,-37,22,-27,-91,56,21,52,-2,-2,37,23,42,-7,21,46,8,-67,-2,25,-48,-16,27,15,33,5,0,17,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.61","t":"in Part IV to evaluate the veracity of these predictions. Moreover, they can work collaboratively with patients to identify strategies for managing distress that arises when discussing difficult topics, such as taking a break, changing topics, engaging in a distracting activity, engaging in a controlled breathing or muscle relaxation exercise, or arranging for a follow-up telephone or face-to-face session.","e":[44,10,-206,-33,77,14,15,-38,44,-15,-15,-23,2,30,35,-11,24,-58,-63,14,-50,-14,-23,8,-10,74,-8,17,-27,-15,55,-10,36,-46,-75,-24,40,50,-42,0,37,-14,32,-96,21,-18,42,-26,22,-9,75,-57,-31,-23,91,5,6,20,37,-64,111,11,-35,57,79,-31,-79,74,-17,-3,57,12,51,27,-68,27,13,-17,6,42,45,-48,83,-45,58,11,28,11,-14,92,13,8,45,39,-65,38,-9,4,-50,-59,-53,17,21,-25,-9,39,37,-19,12,18,-41,39,-31,-30,37,10,61,-62,11,24,-21,-15,-5,15,15,63,-48,9,53,-2,-29,-21,-31,9,-1,44,-36,-17,-3,21,62,26,-15,-15,-5,-38,9,-44,-47,12,-10,33,15,14,41,-44,-39,35,28,16,69,-9,-45,31,6,-1,23,43,15,41,-49,-67,-16,-12,75,10,57,-52,-16,-43,34,-42,29,14,-3,-5,39,-46,-37,-59,-16,37,-37,-56,-48,-66,33,-22,26,-18,-12,-9,-37,40,-33,59,-14,-11,-44,-33,64,-14,10,23,-50,-10,24,-6,-34,12,-7,-9,-40,-30,17,-25,-37,20,-25,14,-13,-105,36,20,18,-2,-17,46,5,47,44,19,49,4,-69,56,27,-49,-13,40,10,6,22,-18,6,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.61","t":"Even the most seasoned therapists find that as the session progresses, it is clear that they are not maintaining the time allocated to each agenda item and that one or more agenda items likely will not be covered in that session. In these instances, therapists make this explicit to patients and work collaboratively with them to revise the agenda. Oftentimes, this means that the latter items on the agenda are tabled until the subsequent session. During the subsequent session’s bridge, therapists can remind patients that one or more items were tabled from the previous session and assess the degree to which they are still causing problems for them. However, fluidity in the agenda should be avoided when it is not therapeutically indicated or when the changes are driven by the patient’s tendency to lose focus on the tasks at hand. If this is allowed, it may serve to undermine progress and will reinforce the use of unstructured time.","e":[50,37,-169,-88,35,10,22,2,60,-18,-28,5,37,40,8,-17,14,-73,-48,26,-42,9,-50,-26,-25,52,14,7,-66,-4,90,1,-5,-40,-41,-80,61,25,5,-28,39,32,-6,-108,18,-45,67,12,-8,-51,54,-7,-64,-9,95,35,9,76,58,-35,98,28,-33,76,34,-30,-47,30,-24,11,22,22,86,38,-34,39,-15,-11,-12,-7,-15,9,83,-32,53,50,19,9,-3,114,18,-32,8,26,-105,29,-7,10,-69,-16,-56,11,9,-21,27,16,-14,-7,-2,-7,-50,41,-54,-9,16,-30,70,-37,9,15,-3,-52,18,34,24,69,-33,3,34,-19,-53,-16,-15,23,10,60,24,-26,30,2,45,24,-12,-12,7,-46,60,-44,-25,32,-22,19,0,58,40,-38,6,-17,37,29,66,-14,-34,11,-17,-26,21,32,-8,0,-43,-39,8,-15,61,33,59,-47,6,-30,1,-25,-28,-9,-4,-22,12,-17,-35,-32,15,55,-39,-4,-52,-47,51,-23,13,-30,-19,5,-50,32,-39,67,-12,-2,-26,-46,96,18,0,14,-49,-25,-10,10,-23,51,18,-5,-10,-39,-1,-23,-44,-23,-44,26,-51,-94,11,26,52,-2,-16,62,15,47,-11,16,28,-11,-50,27,48,-50,-6,58,19,21,11,32,-4,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.61","t":"Review of Previous Session Homework It is imperative that cognitive behavioral therapists review the homework assigned in the previous session. Failure to review the previous homework assignment may • Review of increase the risk of communicating to patients that homework is not important. previous Although we reference homework review in between agenda setting and discussion of session agenda items, in reality, it can occur at many different points in the session. Many homework patients spontaneously mention their homework assignments during the brief mood check or when they bridge from the previous session. If homework has not been reviewed by the time the therapist and patient set an agenda for the session, then, in most cases, the therapist encourages the patient to put it on the agenda. If it is clear that discussion of homework will be lengthy, then it is best to put it on the agenda, rather than reviewing homework before setting the agenda.","e":[81,6,-137,-56,7,26,41,-12,13,6,-8,27,39,70,-25,-40,7,-52,-31,0,2,-34,-49,12,26,62,-23,-13,-22,12,51,-4,-24,-36,-57,-32,87,11,-50,-23,45,48,0,-126,49,-24,72,-13,36,-25,21,-21,-19,0,91,21,32,16,37,-46,99,24,-30,66,1,-18,-49,55,-36,8,9,30,63,35,-58,4,-1,-22,-16,13,33,10,78,-30,66,33,-9,41,-28,92,-5,-17,16,14,-59,29,-7,14,-68,-30,-66,-21,13,-25,41,34,-15,-4,-33,3,-45,64,-29,30,30,12,77,-32,21,51,-28,-56,13,16,4,79,-51,-18,48,-16,-50,-22,-17,25,9,34,-16,-32,4,-40,58,-1,13,20,0,-27,34,-40,-61,28,-13,-15,6,-3,57,-29,-31,0,38,31,40,-7,-50,35,-16,-17,1,37,8,41,-37,-31,39,-20,22,49,64,-36,4,-25,16,-36,32,13,0,-3,10,-4,-52,-17,-1,47,-9,-40,-64,-64,27,-15,8,-48,-35,21,-38,26,-62,63,-5,-19,-24,-47,46,14,-17,42,-20,-9,-12,-24,-53,25,-18,-18,44,-23,23,31,-30,-10,-20,40,-51,-92,18,11,38,30,-4,31,5,72,-28,59,56,-5,-77,15,6,-42,-1,37,34,-2,-2,43,16,7]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.61","t":"It is important to use the review of the previous session homework as an \u0002 Mood Check opportunity to consolidate learning and to reinforce the application of CBT \u0002 Bridge from Previous Session strategies in patients’ daily lives. It is not enough to simply acknowledge \u0002 Agenda Setting that a patient has completed a homework assignment. Instead, it is important \u0002 Review of Previous Session to ask patients what they learned from doing the assignment, how it made a Homework difference in their lives, and how they might use the skills they practiced in □ Discussion of Agenda Items a similar situation. Such discussion allows patients the opportunity to □ Periodic Summaries articulate the process by which the homework worked, which reinforces □ Homework Assignment underlying CBT principles and increases the likelihood that they can □ Final Summary & Feedback generalize those principles to other instances they encounter outside of the therapist’s office.","e":[59,-3,-161,-71,15,2,43,-4,21,8,19,21,55,44,-2,-35,-2,-40,-37,-5,-5,-39,-42,13,8,55,-28,-10,-32,13,54,-37,0,-28,-70,-28,84,19,-53,-23,49,36,-2,-103,65,-16,87,-24,36,-35,3,-46,3,-16,136,41,32,24,41,-30,87,26,-23,75,7,-36,-39,43,-41,22,11,21,58,36,-57,3,-10,-19,-14,24,39,-23,60,-16,75,17,15,10,-51,84,9,-35,30,29,-75,46,-2,1,-39,-10,-79,-25,7,-30,28,55,-25,-9,-14,-10,-50,53,-22,21,22,25,70,-22,-6,48,-10,-36,13,15,20,69,-49,-24,47,-17,-51,-27,-15,26,22,24,-28,-41,12,-23,52,1,-20,26,-10,-14,20,-46,-74,43,-27,-16,17,8,56,-28,-16,1,46,47,46,-13,-68,39,-19,-28,19,30,24,44,-43,-57,25,-31,32,31,64,-36,37,-17,29,-33,28,20,-3,17,9,-30,-49,-14,13,43,-18,-32,-80,-44,30,-2,-13,-47,-47,39,-27,25,-75,64,8,-11,-23,-52,60,21,-16,28,-40,-6,-17,-15,-37,28,-15,-13,38,-35,0,35,-23,-25,-37,39,-51,-79,11,2,30,37,15,32,10,72,-5,48,50,-13,-77,27,15,-52,-3,31,36,-5,-4,17,22,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.61","t":"All therapists have instances in which their patients fail to complete their homework assignments. Although this can be discouraging for therapists, it can also be seen as an opportunity to model problem-solving using cognitive and behavioral strategies. Therapists are advised to monitor their own automatic thoughts about the CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 47","e":[46,1,-151,-58,79,21,47,-27,26,2,-34,2,52,26,-15,-28,2,-45,-35,6,-3,-16,-55,-11,19,73,-48,11,-20,12,36,-4,-36,-49,-48,-19,82,53,-19,24,46,-20,1,-99,7,-18,85,29,43,1,53,-99,14,-31,95,-3,-15,18,10,-55,113,43,-63,63,20,-35,-62,57,-38,-3,37,-2,68,34,-66,0,-45,5,-15,29,61,-4,41,-38,77,9,-13,13,-23,99,3,1,12,34,-75,13,-11,5,-49,-35,-58,-20,-8,-40,35,27,17,-23,-5,7,-62,60,-13,-21,26,24,57,-59,2,49,3,-7,-5,21,-9,77,-40,3,38,-14,-21,-27,-11,25,2,29,-28,-30,2,-16,59,-9,-14,33,-3,-28,-4,-27,-66,-3,0,4,0,5,68,-44,-29,17,46,6,39,12,-48,42,11,-27,-2,55,29,46,-73,-61,6,-14,74,33,29,-12,32,-31,12,-44,43,17,-2,-27,-10,-37,-32,-38,36,45,-8,-25,-89,-46,44,-20,36,-22,-16,48,-22,14,-85,54,-39,-9,-30,-66,54,-8,4,39,-30,-20,-9,-22,-56,8,11,-4,13,-14,12,18,-50,-25,3,11,4,-94,45,-4,33,32,-25,43,25,82,11,34,35,33,-94,31,1,-39,0,12,11,6,-24,38,18,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.62","t":"noncompliant behavior of their patients in order to avoid counterproductive emotions during the sessions. Novice therapists often think, Patients should always do their homework because it was well designed and will lead to therapeutic progress. Such thinking may seem sensible but will contribute to therapist discouragement. Alternatively, therapists could think, Homework is often difficult even when it is well designed and, therefore, it is best for me to graciously When patients report that they bear and problem solve this with my patient. When patients report that have not completed their they have not completed their homework assignments, therapists can homework assignments, encourage them to review the rationale for the homework, identify the therapists can encourage them obstacles to completing the assignments, and brainstorm ways to to review the rationale for the overcome similar obstacles in the future. Therapists also can prompt homework, identify the these patients to identify the pros and cons of completing the obstacles to completing the assignment. An illustration of the manner in which the pros outweigh assignments, and brainstorm the cons can motivate patients to engage in similar assignments in the ways to overcome similar future. When it is clear that the cons outweigh the pros, therapists regard obstacles in the future. this as useful information and take care to approach future homework assignments in as collaborative a manner as possible. The following transcript illustrates the manner in which Jack’s therapist handled his failure to complete his homework assignment, which was to eat dinner with his wife one evening in between sessions.","e":[84,44,-153,-70,21,23,46,-13,33,2,-56,-8,35,53,-48,10,34,-64,-41,10,-10,-14,-27,-3,3,33,-22,-19,-48,9,35,-16,-34,-54,-63,-20,84,33,-30,-6,25,1,-4,-101,22,-40,60,-8,47,-12,40,-82,-1,17,96,14,22,23,38,-59,107,34,-58,89,20,-12,-39,49,-24,7,20,14,67,28,-51,24,-32,-5,8,21,54,-9,61,-38,73,24,-3,12,-30,78,-1,2,25,-2,-79,37,-23,25,-64,-31,-45,-5,21,-27,37,17,29,11,-16,-3,-50,66,-24,-33,39,15,80,-51,29,39,-18,-18,-14,28,-1,95,-30,0,35,-7,-21,-22,-34,39,-13,54,-13,-44,16,-10,58,22,-2,11,-5,-22,-11,-27,-65,38,-7,11,17,8,46,-40,-4,-18,47,21,42,9,-45,56,-2,-17,15,47,10,28,-48,-47,51,-24,55,20,50,-21,7,-41,12,-27,37,6,-6,-1,-2,7,-59,-34,26,37,-5,-28,-81,-46,25,-9,24,-36,-37,4,-29,13,-71,69,-28,-20,-10,-40,41,-16,-22,32,-35,-32,-26,-12,-67,12,16,-22,44,-32,14,39,-37,-9,-30,14,-26,-84,36,11,66,15,-11,42,22,73,-16,39,24,10,-78,15,8,-37,-24,37,20,-6,3,10,13,13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.62","t":"Therapist: Let’s go on to the second item on our agenda—reviewing your homework assignment. It sounds like you did not have the opportunity to eat dinner with your wife in the past week. Jack: Nope. Therapist: [gently] What got in the way of doing that? Jack: Just didn’t think of it. She does her thing, I do my thing. Therapist: Is this something you wanted to do? Jack: Yeah, I guess. Therapist: Jack, do you remember the reason why, last week, we determined that having dinner with your wife might be a good thing for you? Jack: You were saying that it could help me to see that other people care, make those relationships better. Therapist: You’re right—my theory was that your depression and anger problems might soften up a bit if you were able to connect with someone who cares about you. But that’s my theory. Do you buy that? Jack: I don’t know; it just seems too far gone. Therapist: What seems too far gone? The relationship with your wife? Or relationships in general? Jack: That one in particular, I guess. Therapist: Do you buy the general idea that re-establishing relationships with others with whom you were once close would have a positive effect on your mood? Jack: [bitterly] Sometimes I think I would be better off without anyone. Everyone just disappoints me anyway. Therapist: [reinterprets] So are you saying that maybe we were barking up the wrong tree? That it might be more effective to develop strategies to improve your mood that don’t involve other people?","e":[52,34,-154,-69,16,65,-17,-59,39,-28,-45,27,29,57,-19,20,36,-30,-68,58,-33,-41,-30,-10,-13,38,-49,46,-85,36,38,-40,-55,-19,-76,-8,33,75,19,-34,32,19,12,-104,51,-89,74,26,19,-23,25,-63,-12,-5,76,30,27,44,39,-75,67,19,-53,75,42,-26,-56,35,-33,-41,40,-30,46,-10,-45,29,-23,-1,46,-19,34,-35,39,-70,20,18,31,9,-11,73,37,2,0,35,-51,2,-11,-15,-39,-42,-49,22,-5,-4,18,34,-15,-7,-3,32,-57,33,-17,-41,10,-27,74,-88,42,49,-18,38,-20,24,35,51,-52,25,-21,-20,-3,-35,-16,45,-8,13,16,-43,-5,7,73,21,-25,-42,-13,-6,-20,-46,-75,34,39,-2,-1,53,33,-60,-23,-11,73,5,35,0,0,6,20,-8,40,55,1,53,-18,-69,-10,-39,21,28,48,-34,5,-5,59,-6,55,-5,18,-4,34,-1,-24,-45,-12,23,-57,-18,-40,-28,45,-37,2,-22,-34,11,-23,50,-52,51,-17,-2,-31,-56,30,-30,-12,34,-33,-26,-12,8,-79,18,41,-8,-16,-6,27,31,-19,-16,-63,4,-44,-119,47,-12,30,31,-18,5,0,100,1,19,17,24,-75,42,9,-24,7,-2,50,30,17,-16,41,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.63","t":"Jack: I don’t know. I think part of my problem is that I’m lonely, too. It’s just that the thing with my wife—it’s probably my worst relationship. Therapist: Ah, so perhaps it would be easier to start with a relationship that wasn’t so strained? Jack: [seems relieved] Yeah, definitely. Therapist: Who might that be? Jack: Maybe I could go over to my neighbor’s. He fixes his truck in the garage a lot. Therapist: Would it be enjoyable to you to go over there and chat with him while he’s fixing his truck? Maybe even help him out? Jack: Yeah. [shows pride] I probably could even show him a thing or two. I used to sell a lot of trucks. Therapist: Given our current discussion, then, what might be a logical homework assignment for the next week? Jack: I see where you’re going. OK, I’ll go over to my neighbor’s when he’s working on the truck. Therapist: OK, we’ve addressed one problem—the fact that last week’s assignment wasn’t a good match for you, since you’re just starting with therapy. We can focus on the relationship with your wife after we’ve had some success with other relationships that have less baggage associated with them. Jack: [laughs out loud] Baggage is an understatement! Therapist: [makes sure to respond to Jack’s positive affect, especially in light of the fact that to this point, he has not demonstrated much motivation for treatment] It certainly sounds like it! [pause] The other issue, I wonder, is having trouble remembering to do the homework. Do you think that’s a problem for you? Jack: Yeah, I guess I just didn’t think about it after I left the office. Therapist: How might we solve that problem? Jack: I don’t know. I’ll have to remember just to look out the window to see if my neighbor is out there. Therapist: What if I were to write down your assignment on this appointment card, underneath the date and time of your next appointment? Jack: That would work. Therapist: And where would you keep this card, so that you have easy access to it? Jack: I’ll have it in my wallet. I have so many appointments these days, it seems like I have to go through the cards every day just to keep them straight.","e":[21,13,-158,-82,-11,23,-3,-31,46,-30,-55,-4,18,36,-40,30,49,-78,-53,19,-6,-21,-24,-15,8,31,-44,18,-55,59,41,-36,-58,-17,-79,-27,56,50,18,-32,32,-8,-34,-114,55,-96,70,31,60,-2,18,-69,-34,46,68,24,38,17,38,-56,82,29,-33,97,45,-15,-17,44,-20,-38,33,6,59,38,-48,67,-13,8,40,16,22,-2,64,-54,23,14,35,31,-27,59,20,52,-1,38,-34,16,-27,1,-49,-53,-49,1,-12,-7,22,41,-29,-3,-16,5,-52,28,-24,-22,20,-6,69,-74,69,41,-26,19,-19,14,26,45,-50,35,6,-18,-16,-35,2,26,-18,36,-2,-20,-16,1,74,7,-21,-24,-11,-11,-19,-67,-57,-1,28,0,3,26,38,-39,-17,-32,84,20,37,-22,-12,31,23,-13,3,55,19,45,-4,-83,-4,-21,26,2,39,-23,17,6,98,-32,81,-4,-20,-19,16,-34,-25,-51,1,28,-51,-17,-44,-32,59,-29,-25,-31,-9,13,9,45,-43,36,11,1,-27,-37,41,-55,-36,37,-21,-26,-1,-2,-89,-5,34,-6,21,-10,9,40,-30,3,-50,14,-62,-79,51,14,39,22,-12,38,5,80,-2,42,24,12,-67,19,3,-24,28,4,53,20,19,-18,29,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.63","t":"Notice that not only did the therapist enlist Jack’s help in brainstorming a way to remember his homework assignment, but she also worked with him to identify a location where he would store the reminder. Helping patients to identify locations for reminders, homework assignments, and the like is crucial, as disorganization and procrastination are problems for many patients, and a concrete plan for doing their homework assignment needs to be in place. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 49","e":[40,0,-170,-77,51,4,33,-19,23,-9,-58,-11,48,23,-12,-25,4,-25,-34,-5,2,-31,-64,-12,19,61,-36,9,-40,27,38,-34,-40,-40,-27,-29,63,55,-18,14,26,-18,-5,-117,18,-18,62,16,31,-6,28,-82,-2,-19,109,-7,19,-1,22,-44,125,59,-68,69,16,-17,-42,41,-63,7,43,4,51,49,-80,13,-38,10,-9,14,63,-1,58,-51,66,18,-4,25,-17,76,-7,18,11,52,-76,25,3,8,-49,-55,-59,-33,1,-14,26,40,5,-17,-9,-14,-57,44,-24,-6,25,30,70,-44,18,22,1,-11,7,23,-6,59,-38,3,32,-9,-28,-26,-19,20,-11,28,-47,-39,7,7,59,2,-19,15,5,-12,-19,-23,-66,-12,4,5,-3,1,59,-38,-34,4,56,30,33,11,-32,39,26,-48,-6,42,22,47,-53,-67,9,-14,68,27,29,-11,36,-16,38,-39,47,28,-22,-11,-1,-28,-39,-55,6,54,-23,-12,-93,-30,50,-29,13,-19,-30,11,-7,15,-55,64,-22,-7,-29,-38,49,-20,-7,16,-22,-7,-9,-3,-64,-3,-1,-10,25,-25,1,31,-29,-29,-19,10,-25,-77,47,2,32,16,-25,43,4,78,0,30,69,23,-79,36,13,-59,2,32,15,-14,-24,5,20,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.64","t":"Discussion of Agenda Items Discussion of agenda items is the central activity that occurs in a CBT \u0002 Mood Check session. Typically, agenda items are addressed in the order agreed upon by \u0002 Bridge from Previous Session both the therapist and patient. As each issue is discussed, the therapist \u0002 Agenda Setting remains cognizant of cognitive behavioral principles underlying the problem \u0002 Review of Preview Session itself and begins to identify ways to use the problem as a means for Homework advancing the case conceptualization and/or skill building. In other words, \u0002 Discussion of Agenda Items regardless of the specific content of the problem introduced by the patient, □ Periodic Summaries the therapist encourages the application of strategies that balance empathic □ Homework Assignment understanding and cognitive and behavioral change to resolve it. Some of these strategies may have been used or taught in previous sessions, and the □ Final Summary & Feedback therapist will work with the patient to identify ways to generalize them to a new problem or issue. Other times, the situation requires a strategy that has not yet been considered in the course of treatment, and the therapist uses that opportunity to introduce it. Throughout the discussion of agenda items, the therapist works to understand the patient’s symptoms and problems in light of the therapeutic relationship and cognitive behavioral theory, and she strategically selects specific cognitive and behavioral intervention strategies (including those interventions that primarily enhance the therapeutic relationship) to address those symptoms and problems. The most important point here is that agenda setting is strategic, rather than an open-ended discussion of the details of patients’ life problems.","e":[31,20,-148,-66,27,10,46,-30,30,18,30,22,38,41,16,-46,-28,-57,-46,-1,-23,-24,-65,9,32,92,-2,30,-44,-9,30,-30,-10,-15,-64,-53,87,23,-32,9,40,15,-2,-115,15,-23,63,5,-4,-61,17,-18,29,-55,101,27,27,74,25,-55,116,26,-32,75,46,-50,-28,36,-32,0,69,15,49,17,-51,5,-16,-30,-22,-3,3,-18,79,-36,46,27,43,27,-18,61,3,-15,5,3,-81,47,-6,-40,-46,-40,-79,-1,-7,-3,-1,6,-29,21,-12,14,-64,30,-63,2,14,-5,78,-17,36,38,10,-30,36,27,24,59,-51,-36,27,-14,-25,-30,-16,-3,-16,42,0,-44,19,-4,29,-2,-8,-8,18,-27,60,-37,-31,18,-18,25,6,4,43,-7,-20,-4,32,50,41,4,-57,33,-29,-28,33,55,46,27,-48,-43,-6,-8,51,50,69,-20,9,-41,1,-6,25,9,-9,-15,27,-60,-18,-31,-3,51,-63,-26,-67,-52,40,-9,34,-51,-29,12,-36,12,-53,64,31,3,-20,-42,77,-24,-11,17,-16,10,-4,18,-6,36,28,-25,-34,-14,2,2,-33,-31,-33,13,-70,-65,13,8,24,13,-8,32,18,52,11,66,52,19,-60,18,-3,-21,-10,34,-5,0,7,14,28,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.64","t":"Many novice cognitive behavioral therapists find it difficult to maintain an agenda as patients begin to talk about their problems. As they begin to discuss their problems, some patients provide excessive detail and background information, which can easily lead to discussion of tangential or secondary issues. In fact, it is often the case that the tendency to become derailed in session mirrors patients’ tendency to become derailed outside of session as they attempt to cope with stress. Thus, we strongly suggest that therapists not reinforce the use of unstructured time. For patients who become unfocused during the discussion of agenda items, we encourage the therapist to model adherence to the predetermined schedule in order to (a) model an organized approach to dealing with life problems, and (b) ensure that there is time to implement one or more cognitive behavioral interventions, so that patients will leave the session with a tangible strategy for addressing their problem and/or managing their distress.","e":[42,31,-155,-72,51,23,49,-25,51,-25,-31,-11,26,79,20,-26,-13,-72,-62,28,-25,-5,-27,-16,-34,60,8,-3,-19,39,57,5,0,-29,-47,-63,52,30,-19,-10,37,11,4,-123,1,-26,74,20,-1,-34,38,-7,4,-28,90,13,2,59,44,-61,125,3,-45,83,2,-19,-51,56,-38,-11,31,-10,47,48,-37,30,9,-28,-13,24,7,-8,46,-46,47,36,37,19,-8,88,1,-17,-16,9,-83,29,-34,-9,-30,-32,-73,-5,-6,-11,12,18,-18,5,-8,-5,-61,50,-34,-9,16,-7,73,-40,36,17,-20,-43,33,59,13,84,-42,-15,53,-2,-60,-27,-6,9,6,33,-1,2,-4,33,42,5,-2,-2,-18,-13,31,-38,-11,25,-15,45,-17,12,43,-34,-27,-24,29,13,58,-4,-47,18,-8,-36,31,36,5,0,-42,-16,-14,-8,79,49,57,-18,28,-41,12,6,-9,-4,4,8,20,-24,-30,-54,-3,36,-33,-4,-65,-50,71,-19,18,-28,-13,-5,-23,19,-49,54,-20,-5,-48,-56,75,-4,-11,29,-53,-39,22,10,-29,66,18,-28,11,-28,12,-13,-54,-9,-27,32,-27,-106,21,30,73,23,-25,46,8,29,-1,45,52,5,-77,-14,22,-39,-16,31,5,11,-10,-10,39,-10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.64","t":"Although cognitive behavioral therapists strive to maintain the agenda set at the beginning of the session, there will undoubtedly be instances in which new topics or problems are identified during discussion of agenda items. When these new topics or problems are associated with significant affect, it is natural for therapists to want to shift focus. It is understandable that the agenda might be tabled in these instances; however, we suggest that therapists address this directly and collaboratively with patients, such that both work to re-prioritize the items on the agenda in light of this new topic or problem. In addition, as stated previously, on occasion the therapist realizes that he did not allocate enough time to a particular agenda item. When this occurs, the therapist clearly acknowledges this, and the two collaboratively revisit the agenda and reallocate the time that will be devoted to remaining items. If they decide that one or more items should be put on hold until the following week, then the","e":[36,26,-143,-40,50,28,45,-20,39,-1,-34,11,44,65,29,-33,-15,-54,-35,43,-12,-13,-51,-22,-14,72,-5,14,-28,14,54,7,-30,-40,-30,-78,66,23,-24,-4,27,23,5,-140,21,-28,74,14,28,-58,44,-14,-22,-34,85,15,15,71,41,-61,124,21,-42,74,27,-21,-40,50,-56,-10,39,14,79,42,-40,9,8,-41,-21,10,14,-23,73,-33,34,44,31,52,1,92,26,-14,-18,33,-71,34,-16,-8,-61,-19,-72,-3,0,-17,10,5,-17,10,-17,22,-57,20,-51,18,14,-1,83,-47,40,40,-14,-50,11,55,23,58,-66,-26,48,-17,-40,-26,9,9,5,30,-3,-16,22,18,49,12,3,0,11,-33,43,-26,-12,17,-16,19,-9,19,58,-49,-25,-10,20,5,57,0,-39,21,-21,-24,19,25,8,13,-49,-22,-7,-4,66,51,65,-13,8,-40,-13,-25,-2,4,-1,8,10,-23,-23,-38,-8,41,-36,0,-50,-64,44,-35,23,-31,-26,0,-45,28,-54,54,14,-12,-42,-61,84,-13,-29,24,-39,7,-20,-3,-37,62,6,-10,-17,-4,18,-14,-43,-22,-13,33,-29,-92,33,47,60,29,-29,45,22,53,8,28,62,1,-84,27,36,-32,-18,35,11,3,11,26,29,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.65","t":"therapist takes care to make note of this and adds it to the agenda in the following session if the patient continues to view it as a priority. Periodic Summaries Periodic summaries occur throughout the course of the session and ensure that the therapist and patient have a mutual understanding of the nature of \u0002 Mood Check the problem being discussed as well as the solutions that have been \u0002 Bridge from Previous Session identified. Periodic summaries are often made at the close of discussion of \u0002 Agenda Setting an agenda item. The therapist and patient can both make periodic \u0002 Review of Previous Session summaries. When a therapist makes periodic summaries, it communicates Homework","e":[39,-8,-182,-68,0,-31,23,-4,36,-11,-13,9,56,38,-7,-44,-12,-55,-48,5,-44,-16,-50,-2,11,88,15,-11,-41,-16,41,-36,-31,-26,-45,-60,44,15,-24,13,54,43,-4,-82,22,-51,54,-28,-27,-43,23,-65,-16,-14,103,49,31,31,88,-47,115,38,-36,55,30,-14,-28,31,-31,12,38,9,48,9,-22,29,-23,5,-20,4,27,-16,108,-48,50,27,18,29,-47,96,4,-20,21,29,-95,15,-7,-4,-61,-47,-60,2,25,-25,37,14,-10,-21,-9,7,-35,31,-43,17,45,-8,83,-42,34,71,-46,-33,2,44,3,58,11,3,17,-14,-5,-29,-26,31,17,57,12,-24,14,-6,63,-14,-4,-1,-5,-34,12,-53,-40,37,-1,32,-22,12,38,-31,-32,8,60,15,46,-26,-73,47,7,-25,35,50,9,13,-33,-26,7,-6,61,28,55,-35,56,-46,30,-52,45,-8,-9,-36,16,-44,-39,-22,-8,58,-30,-3,-42,-38,31,-36,17,-48,-13,25,-43,14,-56,82,10,-10,-40,-28,49,-33,-7,46,-15,13,-30,-30,-9,44,35,-24,-13,-40,-4,15,-43,-3,-42,12,-57,-116,25,-12,21,14,-13,45,18,53,10,7,59,14,-72,40,2,-18,-1,43,43,-1,6,24,11,-35]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.65","t":"empathy because it demonstrates an accurate understanding of the \u0002 Discussion of Agenda Items symptoms and problems with which patients present. When patients make \u0002 Periodic Summaries periodic summaries, it consolidates learning and provides a base from which □ Homework Assignment they can implement meaningful changes in their lives. Below we summarize □ Final Summary & Feedback prompts that therapists can use to encourage patients to make periodic summaries.","e":[52,24,-175,-103,27,-17,32,11,43,20,-8,-4,85,35,-8,-14,-4,-29,-54,29,-64,-13,-29,-5,15,72,15,-25,-52,-11,32,-11,1,-12,-38,-53,61,41,-2,16,30,34,30,-65,20,-44,45,-10,35,-70,-13,-85,-20,21,139,27,49,23,58,-36,66,43,-31,79,55,-17,-30,6,-12,1,51,-19,28,27,-24,11,-35,5,-3,31,58,-13,50,-16,56,4,4,14,-29,85,0,13,43,25,-87,13,-6,30,-24,-33,-69,-3,41,-29,70,1,-20,2,27,-2,-20,55,-30,-20,49,-18,67,-33,19,89,2,-41,-27,57,-3,46,-1,9,8,-20,12,-32,-55,7,23,48,-9,-32,28,36,58,2,-11,-8,-28,-31,-11,-46,-27,31,-13,47,-7,16,28,-36,-22,7,56,3,47,-16,-88,38,-2,-20,36,8,5,4,-30,-4,30,1,35,1,45,-27,51,-59,29,-69,76,-29,0,-25,3,-47,-26,-17,29,54,-20,-1,-55,-37,17,-16,14,-57,-3,22,-50,12,-48,66,-15,-28,-13,-30,62,-27,-11,41,-7,15,-36,-35,-12,28,38,-44,0,-24,-40,7,-17,-22,-60,7,-60,-109,56,5,32,21,18,29,14,42,27,-13,28,7,-76,33,11,-48,-7,38,21,15,10,-9,41,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.65","t":"Strategies for Eliciting Periodic Summaries from Patients Can you summarize for me, in your own words, the key elements to this problem? The key parts of the solution? What are you going to take away from this discussion? What are you going to do differently as a result of this discussion? What have you learned from this discussion?","e":[16,30,-170,-47,32,-38,7,-27,61,-8,-14,7,71,34,-1,-37,-8,-56,-30,29,-50,-30,-30,-39,25,47,14,10,-67,5,4,-14,29,-34,-57,-32,14,2,-32,2,56,33,8,-63,33,-40,37,-21,-38,-39,30,-65,4,-14,113,22,19,14,94,-29,132,11,-49,34,38,-24,-42,65,-14,0,37,28,46,-26,-51,12,-28,18,10,39,46,-37,91,-40,42,43,0,5,-15,64,-10,-2,54,23,-98,5,-10,-7,-71,-48,-55,-2,32,-25,43,24,14,7,19,4,-48,31,-29,-12,-4,13,85,-37,25,66,-33,-9,-8,43,0,50,-27,8,31,5,29,-44,-67,21,31,48,6,-22,67,6,70,3,-1,1,-24,-41,-35,-27,-12,20,16,43,16,22,57,-58,-9,8,5,-17,43,-37,-62,23,-2,-34,38,44,19,28,-22,-23,-4,-7,85,3,74,-23,-8,-51,48,-41,27,4,1,-18,27,6,-34,-32,7,47,-8,-30,-33,-19,55,-12,52,-46,-9,0,-60,29,-33,88,-15,-37,-23,-16,51,-22,-33,38,-42,7,-16,-34,-17,56,40,-24,-49,13,-7,8,-16,4,-55,-10,-43,-115,35,-18,11,-14,-7,46,-26,21,19,-14,61,-20,-82,33,7,-28,-4,24,32,15,15,3,22,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.65","t":"Periodic summaries also can be used strategically when the therapist perceives that the session is not running as smoothly as it might. For example, patients who are becoming increasingly agitated and unfocused while discussing an agenda item benefit from periodic summaries that slow down the pace of the session and hone in on the main points of the issue. Moreover, periodic As Dr. Aaron Beck has said summaries allow the therapist and patient an opportunity to revisit the numerous times when training agenda and make modifications to existing agenda items as necessary. therapists, “When you feel At other times, the therapist may feel “stuck” in determining the next ‘stuck,’ then do a summary.” step to take or may find that the patient is responding negatively to all of the therapist’s interventions. In such instances, periodic summaries allow for time for both the patient and therapist to reflect on the problem and may facilitate engagement in the therapeutic process. As Dr. Aaron Beck has said numerous times when training therapists, “When you feel ‘stuck,’ then do a summary.”","e":[32,32,-191,-76,11,-65,50,1,66,-21,-16,0,54,27,-6,-58,8,-45,-60,9,-35,-3,-31,-11,12,79,6,-35,-48,12,50,-38,-34,-3,-60,-58,51,4,-9,-2,59,31,7,-79,19,-52,72,-30,-46,-66,25,-70,-22,2,105,21,51,9,74,-42,98,14,-40,42,28,-36,-30,16,-27,-20,58,-6,49,1,-53,29,-29,4,-9,13,12,-22,95,-37,39,33,25,2,-29,73,1,-10,11,58,-82,23,0,-19,-48,-35,-83,16,34,-23,27,13,10,-32,1,3,-24,41,-34,-9,8,0,82,-43,11,69,-34,-18,-18,50,8,72,-6,4,40,-12,4,-31,-48,28,18,76,-5,-19,11,47,75,-46,5,6,-4,-30,-20,-36,-28,31,-7,45,-21,30,40,-42,-12,18,50,7,38,-28,-78,33,16,-1,16,47,-12,-13,-7,-18,-2,-30,65,19,75,-28,16,-56,33,-30,53,-16,4,5,12,-26,-19,-28,12,50,-47,12,-49,-42,39,-21,20,-43,8,-4,-44,2,-27,52,-17,-8,-37,-10,75,-24,7,59,-44,-10,-6,-25,-3,60,30,-19,-36,-33,-7,-13,-22,-20,-54,0,-84,-117,28,4,34,-23,18,48,5,69,24,-5,38,-4,-67,45,22,-16,-2,34,49,2,26,-16,36,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.65","t":"We caution therapists to resist making statements of interpretation during periodic summaries. The purposes of periodic summaries are to reinforce the learning that has taken place, communicate that the therapist accurately understands the patient’s problems, and link the patient’s problems back to the cognitive behavioral model. Making interpretations of the material patients discuss in session runs the risk of inaccurately characterizing their internal reality or telling them which maladaptive cognitions and/or behaviors contribute to their problems, rather than allowing them to determine this on their own. The following is a dialogue that represents a straightforward periodic summary with Michael, which occurred after he and his therapist finished the first item on their agenda—addressing suicidal thoughts.","e":[42,9,-165,-98,10,-35,40,3,41,-14,-10,0,66,45,-9,-41,-13,-41,-46,24,-66,7,-46,5,28,77,12,-23,-47,25,51,-17,-29,-15,-72,-58,43,45,-33,-9,25,39,3,-60,19,-28,53,-41,-37,-70,44,-84,34,-6,119,34,19,-13,52,-63,104,38,-33,27,18,-45,-46,20,-32,5,72,-5,26,-17,-35,0,-19,19,-3,10,18,-25,70,-29,40,45,38,4,-26,67,-7,-21,16,27,-85,9,-34,-9,-39,9,-92,16,35,-33,24,23,20,0,23,5,-37,73,-41,-42,41,-7,92,-40,18,69,-32,-15,-11,56,-20,46,16,3,35,-34,-3,-31,-48,42,51,34,-13,-32,13,34,77,-12,-28,-4,9,-39,6,-61,-29,30,-6,80,-23,12,31,-32,-42,-14,37,28,42,-16,-89,58,-14,-10,21,43,-1,1,-24,-12,-4,-10,46,17,51,-35,24,-35,33,-33,84,-10,4,-23,15,-21,-33,-1,10,54,-65,-2,-53,-50,32,-14,27,-44,-19,1,-54,16,-44,67,-44,-13,-58,-3,43,-43,6,48,-16,-22,-2,-35,2,52,7,-21,-15,-39,-22,4,-15,-40,-48,-9,-60,-106,30,10,22,9,18,31,8,41,16,9,30,-6,-61,40,31,-39,-17,15,29,3,15,13,37,-39]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.66","t":"Therapist: Michael, can you summarize for me what we’ve done here for the past 15 minutes or so? Michael: We’re thinking of ways to deal with my suicidal thoughts. Therapist: That’s right. And which of these strategies do you think will be most helpful to you? Michael: Talking to my mom, definitely. Therapist: Anything else? Michael: I liked the idea of going for a walk in the park. Anything to get out of that cramped apartment. Therapist: What have you learned from this discussion? Michael: That, really, I’m not feeling suicidal all the time. I guess if I can get my mind on something else, it will pass. Therapist: And why do you think these strategies will be helpful for you? Michael: Um, I guess I don’t feel so alone when I talk to my mom. And walking in the park lets me clear my head. Therapist: That’s great, Michael. You are taking an important step in your recovery. Should we move onto the next item on the agenda?","e":[34,15,-132,-23,36,33,13,0,32,-10,-59,-29,24,36,-53,15,1,-80,-20,53,-85,-27,-34,8,19,50,-13,37,-76,66,82,-38,-34,-4,-94,-21,26,83,17,-56,29,2,3,-113,27,-76,77,-20,12,-37,10,-42,-3,1,61,-4,49,13,23,-53,97,37,-24,25,57,3,-98,52,-46,-19,82,-8,25,6,-50,63,12,-17,50,28,-9,-22,38,-53,21,40,21,20,-25,66,-18,34,2,33,-81,36,-42,8,-27,-70,-69,-2,-31,-25,62,63,13,-33,-13,30,-30,16,-34,-25,-8,1,65,-108,62,46,-21,33,-12,9,50,49,-32,19,-4,-4,-4,-43,-38,41,-30,51,19,-22,-12,-10,63,11,-15,-14,4,-39,15,-7,-31,-13,8,38,4,28,15,-78,-24,-3,59,1,13,24,-7,36,16,-43,50,39,17,-12,-16,-71,-11,-10,72,-28,46,-19,-10,-27,79,15,50,7,-6,-19,16,-26,-32,-48,6,20,-46,-23,-42,-16,89,-69,34,-24,-28,6,-49,10,-33,61,-9,-5,-14,-14,64,-29,5,17,-55,-15,-7,-9,-47,29,0,20,-9,2,14,30,-52,4,-1,4,-30,-71,44,3,15,17,-27,19,12,84,22,48,44,16,-71,44,20,1,25,35,36,29,-4,-22,45,-10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.66","t":"Homework Assignment Homework is an essential component of CBT. We find that patients are often adept at • Homework “talking through” strategies for managing their symptoms and problems in session, assignment but that it is much more difficult for them to implement these strategies in their daily lives. Homework provides an opportunity for patients to test out cognitive and behavioral skills in their own environment. Practicing cognitive strategies can help to make the process of gaining a balanced perspective just as automatic as the automatic thoughts patients experience. Moreover, approaches for \u0002 Mood Check modifying unhelpful thinking are strengthened by carrying out behavioral \u0002 Bridge from Previous Session \u0002 Agenda Setting homework assignments that are consistent with a new way of thinking. For \u0002 Review of Previous Session example, individuals who think that they no longer enjoy anything may find Homework that engaging in pleasant activities helps them to recognize that they do \u0002 Discussion of Agenda Items enjoy some activities. Although we include this section on assigning \u0002 Periodic Summaries homework near the end of the section on CBT session structure, in practice, \u0002 Homework Assignment homework assignments can be developed at any point in the session when it □ Final Summary & Feedback is logical to devise a homework assignment following the discussion of an agenda item.","e":[52,6,-163,-57,41,-20,30,-10,37,3,6,8,54,57,-10,-24,-18,-47,-28,1,-3,-28,-19,8,30,54,-36,-6,-30,24,22,-32,-17,-10,-65,-34,79,25,-43,7,26,3,3,-83,51,-7,95,1,35,4,7,-71,23,0,116,32,23,16,25,-33,113,46,-48,75,2,-26,-39,68,-51,32,39,3,69,28,-64,-3,-17,-19,-5,25,58,-21,77,-28,94,13,2,2,-49,85,0,-13,9,18,-65,30,-2,20,-53,-30,-86,-5,12,-10,20,38,-19,-14,-11,13,-62,38,-28,-3,35,37,78,-31,46,68,-4,-34,3,35,10,85,-55,-20,39,-23,-24,-28,-21,9,8,37,-32,-29,6,-10,49,10,1,39,-4,-16,12,-39,-64,12,-13,-5,27,-14,46,-29,-15,-12,39,26,34,-11,-83,37,-8,-36,10,71,37,48,-65,-59,17,11,45,27,40,-16,21,-18,23,-17,17,30,2,-11,12,-16,-40,-28,21,41,-13,-24,-79,-47,33,-22,11,-44,-27,13,-22,14,-48,79,-12,-27,-10,-45,70,5,-19,14,-21,5,-28,-22,-43,-1,16,-19,28,-25,12,27,-16,-13,-33,32,-30,-82,45,-13,28,37,2,24,5,62,0,48,51,-2,-92,40,19,-55,-20,27,21,-21,-4,13,33,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.66","t":"It is more likely that patients will actually do the homework assignment if they develop the assignment themselves rather than complying with an assignment that the therapist gives them. To foster collaboration, the therapist may say, “On It is more likely that patients the basis of what we have discussed today, what is something that you will actually do the homework would like to work on this week?” The therapist then helps the patient to shape the homework assignment to best meet his or her needs or assignment if they develop the goals. It is vital that the therapist and patient collaborate in developing assignment themselves rather the homework assignment so that the patient takes ownership over it than complying with an and invests in it. If therapists find themselves in a situation in which assignment that the therapist they are taking the lead in developing a homework assignment, then gives them. they can solicit patients’ input in modifying the assignment so that it is as individualized as possible.","e":[40,16,-138,-33,43,16,17,5,13,-11,-29,-6,58,33,-49,14,41,-59,-32,38,-28,-41,-29,0,14,24,-34,-23,-40,9,48,5,-14,-37,-66,-49,68,34,-29,-11,-20,22,-17,-104,32,-54,59,-29,57,-4,19,-54,-20,29,100,41,32,4,36,-49,83,68,-71,62,30,0,-33,57,-12,22,21,32,90,2,-63,10,12,-20,26,17,79,-18,43,-47,68,26,-14,30,-33,102,22,16,38,4,-86,2,-17,21,-58,-46,-60,3,35,-27,25,33,20,4,-18,22,-50,49,-43,-20,43,10,58,-44,37,54,-14,-25,-13,38,12,81,-54,-2,33,-18,-5,-22,-61,9,-27,55,-40,-27,26,-3,44,25,1,8,-21,-12,16,-12,-58,42,-8,6,30,11,32,-50,-15,-14,33,4,64,-5,-44,57,-2,-37,22,43,0,25,-20,-50,29,37,48,32,41,-3,19,20,49,-46,26,-18,5,-21,-3,-36,-60,-14,26,37,13,-23,-61,-44,37,-36,21,-23,-39,14,-37,26,-65,84,-35,-16,-19,-43,40,-8,-30,25,-28,-17,-42,-1,-90,12,19,0,27,-16,-3,25,-42,-15,-18,47,2,-67,40,-11,52,24,-15,31,24,81,10,5,53,-3,-62,44,17,-56,-22,34,23,-13,-1,10,-2,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.67","t":"There are several other strategies that cognitive behavioral therapists can use to ensure that homework is successful. As much as possible, the homework assignment should be a “win-win” proposition, so that patients are set up for success and that the possibility of falling short is minimal. In most instances, there should be no more than two components of the homework assignment so that patients do not become overwhelmed or discouraged by their magnitude. Homework Homework assignments should assignments should always be written down during the session, and both always be written down during the patient and the therapist should retain a copy of the assignment. the session. When relevant and time-permitting, homework assignments should be started in session so that patients have a model when they attempt to complete it on their own. When development of the homework assignment is saved until the last few minutes of the session, it runs the risk that it will not be developed fully, patients will not fully understand the rationale for it, and patients will not fully understand how to carry it out.","e":[75,12,-140,-26,49,-11,33,-10,8,9,-25,-5,48,55,-26,-19,13,-71,-17,15,-2,-27,-44,14,20,51,-43,-19,-27,25,28,18,-44,-54,-59,-41,73,21,-43,-1,13,16,1,-83,51,-30,65,-24,56,19,31,-65,-8,14,92,19,4,-10,19,-51,118,25,-64,66,1,0,-46,84,-29,27,35,7,108,11,-49,-16,-19,-26,19,30,42,-6,66,-38,76,22,-10,15,-40,85,-11,6,23,23,-47,30,-17,48,-68,-25,-63,-8,1,-21,17,33,17,1,-17,14,-61,52,-28,-16,25,53,80,-35,53,48,-11,-42,-4,16,6,78,-64,-18,46,-16,-35,-24,-28,18,-18,40,-28,-13,22,-25,35,20,-1,34,-12,-23,1,-23,-27,21,-7,10,21,-8,55,-42,-15,-28,29,32,40,-17,-70,42,-27,-24,3,54,-3,30,-63,-43,17,9,40,22,26,-9,16,-10,30,-24,17,21,0,-3,18,11,-54,-7,41,22,-22,-11,-75,-48,48,-32,24,-16,-37,27,-20,17,-68,73,-13,-18,-11,-49,47,1,-29,22,-22,-21,-35,-15,-70,12,-4,-12,39,-24,-4,47,-45,-2,-15,46,-12,-80,22,-14,57,28,-13,33,22,78,-21,30,66,-5,-95,34,0,-51,-14,30,27,-22,7,25,1,0]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.67","t":"In most instances, it is helpful to obtain a commitment to complete the homework assignment by asking the patient, “On a scale of 0 to 100, with 0 being ‘very unlikely’ and 100 being ‘very likely,’ how likely is it that you will do the homework?” If the patient indicates a rating less than 90, then more time is devoted to ensuring that the assignment will be successful. For example, it often is helpful to ensure that the patient can articulate the reason for doing the assignment. Obstacles to completing the assignment can be anticipated, and strategies for overcoming those obstacles can be identified.","e":[44,53,-155,-43,50,18,6,4,5,7,-23,1,42,51,-24,7,43,-101,-17,17,-11,-38,-39,-13,16,22,-32,-43,-63,31,-4,-2,5,-52,-53,-47,41,35,1,-27,4,-21,21,-52,50,3,51,9,70,-5,5,-42,-1,24,68,61,-15,9,46,7,117,32,-44,59,32,12,-50,69,-12,26,11,-1,39,-5,-96,24,-4,-14,12,37,65,-15,84,-13,57,27,-23,11,-34,92,-9,6,31,4,-59,35,-21,55,-60,-53,-39,-2,-2,-17,5,59,30,29,17,4,-34,39,-34,-40,28,28,69,-43,34,36,-19,-19,5,54,-19,36,-38,12,47,-25,-1,-23,-44,12,-39,52,-27,-23,15,2,52,24,16,15,-31,-9,-13,0,-27,14,-3,-4,38,-19,24,-56,6,-4,19,25,101,1,-47,55,-11,-39,8,51,-2,38,-45,-41,69,18,51,7,40,2,15,-4,62,-34,40,14,-40,-29,39,1,-64,-6,7,5,11,-25,-61,-24,64,-29,11,-37,-38,13,-36,11,-55,71,-1,9,-15,-35,37,-18,-34,29,-5,-15,-32,7,-64,20,32,-34,69,-5,38,52,-54,1,-30,30,9,-89,45,4,15,34,-2,19,11,42,-19,2,41,-15,-80,22,17,-47,-9,71,26,-23,-1,30,8,18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.67","t":"The following is an illustration of an instance in which the development of the homework assignment runs smoothly. At this point in the session, Kate and her therapist were discussing Kate’s financial concerns and her difficulty finding a job.","e":[49,31,-165,-16,21,41,11,-18,17,5,-49,-6,68,59,-46,18,26,-33,-21,43,-9,-23,-27,19,33,42,-57,-27,-41,7,27,-9,-9,-68,-67,-57,69,40,-4,-27,18,7,14,-80,33,-67,38,1,11,-26,14,-36,-19,18,86,49,23,23,29,-45,88,32,-50,76,40,-31,-34,77,-29,1,36,-1,52,16,-53,-22,-10,-21,-8,29,57,-2,28,-18,65,23,11,31,-9,80,-5,28,38,13,-81,2,-24,26,-61,-49,-58,-28,20,-2,70,39,-3,-8,-22,10,-46,39,-26,-6,46,1,57,-35,45,38,-25,-20,5,38,23,86,-42,16,23,2,-8,-33,-27,29,-21,68,-36,-20,6,-18,95,6,-30,-15,-7,-35,33,-29,-19,30,0,1,-2,6,37,-26,-4,4,59,16,68,-10,-12,39,-20,-13,13,41,20,25,-39,-72,11,19,29,6,70,-2,13,-6,41,-86,40,-31,-8,-17,-16,-40,-45,-40,2,28,-24,-34,-56,-83,65,-31,21,-33,-3,26,-57,48,-48,70,-17,-24,-11,-33,72,-3,-14,39,-1,-41,-5,-6,-67,6,8,-18,-4,-9,41,14,-52,3,-42,40,-51,-81,33,7,17,42,-20,25,-10,73,-13,20,24,-3,-41,29,31,-37,-3,35,8,-29,27,28,14,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.67","t":"Therapist: It sounds like there is one job possibility out there, the one at the clinic, even if it is not optimal. What might be a next step in resolving this issue? Kate: I guess I should put in an application. Therapist: Would you like to make that your homework assignment? Kate: Yes, I think that would be a good idea. Therapist: Let’s do everything we can to make sure this is successful. What are the steps you will take in submitting a job application? Kate: I need to complete the application on the Internet, have my transcripts from the nursing school sent, make sure my references know that someone may contact them … Ugh, it seems like a lot of work. Therapist: Yes, there are several steps to making this happen. Let’s talk about each of these steps. Maybe it would be a good idea for you to write down the steps so that you have a guide you can follow? Kate: OK. [pulls out a notebook and pen] Therapist: The first thing you had mentioned was that you need to complete the application on the Internet. How are you going to do that? Kate: I need to find the website for the clinic. Therapist: And how are you going to do that? Kate: I’ll search for the name of the clinic. I should be able to find it.","e":[-20,14,-136,-34,22,7,2,10,37,-11,-59,-32,74,29,-59,-3,16,-64,-23,10,-29,-92,-4,-12,3,32,-43,15,-46,23,35,-26,-9,-58,-59,-49,25,23,-33,-11,52,-29,-13,-104,23,-68,77,24,27,-66,-12,-61,-16,47,62,17,86,54,-8,-23,135,61,-70,84,35,2,-31,64,3,-34,5,39,67,30,-38,19,-31,-41,-2,32,67,-7,62,-22,3,29,12,40,-9,85,-28,61,-11,11,-49,15,-11,6,-57,-71,-78,-39,-2,-24,44,33,18,-44,11,8,-21,33,-36,8,36,6,49,-38,49,61,-10,6,-21,45,47,60,-78,-9,-13,17,24,-25,-28,42,-2,31,-16,-39,23,-10,58,-3,-6,-12,-13,-47,0,2,-28,20,16,9,24,8,74,-44,1,11,51,42,96,-12,-5,51,-16,-14,-11,48,-3,20,-22,-41,11,-2,42,1,27,-9,2,-24,91,-71,26,1,-10,-11,4,-8,-20,-46,9,62,-21,3,-57,-18,46,-65,22,-32,11,53,-43,28,-22,51,29,-10,-32,-20,56,-16,-17,60,3,-9,-2,-28,-111,32,43,-40,33,-14,3,28,-55,18,-8,50,-17,-66,29,3,33,34,-9,28,-15,83,-12,29,25,-15,-74,4,18,-29,-9,55,43,-7,27,8,40,-36]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.68","t":"Therapist: Sounds good. Do you need to do anything else in completing the application online? Kate: Yeah, I need to look at my resume because it has information about my job history that I’ll need to list on the application. Therapist: So, to fill out the application, you are going to search the Internet for the clinic website and retrieve your resume. Do you know where it is? Kate: Sure do. I keep a copy on my home computer. [writes down the steps] Therapist: The next step you mentioned was to have your transcripts sent to the clinic. What does that involve? Kate: I need to go to the school website and request that they send the transcripts to the clinic. [writes down next step] Therapist: Have you done that before? Kate: Yeah, it’s easy when you can just place an order online to have your transcripts sent. Therapist: Let’s see, the final step was that you were going to contact your references. What does that involve? Kate: My references are listed on my resume. I just need to let them know that a potential employer might be contacting them. Therapist: How are you going to do that? Kate: Well, I could give them a call and ask them. Hmm, maybe I could just send them an e-mail. That would be easier. [writes down to e-mail her references] Therapist: So, what have you written down? Kate: First, I’m going to search the Internet to find the website where I can apply online. Then, I’m going to find my resume on my computer to complete the application. Next, I’m going to the nursing school website and request that they forward my transcripts, and then I’ll e- mail my references and let them know that they might be contacted. Therapist: That’s terrific. So, on a scale of 0 to 100, with 0 being extremely unlikely and 100 being extremely likely, how likely is it that you will complete all of these tasks? Kate: Oh, it’s very likely. I have to, or I’m going to get evicted. Therapist: So you’re 100% likely to do this? Kate: Definitely. Therapist: Do you think it would be helpful to plan out when you will do each of these steps, in order to make sure you get to all of them in between now and the next session? Kate: Yeah, that’s a good idea. I can start by filling out the application online when I leave here today. Therapist: That sounds like a great start. What about getting your transcripts from the nursing school? Kate: I can do that today as well. Therapist: Sounds like a plan. Kate: And then I’ll send the e-mail messages to my references tomorrow. Therapist: So, today you will complete the application online as well as get the transcripts sent and then tomorrow you will e-mail your references. I think you’re all set.","e":[10,14,-139,-55,14,-6,4,36,39,-10,-74,-24,70,15,-46,0,30,-70,-46,6,-34,-107,-30,-2,-12,28,-49,-6,-62,24,63,-14,11,-39,-55,-49,-6,7,-32,-26,82,-8,-38,-72,31,-44,88,17,-3,-59,-20,-52,-38,53,60,-17,75,67,-4,-34,144,70,-71,87,40,7,-15,70,6,-15,15,26,44,11,-6,20,-40,-56,7,43,53,-13,49,-15,5,16,18,46,3,51,-22,61,-26,25,-36,34,5,-14,-55,-77,-66,-35,1,-18,45,28,18,-42,33,-1,-12,40,-45,27,16,-1,55,-42,51,38,3,2,-17,23,41,53,-59,-4,-1,5,-3,-3,-56,28,17,42,-3,-53,10,3,57,2,-14,-32,-8,-36,3,-7,-21,20,4,6,-9,22,83,-56,-12,-10,60,62,83,-22,22,52,-3,-18,-20,39,-1,15,8,-26,5,-8,11,-1,42,-4,15,-35,110,-68,31,5,-5,-15,5,4,1,-46,19,47,-36,6,-47,-14,48,-16,3,-43,9,45,-23,14,-12,55,43,-1,-53,-24,51,-37,-1,62,33,-1,11,-43,-80,35,55,-30,46,-9,-14,30,-57,8,-9,27,-24,-69,30,12,26,14,-36,26,-36,78,8,30,18,7,-75,-24,27,-38,-14,45,41,12,41,-10,44,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.69","t":"Developing homework often does not run as smoothly as it did in this example with Kate. For example, Claire’s therapist suspected that her anxiety and agitation would escalate if she continued to stay at home ruminating over the fact she had not heard back from the medical board about being reinstated to her position. Her therapist also anticipated that it would be helpful to begin developing adaptive coping skills in the event that the board determined that she would be unable to fly again. Thus, she presented this rationale to Claire and encouraged Claire to identify pleasurable, distracting activities in which she could engage while she was waiting for the board’s response. Although Claire agreed, in theory, that these strategies would be helpful, she had trouble committing when they began to develop a concrete homework assignment.","e":[85,19,-154,-25,42,24,10,9,40,-26,-74,-18,90,90,-22,9,3,-45,-44,-10,-11,-38,-20,19,10,44,-38,-24,-61,31,21,-34,-41,-77,-45,-18,40,25,-16,-25,21,5,17,-85,25,-44,77,-29,24,-31,34,-50,-23,0,102,55,30,-6,40,-63,94,26,-54,57,22,-1,-52,60,-31,3,53,-17,44,20,-52,-2,-11,-31,0,25,58,-3,50,-36,65,43,18,19,-17,80,10,14,15,3,-65,14,15,10,-83,-21,-58,-19,18,-10,22,19,-13,-19,-2,10,-53,33,-67,-16,36,4,46,-55,20,13,-28,-16,-13,24,35,98,-55,-17,23,5,-11,-18,-51,38,0,52,-35,-15,9,16,82,-6,-20,-30,-19,-21,16,-2,-38,-11,-14,4,11,20,71,-12,-26,31,40,29,83,-6,-49,47,-9,-15,12,57,24,37,-54,-52,21,-11,43,6,97,-21,-13,-21,39,-64,23,17,5,-21,16,-4,-59,-78,5,18,-29,-13,-69,-66,46,-27,24,-17,-13,12,-27,28,-35,66,-16,-59,7,-46,78,18,-25,26,-1,-23,-19,-9,-47,17,1,-40,-18,7,3,36,-26,-16,-16,8,-18,-102,35,10,44,32,-47,35,-9,62,-12,36,44,-13,-51,8,34,-4,-43,33,15,-11,26,18,12,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.69","t":"Therapist: It sounds like you agree that finding some activities that you enjoy to occupy your time in the next week would be helpful. Might this be a good homework assignment for the next week? Claire: Sure, I guess so. Therapist: OK, let’s talk more specifically about what you might do and when. Any ideas? Claire: Well, I really need to read up so that I can take the test so that I can be promoted to the next level, so that I can fly a bigger plane. Therapist: [hypothesizing that focusing on a work-related activity would likely increase her rumination on the board’s decision and would not contribute to increasing her repertoire of coping strategies] How much do you enjoy studying for a test like that? Claire: Oh, I enjoy it a lot. I would feel totally stressed out if I didn’t prepare. Therapist: It sounds like you enjoy studying because it reduces stress. But what about an activity that you enjoy in its own right, not just because it makes you feel less stressed? Claire: You mean like going out to dinner or something? Therapist: Sure, if that’s something you truly find enjoyable. Claire: Well, I wouldn’t find it enjoyable. It’s a waste of time. I have too much studying to do right now. Between studying and all of these medical appointments, I don’t have much free time. Therapist: So over the past few weeks, you’ve pretty much been spending your time studying and going to appointments, right? [Claire nods] Anything else? Claire: Not really. Just those things and taking care of my apartment, which takes more effort now that I’m an amputee. Therapist: And how would you say your mood has been in the past few weeks? Claire: [reluctantly] Bad, I guess. I’ve been really preoccupied with the board’s decision. And I’ve been so anxious that I haven’t been sleeping well. Therapist: Is it preferable to keep things the way they are, or is it preferable to do something different? Claire: [becomes tearful] Of course, it’s preferable to do something different. I hate feeling like this. And people hate being around me, too. But I just don’t know what I can do. Therapist: That’s what I’m here for—I can help you find ways to manage your anxiety and improve your life, no matter what the board says.","e":[30,37,-140,-47,2,5,22,-38,73,-12,-40,15,36,37,10,-13,18,-65,-49,-7,-51,-42,-28,23,-14,73,-51,10,-83,50,20,-36,-16,-34,-44,-13,33,102,2,5,52,8,22,-141,32,-78,106,-37,23,-44,22,-93,-28,37,124,1,24,17,41,-63,122,8,-72,81,43,-16,-50,33,-37,-14,57,3,52,24,-57,19,-6,-31,23,4,17,-5,52,-34,42,15,23,19,2,96,16,25,16,25,-55,3,38,0,-53,-58,-61,14,-19,-1,27,12,-27,-60,-19,8,-38,51,-23,-45,5,22,50,-88,12,15,-16,4,-10,12,34,72,-72,17,13,32,-5,-26,-26,40,-27,68,8,-31,0,14,59,4,-41,-26,-11,-7,3,-1,-33,-7,-1,8,5,10,58,-24,-13,9,46,30,61,-10,-41,33,19,-5,21,62,34,32,-23,-72,-4,-8,26,-36,28,-5,1,-20,71,-15,28,-10,4,-12,10,-3,-44,-51,-3,-2,-46,-14,-80,-25,37,-38,-9,-9,-52,9,-29,11,-33,51,-4,-62,-41,-32,74,-6,-17,60,-11,-45,-22,3,-47,45,44,-55,10,-4,-9,26,-25,-5,-33,-31,-25,-85,55,15,31,40,-42,38,3,86,11,47,40,-17,-52,23,22,20,-15,22,38,7,29,21,27,9]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.70","t":"Claire: OK. Therapist: Think back to a time when you were feeling much less anxious. [pauses so that Claire can generate a mental image] How were you spending your time? Claire: I guess that would be two years ago. I was working a lot—of course, you know how much I love flying. But I guess I was doing other things, too. I had just moved into my apartment, and I was having a lot of fun decorating it. And there were some other people that had also started the new job with me—we went out and socialized from time to time. Therapist: Good, Claire. You’ve identified two activities—decorating your apartment and socializing with friends. Is there any way to do either one of those activities in the next week, to take a break from studying? Claire: I can call one of the guys I work with, Thomas, and see if he wants to go out. Actually, he’s called me a few times, but I haven’t gotten back to him. I guess I don’t want people to pity me just because I lost my leg. Therapist: [choosing to ignore Claire’s prediction that people will pity her in the interest of focusing on a behavioral homework assignment] Before your injury, had you spent much time with Thomas? Claire: Yeah, we probably went out, like, every other week. Therapist: And did you enjoy going out with him? Claire: Oh, yes. He has a fabulous sense of humor. Therapist: Can you predict what effect spending time with Thomas would have on your anxiety? Claire: I’m sure it would be a positive effect. Maybe it would take my mind off of my problems. Therapist: [gently] What do you think, then, of a homework assignment in which you return Thomas’ phone call and see if he wants to get together. Claire: [proudly] Yes, I can do that. Therapist: [goes on to identify any obstacles to completing this assignment and obtain likelihood ratings of its completion]","e":[45,-14,-166,-50,12,33,27,-19,43,-14,-70,9,36,28,1,11,1,-75,-59,-16,-49,-58,-30,12,-5,68,-67,37,-98,27,40,-11,-43,-52,-48,10,19,89,7,-18,62,26,1,-92,31,-71,96,-36,24,-19,-6,-42,-40,8,112,8,32,15,57,-42,101,14,-35,66,43,-9,-63,44,-26,-32,49,3,41,64,-62,60,-11,-21,16,-3,28,-18,31,-66,35,25,26,23,-32,103,16,23,33,31,-43,14,17,-28,-56,-58,-47,12,-3,-1,11,26,-31,-52,-19,17,-26,40,-31,-10,-1,10,63,-90,39,16,-22,13,-7,13,41,59,-68,11,0,13,-28,-23,-12,57,-16,66,12,-28,2,22,77,-4,-31,-56,-17,-14,5,-19,-34,-11,-15,11,15,24,60,-35,-51,19,58,33,38,-6,0,15,12,-26,17,50,30,36,-25,-55,5,-43,23,-37,10,-28,-16,-24,68,-54,34,-18,3,-20,22,-9,-41,-64,-14,11,-40,-12,-65,-29,51,-34,-2,-6,-45,9,-25,26,-28,51,18,-60,-40,-47,69,-16,-25,50,-25,-23,-15,-10,-41,30,11,-10,-1,-3,-9,42,-20,28,-36,-11,-29,-61,26,14,15,43,-39,40,-12,65,20,52,10,-4,-66,17,-9,-9,-7,33,30,24,19,10,13,-10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.70","t":"Several points about this dialogue deserve note. First, in actuality, Claire’s therapist judged that it was premature and potentially harmful for Claire to be putting so much effort into studying for a pilot examination when it was unclear whether she would even be allowed to return to her post. However, because being a pilot and excelling professionally were so central to Claire’s self-concept, the therapist reasoned that it would be unwise to directly challenge her need to study at this time. Second, Claire’s therapist took care to ensure that she was not arguing with Claire or trying to bully her to “come around” to the therapist’s point of view. Thus, the therapist used open- ended questions that helped Claire to critically evaluate her situation and ultimately draw her own conclusions. As therapists gain experience with CBT, they begin to see that cognitive and behavioral changes are much more powerful when they stem from the patient’s insights and own conclusions, rather than being supplied with an insight or a conclusion by the therapist.","e":[64,18,-134,-51,63,36,20,-2,30,-7,-53,-9,86,45,12,-46,3,-66,-13,-11,-75,-52,-66,10,8,9,-66,43,-63,23,86,-18,-12,-75,-54,-37,17,88,-10,-15,46,12,4,-103,2,-39,83,5,5,-48,36,-39,-19,6,135,51,6,47,45,-93,75,37,-50,75,17,-27,-28,34,-37,-9,37,-23,35,59,-24,2,-12,-45,-18,7,53,-50,21,-33,54,35,31,2,4,77,27,19,12,40,-78,2,4,-12,-48,-10,-81,-13,-2,5,24,26,-8,-12,4,-5,-78,15,-60,9,5,11,64,-61,18,46,0,8,-25,37,14,91,-58,-38,24,2,-30,-25,-11,25,13,40,-1,-26,3,34,37,-10,-17,-9,4,-44,20,16,-34,9,26,32,9,38,34,-20,-27,34,37,30,59,14,-23,24,-29,-18,-7,18,36,32,-53,-43,18,-18,94,-1,70,-14,2,-21,39,-32,9,15,47,12,5,-24,-43,-74,-3,20,-75,9,-82,-54,42,-2,13,-26,-35,24,-28,47,-67,58,-27,-57,-47,-44,40,-10,-11,65,-54,-8,-31,-9,-39,54,19,-15,-3,-11,-22,13,-28,-26,3,0,-9,-97,58,25,20,30,-42,45,-14,58,9,32,33,-5,-61,-12,33,-19,-12,24,1,27,34,18,3,2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.71","t":"Final Summary and Feedback At the end of session, the therapist conducts a final summary or, alternatively, has the • Final summary patient summarize the most important lessons gleaned from the session. In obtaining and session feedback about the session, you should avoid asking patients if the session was feedback helpful. In our experience, patients will usually respond that the session was helpful. Although such responses may be reassuring to the therapist, they do not necessarily facilitate the treatment. Rather, we suggest that you ask, “What was the most helpful thing that we discussed in today’s session?” or “What will you take away from this session?” Asking for feedback in this manner allows for the therapist to gain a better understanding of the specific points that resonated most with the patient. Therapists should also ask about how the patient felt about the session, especially if a particularly upsetting or sensitive topic was discussed. This is an important question to ask because patients may avoid future sessions if they leave sessions \u0002 Mood Check feeling distressed and do not have a plan for dealing with this distress. The \u0002 Bridge from Previous Session therapist can also assess whether the patient thinks she was understood \u0002 Agenda Setting correctly and whether she wants to do anything differently in the next \u0002 Discussion of Previous Session session. Items not discussed in this session could be identified at this point Homework and established as agenda items for the following week. The therapist writes \u0002 Discussion of Agenda Items down this feedback and is sure to introduce the items identified by the \u0002 Periodic Summaries patient in the next session. Many of the questions used to bridge from the \u0002 Homework Assignment previous session (see page 39) can be modified to obtain a final summary \u0002 Final Summary & Feedback and feedback from patients.","e":[46,-10,-153,-102,20,-12,48,2,46,-4,-28,-1,35,20,17,-33,41,-85,-40,11,-43,-27,-56,21,21,72,3,24,-29,16,42,-38,-5,4,-83,-45,48,23,-50,-57,65,29,-36,-77,37,-52,59,-4,-22,-21,32,-15,-33,4,105,13,27,26,74,-50,79,32,-51,76,17,-52,-51,47,-33,-5,40,10,49,13,-55,29,-14,-26,-9,-3,12,-25,63,-34,21,20,-10,22,-33,83,16,-1,23,37,-96,31,2,-11,-42,-50,-56,-3,23,-27,51,31,-13,-4,-3,6,-53,30,-62,0,19,-10,97,-52,18,66,-31,-21,-7,9,33,78,-18,13,20,8,-19,-25,-45,26,23,77,17,-26,33,17,37,-18,-18,-4,7,-12,63,-9,-30,2,25,12,21,41,19,-63,-27,2,43,17,40,-11,-68,39,5,-38,16,14,37,-16,-48,-54,42,-28,61,30,51,-21,3,-28,64,-23,64,8,19,-10,24,-47,-18,-28,7,73,-33,-37,-83,-25,50,-28,21,-17,-21,33,-44,30,-71,50,-31,-22,-42,-12,60,-13,-6,53,-40,32,-14,-7,-23,34,16,-14,-1,-26,7,5,-51,-17,-58,19,-70,-112,10,-8,25,-18,-14,34,-3,64,-2,18,53,-9,-91,46,-4,-14,21,16,28,45,41,24,36,-39]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.71","t":"Therapist: We’re about at the end of our session, Jack. What was the most helpful thing that you got out of the session today? Jack: Well, I appreciate that you want to do things at my speed, you know, focus on what I think is important. It hasn’t always been that way with other doctors. Therapist: Good. So how would you summarize today’s session? Jack: Basically, that I need to stop avoiding being around other people all the time. And when I am around them, I need to try and be less irritable. Therapist: I agree. So it sounds like you’re on board with the goals we set for treatment. Jack: Yeah, I’ll give them a try. Therapist: Is there anything else that you learned from today’s session? Jack: Well, put my money where my mouth is and actually do the things I say I’m going to do. Therapist: In that spirit, what are you going to do in between now and the next time I see you? Jack: I’ll go over to my neighbor’s when I see he’s working on his truck. [smirks and waves his appointment card with his homework assignment written on the back] And I have this card to keep me in line if I forget.","e":[27,2,-144,-72,9,8,13,-35,39,-30,-22,0,-12,46,21,0,47,-89,-44,25,-54,-34,-23,-29,3,31,-26,23,-50,24,61,-51,-21,-26,-58,-23,66,57,-18,-48,49,2,-21,-133,71,-87,67,32,3,-32,15,-54,-62,-3,117,29,24,22,37,-54,86,-12,-76,53,28,-39,-55,51,-56,4,46,4,46,15,-24,54,-7,-24,21,29,-6,-29,52,-78,18,13,18,30,-31,80,22,8,5,48,-61,18,-11,3,-21,-66,-57,-5,4,-21,50,58,-3,-4,-20,-14,-36,13,-29,-19,-7,-11,61,-48,53,17,-15,12,-17,26,33,80,-54,9,-1,29,3,-20,-19,40,-13,75,31,-57,23,-14,74,11,-11,-2,0,-34,-4,-30,-30,25,35,-15,20,52,39,-49,-15,2,60,31,35,-22,-36,13,17,-44,13,61,31,42,-7,-74,7,-29,34,16,54,-32,-21,-29,89,-35,55,-3,-5,11,11,-47,-35,-47,-2,11,-25,3,-57,-43,69,-61,-6,-9,-19,7,-29,32,-53,60,0,9,-31,-19,60,-13,-11,30,-28,-8,24,3,-74,49,27,9,-1,-24,0,17,-23,12,-37,16,-68,-93,10,18,47,24,2,52,1,81,-2,41,27,-18,-98,23,8,-39,15,22,37,23,39,-12,37,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.72","t":"The therapist may also desire written feedback from the Veteran. On occasion, patients may be more comfortable providing written feedback to the therapist rather than providing face-to-face verbal feedback. Therapists can provide patients with simple forms that ask them to respond to open-ended questions such as, “What was the most helpful aspect of the session today?” Therapists can also obtain brief ratings to standardized questions such as, “On a scale of 0 to 10, with 0 being not at all helpful and 10 being very helpful, how helpful did you find today’s session?”","e":[17,-6,-171,-93,76,15,27,-6,36,-21,17,-16,19,36,-12,-33,53,-100,-14,11,-39,-58,-65,-23,15,22,-18,27,-73,7,56,13,15,7,-39,-32,15,33,-37,-40,80,10,-7,-67,22,-46,63,5,-1,-25,21,-75,-29,27,105,-21,14,9,47,-36,83,24,-95,68,54,-13,-21,57,-29,-11,24,-4,41,28,-64,38,-36,-49,-5,37,52,-39,49,-48,52,7,-6,45,-4,106,-14,28,18,20,-95,23,-9,-24,-38,-47,-25,-11,14,-18,62,27,6,11,-24,-3,-46,25,-37,-7,8,-12,84,-56,10,61,-25,4,-35,9,3,58,-33,1,12,-1,-7,-18,-58,-16,4,66,-15,-32,39,3,70,8,-17,12,6,-37,15,10,2,5,20,0,35,25,18,-62,-6,18,18,33,39,35,-50,42,24,-42,-8,12,29,-8,-16,-55,45,-18,69,12,53,-21,26,-28,34,-28,48,12,19,-30,35,-38,-60,-61,8,42,-39,-7,-76,-39,61,-35,14,-13,-46,41,-19,17,-56,56,-35,-17,-35,-50,40,-43,-11,41,-52,14,-26,11,-42,55,52,-12,6,-9,-14,-13,-60,9,-10,11,-42,-100,42,1,14,-20,-28,49,15,38,10,5,61,4,-88,18,-17,-30,-5,11,-4,35,22,-8,5,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.72","t":"Inquiring about the therapeutic alliance can also be beneficial for assessing the strength or degree of collaboration of the therapeutic relationship. One excellent • Working measure of the therapeutic alliance is the Working Alliance Inventory (WAI; Horvath Alliance & Greenberg, 1989). The WAI was derived from Bordin’s (1979) theory of change- Inventory inducing relationships, which has as key components of the working alliance (a) agreement on the treatment goals, (b) agreement on how to achieve the goals (task agreement), and (c) development of a personal bond between patient and therapist. An abbreviated version of this measure that can be easily and effectively incorporated into CBT for depression, and which we use in training clinicians in CBT for depression, is the Working Alliance Inventory–Short Revised (WAI-SR; Hatcher & Gillaspy, 2006). Therapists can ask patients to complete this Inquiring about the therapeutic at the end of some therapy sessions. We recommend administering the alliance can also be beneficial 12-item WAI-SR at sessions 1, 4, 7, and 11. An effective way to use the for assessing the strength or WAI-SR in therapy is by reviewing individual items and discussing, in degree of collaboration of the particular, any issues with respect to the therapeutic alliance suggested therapeutic relationship. by the patient’s responses.","e":[2,22,-183,-89,22,-38,27,-14,47,15,-26,11,34,-13,36,-25,17,-35,-35,1,-73,-40,-61,-17,51,32,-12,22,-41,6,59,-12,60,-42,-62,-32,65,74,29,-18,13,9,14,-51,34,-39,64,-8,51,-21,15,-30,11,14,80,9,-25,45,-19,-30,50,39,-50,35,102,-25,-19,9,14,-21,38,5,82,47,-63,16,-13,-39,1,10,59,-50,75,-18,59,15,34,3,-3,83,25,27,1,39,-110,11,-35,-42,-67,-14,-31,20,5,-24,32,15,0,-14,-42,21,-61,47,-18,-31,11,-46,45,-65,-15,32,-29,0,-26,44,5,12,-50,20,37,-19,-19,-17,-40,1,-17,41,-7,-27,-28,18,14,14,-3,-25,16,-17,19,-5,-32,-2,-26,39,-22,26,-14,-70,-31,21,34,31,53,6,8,24,4,-26,41,75,56,35,-50,-73,-4,-39,56,16,92,-12,10,19,35,-29,49,-21,-17,-28,45,-68,-46,-34,30,41,-57,-44,-80,-31,40,16,47,-46,-34,24,-52,41,-29,63,-43,0,9,-31,53,-39,-3,24,-32,13,-2,-4,-44,13,34,-12,-14,6,1,-16,-50,26,-2,10,-38,-78,23,36,12,-5,-4,69,2,65,41,17,9,41,-51,83,-16,-36,14,36,-14,37,6,-22,44,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.72","t":"Implementing the Session Structure When learning to structure CBT sessions, we recognize that it can be challenging for therapists who are learning the CBT protocol to remember to do all of the components described. In response to this concern, we have created a brief checklist to serve as a reminder to therapists of the various session components. This brief checklist may be displayed or consulted while the session is taking place. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 58","e":[-4,-5,-165,-91,63,-24,45,-49,23,-33,-24,-6,31,-4,-4,-71,-17,-46,-30,1,-43,-15,-45,-24,13,92,-39,35,-36,-5,60,-16,14,-21,-36,-60,31,41,-39,-9,31,-11,-25,-89,23,-28,107,14,-20,-14,50,-65,-1,-51,110,-4,-14,18,22,-54,122,52,-58,69,15,-32,-64,44,-31,-6,57,21,48,44,-50,11,-43,12,-17,20,44,10,67,-54,40,6,-7,20,-13,83,0,-12,21,65,-88,11,-35,36,-21,-33,-47,-12,2,-28,10,49,-6,-20,-18,-20,-60,32,-23,14,-21,-8,64,-46,14,39,-15,-26,35,16,13,40,-42,-2,43,-26,-1,-13,-31,7,7,29,-14,-40,1,8,19,20,-23,1,11,-12,17,-54,-33,-15,39,21,-16,13,50,-57,-15,-4,65,49,37,22,-53,15,-8,-42,6,37,38,25,-50,-68,-29,-8,84,32,33,-18,27,-37,20,-16,27,44,-27,-22,11,-62,-48,-44,15,49,-36,-15,-75,-46,40,-22,26,-9,9,39,-39,30,-58,67,-35,10,-34,-57,79,-10,16,-3,-40,7,11,-4,-53,12,20,6,-10,-38,0,27,-35,-15,9,7,-36,-51,-7,-20,29,26,-18,31,6,57,44,23,77,20,-75,21,-7,-50,4,35,-18,-15,-10,12,32,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.73","t":"We encourage therapists to keep in mind several benefits of implementing CBT session structure. Most fundamentally, it models to patients a systematic approach to organizing and addressing their life problems. When therapists exhibit a calm, reasoned approach to setting an agenda and discussing each of the agenda items, it communicates a sense of hope and optimism that patients can indeed manage their life problems and associated distress. In addition, implementation of CBT session structure has the potential to enhance the therapeutic relationship, in that it communicates to patients that their therapist wants to ensure that they thoroughly cover the issues that are important to them. Finally, maintenance of a session structure allows for a natural thread to run across sessions, in that the patient’s mood is assessed each week on the same scale (thereby facilitating evaluation of the degree to which therapy is effective), topics or themes from the previous session are reviewed, and progress on homework completion can be monitored.","e":[-1,22,-144,-98,48,-39,47,-7,48,-32,-10,-21,43,13,-9,-45,-22,-47,-47,9,-38,-13,-28,-2,-16,90,-41,36,0,-12,76,-42,29,-17,-69,-31,70,46,-37,-41,55,-5,-22,-96,21,-58,108,-6,-11,-22,23,-57,-1,-15,147,34,-15,78,15,-64,89,52,-62,69,31,-9,-47,49,-33,14,33,13,50,34,-35,28,-34,7,-18,34,39,-24,38,-48,40,3,30,9,-22,87,12,-40,22,33,-107,17,-11,-9,-33,-24,-71,9,13,2,-10,28,-20,2,-15,17,-52,25,-37,29,-2,-6,86,-44,30,41,27,-13,-10,31,17,88,-53,-27,51,-9,-9,-23,-28,11,13,44,-12,-30,22,1,19,9,-25,12,11,-27,29,-51,-24,21,9,-8,5,42,41,-46,-1,-14,39,49,38,7,-41,-13,-34,-40,36,21,11,30,-30,-63,-30,13,70,5,53,-5,22,-51,9,5,9,9,-5,1,29,-66,-10,-44,34,46,-52,-10,-73,-54,47,-5,2,-20,-15,22,-40,17,-50,61,-1,-4,-32,-82,67,5,-16,23,-53,-4,3,-10,-53,23,32,-26,-13,-29,-14,12,-30,-21,-21,26,-64,-52,24,-2,42,38,4,11,8,75,41,35,40,13,-75,9,7,-47,-16,48,-2,-1,3,-8,40,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.73","t":"At times, therapists are hesitant to implement a session structure, wondering whether it will be somehow off-putting to patients or prevent patients from spontaneously expressing affect or cognitions that are inconsistent with agenda items. Some therapists have even wondered whether their patients will want to return if they adhere to an agenda and focus on the development of cognitive behavioral skills, rather than allowing the patient to “vent” what is on his or her mind. We encourage therapists to acknowledge their own automatic thoughts about the implementation of CBT session structure and check out the assumptions they are making with their patients. Oftentimes, therapists are surprised to find that patients are relieved to have a session structure because it contributes to a sense of productivity and efficiency. In instances in which therapists are correct in their hypothesis that a patient is having an adverse reaction to CBT session structure, they can work together with the patient to address this concern, thereby enhancing collaboration and the sense that they are working as a team. Ultimately, a collaborative therapeutic relationship is more important than the implementation of every piece of CBT session structure, but we","e":[20,45,-131,-69,54,-18,46,-6,42,-39,-19,-5,22,20,-4,-46,-1,-49,-34,32,-58,-15,-39,-15,-17,77,-32,19,-10,-10,97,-19,26,-26,-74,-60,66,26,-33,-26,36,8,-14,-115,23,-38,88,13,10,-20,43,-55,-27,-26,129,33,8,65,21,-84,80,39,-38,62,25,-8,-61,42,-12,-16,40,19,63,51,-36,24,-21,-9,-27,35,38,-30,43,-53,36,16,41,15,-14,108,22,-67,35,39,-102,3,-20,-17,-42,-14,-87,26,-14,-11,-18,4,-25,10,-7,15,-48,39,-34,10,-4,-5,70,-53,45,40,23,-40,-19,42,10,80,-52,-15,49,-29,-19,-19,-17,24,11,49,-10,-40,20,32,30,31,-20,4,25,-42,29,-42,-40,24,18,0,-3,54,29,-47,-10,5,41,40,62,16,-39,-4,-30,-52,47,40,-5,11,-42,-59,-17,2,65,31,45,-11,20,-49,10,12,3,-6,8,6,8,-44,-6,-57,60,35,-51,-16,-68,-53,26,-4,24,-5,-8,20,-48,27,-72,73,-32,-8,-37,-94,78,4,-24,48,-52,-11,19,-12,-68,44,31,-21,-23,-16,-15,-16,-40,-16,-17,21,-48,-66,19,19,48,20,-18,-4,29,63,40,32,24,9,-66,3,2,-58,-16,24,-15,10,7,-28,35,1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.77","t":"The initial phase of treatment can last as few as one session and as many as three sessions. The main goals of the initial phase of treatment are to (a) conduct an initial clinical assessment; (b) motivate patients for change; (c) socialize patients into treatment, including helping them to understand the structure and process of CBT; and (d) establish clear treatment goals. During the initial sessions, the therapist works to form a sound working alliance with patients that will serve as a basis to develop a case conceptualization and to implement the behavioral and cognitive interventions described in the next section. In other words, during the initial sessions, the therapist makes interventions that will set the stage for success in the middle phase of treatment. The patient, in turn, assents to treatment, communicating a commitment to working on his or her problems within the CBT framework.","e":[11,23,-159,-38,52,-23,30,2,38,-20,-33,7,42,11,9,-50,0,-69,-44,27,-44,-34,-10,-40,-13,66,-19,32,-26,28,57,19,21,-28,-17,-73,56,23,-43,-62,31,-27,46,-90,21,-46,70,5,-14,-1,39,-13,-19,-31,114,48,-41,32,11,-52,115,37,-70,93,26,-35,-22,3,-28,0,41,-6,34,30,-12,8,-34,0,-7,21,33,-37,40,-69,42,24,-4,3,-43,61,-5,16,-14,23,-108,-13,-34,8,-1,-24,-56,-21,26,-39,17,42,7,-3,-7,-9,-80,26,-28,-2,-33,20,60,-18,34,16,10,-24,7,31,34,72,-68,-26,37,10,-14,9,-32,7,19,61,31,-27,-5,21,17,-10,7,21,2,-17,30,-34,-13,31,-5,31,31,32,47,-60,-16,-23,43,10,59,-21,-32,37,-27,-34,6,0,20,24,-25,-60,-43,34,83,52,55,7,12,-25,32,-30,-9,59,2,4,25,-36,-56,-32,28,33,-62,7,-68,-13,52,-27,7,-48,-18,20,-73,41,-57,91,-6,31,-45,-10,60,-20,-28,10,-66,-14,2,-9,-26,50,42,20,-6,-27,-5,17,-42,-1,-9,14,-32,-53,16,-1,6,15,26,-11,3,72,-13,38,48,13,-94,16,4,-39,-12,36,14,21,20,12,29,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.77","t":"As previously mentioned, a strong, collaborative therapeutic relationship is central to • Empathic the success of CBT with patients. Many therapists have the mistaken view that CBT understanding comprises a set of strategies or skills, with little attention given to the therapeutic relationship in session. This could not be further from the truth. In our experience, patients make the most meaningful changes through psychotherapy when they are in an accepting environment in which they feel comfortable articulating sometimes- painful thoughts and beliefs and experimenting with different strategies to improve their lives. Thus, cognitive behavioral therapists strive to exhibit warmth, empathic understanding, validation, and genuineness with their patients. Moreover, empathic understanding is one of the essential therapeutic skills in CBT and is achieved by acknowledging the patient’s suffering and communicating an understanding of their problems from a cognitive behavioral framework. Many therapists have the In our experience, this stance facilitates a “connection” between the mistaken view that CBT therapist and patient and instills hope. In fact, therapists continually comprises a set of strategies or evaluate whether their response to a patient will be one that primarily skills, with little attention enhances the therapeutic relationship versus one that is focused given to the therapeutic primarily on change. We encourage cognitive behavioral therapists to relationship in session. achieve a balance between these two stances in session (see Figure 3.1), realizing that cognitive and behavioral change might be achieved rather slowly with some patients in the interest of building a sound therapeutic relationship. Many therapists ask us when it is best to adopt a stance primarily geared toward empathic understanding as compared to when it is best to adopt a stance primarily geared toward cognitive and behavioral change. We suggest that therapists select whatever strategies are necessary for moving the patient forward. The key issue during the course of treatment is for interventions, whether they target empathic understanding or whether they target cognitive and behavioral change, to be guided by the strategic consideration of the case conceptualization.","e":[36,31,-137,-49,84,2,51,6,39,5,-29,-22,30,14,24,4,5,-55,-13,53,-85,-8,7,-9,-10,47,-42,32,-28,-26,70,12,10,-48,-68,-40,56,51,3,-14,36,29,32,-109,11,-50,75,2,21,-10,23,-43,31,-31,148,15,9,62,-27,-87,80,38,-41,71,48,-4,-68,41,-38,-37,54,-18,17,48,3,-13,-42,-46,1,8,59,-40,37,-57,43,-5,23,11,-19,62,19,-32,11,53,-84,2,-27,-34,-32,-12,-68,12,-11,-27,6,35,-14,-1,-9,22,-77,9,-40,-15,-3,-2,30,-41,26,67,38,10,-13,31,16,59,-77,-48,20,-5,-37,-34,3,-2,-7,51,25,2,-6,45,46,29,32,2,3,-40,-22,-20,5,24,30,48,-6,29,28,-37,0,4,55,43,50,36,-31,1,-4,-34,33,23,16,15,-63,-28,-11,13,52,31,68,-14,-8,-21,15,-14,40,18,1,24,26,-35,-33,-36,21,21,-73,20,-60,-52,21,-18,38,-33,-26,44,-14,47,-64,68,-27,-6,-33,-50,22,-41,-26,17,-43,5,-10,-25,-71,26,40,4,-8,-12,-31,6,-47,18,25,30,-19,-55,49,41,14,50,-20,24,19,77,41,14,7,23,-81,50,9,-70,6,28,18,17,15,-26,28,-25]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.78","t":"Initial Clinical Assessment In the initial clinical assessment, cognitive behavioral therapists collect much of the same information gathered at the beginning of any type of psychotherapy—current mental health problems, personal and family history of mental health problems, current and past alcohol and substance use, medical history, and psychosocial history. All of this information contributes to the development of the CBT case conceptualization, described at the end of Part I of this manual. However, cognitive behavioral therapists also direct their questions in a manner such that they develop hints about patients’ core beliefs, intermediate beliefs, and compensatory strategies. Examples of ways to assess for these constructs are presented in the case conceptualization section of Part I.","e":[62,-25,-154,-51,39,15,64,11,29,-3,-18,-3,47,42,-21,-60,-23,-54,-8,14,-44,-11,-29,-12,18,44,-47,31,-45,-23,38,-8,23,-39,-43,-46,57,18,-24,-15,47,2,14,-103,6,6,70,27,7,29,51,2,33,-8,111,21,-16,47,17,-83,96,54,-81,59,40,-39,-10,45,-40,0,38,-4,44,31,-44,32,-13,-12,9,30,56,-25,68,-70,61,45,-10,44,0,74,31,29,-10,31,-73,32,-53,-27,-29,-30,-33,-26,11,-2,25,31,-14,-30,-31,14,-85,25,-21,-6,7,1,66,-37,3,41,-21,2,8,54,9,71,-75,-14,49,-17,-17,-21,-3,-23,8,37,28,-2,-2,18,43,-2,9,28,35,-10,34,-40,-10,21,-8,26,38,16,18,-58,-29,9,42,9,49,-2,-18,56,-1,-56,29,25,43,10,-34,-42,-3,2,60,24,75,-39,19,-18,2,-23,22,38,18,-46,29,-16,-32,-52,-1,42,-77,-22,-77,-73,26,-15,19,-50,0,33,-53,33,-59,76,-13,-35,-31,-13,41,-30,-10,25,-35,8,-27,-18,-27,-11,15,-13,-3,-19,-7,38,-54,9,-3,12,-30,-93,59,16,34,32,-48,11,32,48,-21,29,50,-4,-83,3,6,-29,3,61,0,24,21,29,47,-36]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.78","t":"Although clinical assessment is an important part of the initial phase of CBT, in reality, assessment takes place across the entire course of psychotherapy. We encourage therapists to assume an inquisitive stance in each session, gathering information to test their hypotheses about their patients’ beliefs and compensatory strategies. As more information is uncovered, you will modify your case conceptualization, which in turn helps to refine the interventions selected in treatment so that the most meaningful cognitive and behavioral changes are achieved in your patients’ lives.","e":[46,-15,-128,-55,68,3,71,23,38,-4,-14,-10,52,23,-24,-83,-29,-40,-24,4,-54,-45,-20,-13,-2,31,-21,16,-28,7,40,11,49,-27,-48,-88,57,54,-29,-43,31,-9,10,-91,22,-18,73,34,-17,9,24,5,27,-5,144,38,-15,45,9,-77,97,49,-80,77,48,-37,-32,15,-66,-11,31,-38,57,38,-47,7,-17,-22,-27,30,35,-14,83,-47,34,39,21,20,-3,67,38,24,10,59,-106,16,-28,-12,-28,-10,-64,10,-10,-39,38,16,-25,-15,-4,-20,-62,12,-54,-3,22,8,56,-42,-13,60,34,6,-6,64,-19,74,-81,2,29,-17,-11,-7,-18,-2,15,65,22,-14,6,20,12,-2,-2,43,9,-17,50,-33,-7,14,17,8,42,19,29,-32,-33,16,66,13,25,4,-37,23,-33,-36,32,-5,76,-18,-17,-50,6,3,43,20,70,-24,15,-6,18,-11,-4,-4,21,-44,19,-36,-32,-43,28,40,-32,7,-66,-79,23,-14,-1,-56,-8,21,-54,27,-59,67,-29,-19,-63,-28,76,-27,-3,19,-30,19,-36,-32,-18,-2,46,-5,-7,-13,-24,27,-58,9,6,35,-13,-62,46,34,24,55,-21,21,17,42,6,21,65,45,-79,9,22,-23,-3,36,3,13,36,14,55,6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.78","t":"Motivational Enhancement Many therapists who work in VA Medical Centers, as well as in other settings, have undoubtedly come across patients who are not motivated for treatment. Although these patients sometimes attend their first appointment, it is clear they are not ready to engage in the therapeutic process and make healthy Some patients do not changes in their lives. Some patients do not understand that the understand that the symptoms symptoms they are experiencing fall under the rubrics of depression or they are experiencing fall under anxiety or do not have an understanding of what psychotherapy the rubrics of depression or involves. Other patients agree to attend therapy sessions for external anxiety or do not have an reasons, such as to appease their primary care physicians or family understanding of what members. In all of these instances, starting a course of psychotherapy psychotherapy involves.","e":[15,62,-166,-44,74,30,19,25,55,-19,-14,24,53,18,-14,7,26,-37,-32,17,-61,-12,-22,-32,1,45,17,18,-57,13,31,12,10,-57,-11,-20,69,79,0,10,22,-38,32,-88,-43,-23,91,10,27,-24,38,-57,-18,-22,92,18,14,43,24,-45,95,35,-39,24,48,-22,-41,19,-41,3,51,-4,-5,15,-43,20,-32,-4,2,6,78,2,53,-54,76,8,11,39,10,65,25,30,14,29,-127,12,-29,13,-36,-53,-43,-4,8,-25,0,-27,43,11,11,17,-41,54,-37,-53,11,-21,46,-37,29,35,26,5,15,61,19,46,-13,-24,25,-8,10,-55,-45,12,19,45,-2,-23,-7,-7,56,-3,-17,-29,-34,-41,-7,-37,-36,30,6,44,34,31,51,-63,-20,9,59,21,88,41,-12,43,0,-26,28,48,4,20,-25,-28,-5,-25,88,32,100,-18,24,-26,7,-63,20,-6,-15,-26,15,-8,-64,-57,0,47,-69,-38,-100,-68,33,-42,59,-20,10,8,-23,1,-59,86,-2,-42,-21,-31,23,-50,12,20,-23,-11,1,-18,-35,24,37,-28,-10,-13,1,-2,-48,-10,19,-4,-8,-88,55,10,6,18,-33,9,11,60,19,32,27,47,-54,-7,9,-14,-23,2,-1,4,26,13,25,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.79","t":"Motivational enhancement is a process that uses some aspects of motivational interviewing to help patients commit to the therapy process and to making change in their lives. According to Rollnick and Miller (1995), motivational interviewing is “a directive, client-centered counseling style for eliciting behavior change by helping • Motivational enhancement clients to explore and resolve ambivalence” (p. 325). It is a style of interacting that and interviewing helps patients elicit the motivation to change from within, rather than agreeing to change because they are responding to persuasion, coercion, or external contingencies. To achieve this aim, the therapist is directive in asking questions that will help patients identify areas of their lives that they would like to change, the benefits of participating in therapy to make those changes, and obstacles that might interfere with them committing to therapy. Below we list several motivational enhancement strategies (Zanjani, Miller, Turiano, Ross, & Oslin, 2008).","e":[56,56,-165,-40,32,-4,37,32,26,10,22,11,80,51,30,21,9,-60,-21,65,-25,-9,7,-34,34,3,8,2,-41,21,24,1,24,4,-66,-11,84,42,-34,-13,-13,-22,36,-76,-23,-29,69,-13,-6,-49,-42,-68,-5,-39,125,16,10,72,15,-56,77,44,-28,36,34,-18,10,29,-62,-26,43,14,-16,20,-23,-15,-40,-9,13,17,65,-25,39,-42,60,15,28,58,-13,53,10,-5,24,23,-149,4,-6,-15,-17,-49,-80,-34,24,-11,25,17,20,14,37,36,-13,53,-46,-14,-25,4,67,-8,17,16,53,-12,-9,20,15,47,-46,-47,-5,12,-6,-51,-43,-16,22,35,-13,-32,4,-4,29,-24,-14,-26,-13,-21,20,-19,-12,19,11,26,63,-32,51,-50,-32,-16,30,59,55,41,-5,36,16,27,7,30,18,33,22,-30,29,-15,67,37,93,-69,2,-49,34,-40,40,14,-12,-39,36,-17,-40,-53,21,22,-28,-28,-96,-36,80,-40,62,-69,-35,15,-37,13,-22,67,17,-9,-44,7,47,-8,6,5,-2,-23,-13,2,4,4,26,-20,2,31,-9,-45,5,-9,-14,32,-43,-55,43,16,43,41,-12,44,10,54,21,29,3,15,-49,-18,25,-30,9,-12,32,11,16,-12,23,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.79","t":"Motivational Enhancement Strategies Identify patients’ short-term goals in many areas of their lives, compare with their current functioning in these areas, and demonstrate the manner in which psychotherapy can help patients to meet these goals. Identify the consequences of their psychological symptoms. Identify the benefits of reducing their psychological symptoms. Assess patients’ attitudes and expectations for treatment and, if necessary, use the cognitive strategies described in Part IV to modify unrealistic or negative attitudes and expectations for treatment. Discuss patients’ previous therapy experiences and examine the manner in which they contribute to negative attitudes and expectations toward treatment. Identify potential obstacles to attending and participating in treatment and brainstorm ways to overcome those obstacles.","e":[39,40,-149,-32,54,3,40,34,31,16,2,13,65,45,16,13,-3,-26,-21,51,-33,-13,-18,-42,17,33,5,-5,-43,8,21,8,2,-25,-54,-12,98,40,-26,-17,0,-37,39,-68,-7,-14,89,-3,14,-11,20,-33,8,-35,120,8,-3,26,31,-35,105,43,-49,41,68,-38,-38,40,-71,-29,52,31,-4,3,-41,-12,-19,-4,1,39,54,-22,44,-60,57,27,30,34,-19,71,-16,33,43,29,-133,6,-14,-35,-20,-23,-62,12,44,-19,0,37,19,22,26,36,-52,30,-30,-6,-16,1,41,-36,37,47,43,8,8,53,15,42,-79,-39,25,27,9,-47,-59,22,1,43,9,-16,9,33,62,-40,10,18,-32,-66,-7,-20,-38,23,-8,28,58,9,62,-68,-21,4,15,13,79,27,-7,62,-13,-17,35,4,6,61,-5,-26,-1,-3,92,31,79,-36,8,-24,20,-30,35,24,-10,-37,39,-22,-66,-34,18,32,-47,-32,-101,-76,32,-26,55,-53,-25,23,-34,30,-20,70,-3,-14,-34,-27,33,-35,24,25,-31,11,-11,-17,-13,7,19,-20,-30,23,8,-6,-24,1,-14,26,-18,-81,31,6,30,31,-13,19,20,45,8,28,37,54,-60,-4,0,-31,-6,37,23,48,8,16,43,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.79","t":"Short-Term Goals To start the motivational enhancement process, therapists often ask patients to identify their short-term goals in a number of important areas of their lives, including their physical and emotional health, employment and career, activities and hobbies, • Short-term relationship and social life, and financial well being. This activity orients patients to goals the positive changes that can be achieved in therapy in a relatively short time frame. Moreover, it starts the initial phase of treatment on a positive, optimistic note rather than a pessimistic note by not focusing exclusively on what is going wrong for the patient.","e":[33,30,-173,-1,2,9,27,-9,27,-10,-12,47,93,7,8,13,18,-59,-26,68,-17,-23,-27,-39,2,43,6,-3,-44,11,30,23,-8,-24,-17,-57,79,44,6,-39,-22,-46,39,-87,25,-36,60,9,45,-38,-10,-37,-34,-20,95,46,0,8,35,-38,93,51,-53,50,61,-29,-2,3,-50,1,47,20,2,51,-26,18,-32,-7,5,0,59,0,38,-67,37,27,21,53,-23,66,2,35,12,32,-156,-2,7,9,14,-42,-65,-16,44,-32,33,18,-8,14,37,14,-49,40,-45,-11,-24,27,74,-17,41,49,12,-21,40,52,6,26,-76,-40,30,31,14,-30,-82,17,-2,67,18,-28,5,18,44,-5,5,-29,-38,-40,36,-27,-25,21,2,23,34,16,43,-50,-13,-6,57,-30,60,10,-4,53,-5,-17,28,-1,-1,66,-19,-56,2,-15,77,24,59,-29,1,-48,33,-61,37,31,-32,-23,34,-31,-62,-25,18,11,-68,-33,-80,-36,61,-40,20,-58,-22,26,-75,31,-32,88,17,-12,-32,-37,55,-20,-46,15,-32,-6,-29,15,-28,7,32,5,-11,-13,19,-5,-42,-9,-11,29,-27,-61,25,6,33,4,-1,1,10,70,1,18,46,26,-58,0,14,-39,-4,8,28,19,16,19,16,-46]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.79","t":"Throughout this section, we illustrate the motivational enhancement process with Jack, who expressed ambivalence about treatment from the outset, complaining that actions of others were the main problem in his life. This dialogue took place in Jack’s second CBT session, when he and his therapist decided to address treatment goals as the first item on the agenda. Therapist: It sounds like it has been a rough few months for you, Jack. [choosing to make an empathy statement rather than questioning his view that others are the cause of his problems] CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 63","e":[40,21,-173,-58,50,52,11,-19,62,2,-20,24,36,37,22,-2,19,-50,-27,32,-48,-29,-48,-35,39,42,-51,29,-52,24,46,-20,-33,-15,-40,-19,67,61,-2,0,11,-17,6,-110,10,-38,77,60,14,-47,24,-62,-4,-47,130,12,-33,26,5,-62,66,38,-44,57,51,-33,-23,22,-80,-6,55,-22,22,62,-38,2,-43,-5,-12,29,53,8,52,-80,65,-2,7,49,-24,60,5,13,11,34,-108,-3,-35,-4,-15,-36,-65,-28,11,-14,30,39,2,-6,16,-24,-57,23,-15,-10,0,-9,54,-34,13,38,8,-8,-20,39,5,58,-41,5,42,-10,-16,-27,-4,4,-8,23,-24,-31,-19,8,66,-6,-10,2,8,-41,-4,-25,-53,7,7,26,28,29,34,-53,-32,20,36,31,53,5,-10,22,27,-9,-5,40,41,43,-24,-71,-10,-15,73,31,51,-24,3,-22,26,-48,53,35,-3,-14,-1,-45,-34,-70,5,47,-60,-31,-79,-47,79,-44,24,-27,1,28,-34,12,-61,53,-11,13,-31,-39,47,-28,-28,13,-18,2,22,-3,-36,12,10,8,-17,-6,-6,8,-14,-37,-36,2,-35,-94,63,15,9,24,-7,32,18,63,18,45,32,43,-67,25,14,-54,26,18,12,17,4,-9,42,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.80","t":"Jack: It sure has. And I really don’t see why I need to be here if they are the ones who are the problem. People these days! They don’t make them like they used to! Therapist: [makes an empathetic facial expression without verbally reinforcing Jack’s rigid perceptions about the world] What I’m interested in hearing more about, Jack, is your life—where you hope to be in the near future. It can often be helpful to identify where you’d like to be in major areas of your life in the next few months and to see if there’s a discrepancy between those estimations and where you are now. Does that make sense? Jack: Yeah, well, I’ve already told you that I have lots of problems. Therapist: Yes, and I am sorry to hear that things have been difficult. [taking the opportunity to communicate another expression of empathy] Why don’t we start with your job? [strategically choosing a concrete problem area, rather than one that is more abstract (e.g., emotional health) in order to help Jack focus] In the next three to six months, what would you like to see changed regarding your employment status? Jack: I need another job. I can’t live without one. Therapist: That makes a lot of sense. So, one short-term goal you have for yourself is to get a new job. Any idea of what kind of job you’d like? Part-time or full-time? Jack: Definitely full-time. I’m not ready to sit around the house doing nothing all day. Therapist: Do you want to stay in the same line of work you were in? Jack: Yeah, that’s really all I know. Cars, trucks, SUVs, you name it. Therapist: It sounds like you’re really onto something, Jack. [restates goal in concrete terms] So it sounds to me that one goal you have is to get a new full-time job in the same line of work as your last job. Jack: Yeah, exactly. [frowns] Easier said than done, though, with the economy like it is. Therapist: Yes, I realize that. Finding a new full-time job is not easy these days. [brightens] But this is a perfect example of something the two of us can work on together in treatment. We can develop strategies to improve your mood and increase motivation, which might help you to find a job. How does that sound? Jack: [sarcastically chuckling] If you can get me a new job where people stay off my back and let me do my thing, I’m all for it. Therapist: [choosing to move onto another area of his life rather than correcting Jack’s misperception that she can get him a new job] Let’s move onto other areas of your life—finances, for example. What are your financial goals for the next three to six months? Jack: Just to make sure I don’t go bankrupt. Therapist: [gently] Are you having some financial troubles right now? Jack: Sort of, now that I lost my job. We’re living paycheck to paycheck right now, not really doing anything for retirement. [snorts] That will definitely have to change, since we can’t count on our kids for anything.","e":[25,16,-156,-43,-17,19,-1,-16,60,-29,-57,-8,12,38,3,25,29,-55,-28,45,-33,-44,-7,-3,-2,45,-52,30,-60,25,52,-41,-38,-37,-67,-18,61,66,36,-17,18,-13,-17,-143,62,-81,66,45,41,-48,-9,-79,-43,30,111,27,9,41,5,-59,63,35,-33,88,42,-18,-15,20,-51,-35,25,-2,24,57,-22,51,-27,6,39,15,43,2,32,-54,4,5,23,47,-15,70,16,57,-4,42,-75,-2,-27,11,-13,-50,-63,-35,-11,-10,51,29,-30,-21,4,3,-20,21,-17,-28,-8,-3,61,-47,38,64,-8,15,-7,36,35,55,-56,7,28,36,-15,-21,-9,40,-10,54,3,-40,-16,20,118,-5,13,3,-1,-37,-14,-41,-45,17,6,14,2,41,28,-46,-24,1,80,17,52,-23,3,30,40,-6,-9,60,-5,82,-2,-70,-5,-21,39,-2,61,-21,-17,-28,86,-61,77,0,-4,15,5,-26,-3,-51,-1,27,-43,-1,-24,-21,48,-83,-22,-27,7,34,-6,12,-33,60,17,-3,-41,-26,73,-42,-52,25,-12,-9,21,-2,-56,18,7,10,13,2,15,13,-43,-25,-32,44,-36,-82,57,19,15,13,3,49,5,87,1,36,10,0,-47,13,25,-49,33,32,48,6,21,-21,21,-44]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.81","t":"Therapist: [reframing Jack’s goal] Let me make sure I understand what you’re saying. Your financial goals for the next three to six months are not only to prevent bankruptcy, but also to begin contributing to your retirement funds? Jack: Yeah, that’s it. Therapist: [summarizing their progress so far] You’re doing great, Jack. You’ve come up with two concrete goals to strive for in the next several months—to get a new job and to improve your financial situation by making sure the bills are paid and contributing to your retirement account. Do you have any short-term goals for any other areas of your life? Jack: Uh, not really. I just live one day at a time. Therapist: [having read Jack’s chart and knowing that he suffers from pancreatitis and diabetes] Well, how about for your physical health? …","e":[51,34,-184,-6,-43,3,-1,-26,45,-57,-47,18,47,28,7,19,21,-47,-21,30,-44,-52,-48,4,24,47,-26,20,-48,31,41,7,-26,-37,-46,-30,44,72,9,-74,-44,10,6,-130,74,-41,64,4,45,-39,31,-63,-30,19,62,43,-29,-15,24,-74,102,22,-38,48,50,-8,-2,31,-41,10,43,-3,25,27,-27,46,-27,6,5,40,37,-8,39,-18,17,12,24,57,1,81,-14,40,24,50,-67,18,-32,25,-1,-20,-88,-19,37,-25,77,37,-6,20,25,-17,-42,11,-15,-23,-10,26,56,-31,29,84,-37,-7,47,63,-24,46,-53,35,45,35,26,3,-29,16,10,47,17,-39,-21,5,74,-15,24,-17,-20,-50,20,-17,-46,12,1,4,-2,27,60,-43,-42,-3,62,4,34,-4,12,48,11,-30,-5,48,-7,90,-11,-72,-8,-10,61,4,23,2,-42,-33,71,-57,76,41,-12,6,22,-2,-16,-25,15,31,-66,-22,-24,10,61,-40,-31,-10,-11,25,-24,3,-41,68,0,6,-32,-16,50,-49,-59,3,-10,-2,11,18,-63,4,-6,2,16,-43,18,-11,-57,-29,4,28,-14,-99,49,14,-4,16,-15,36,15,61,3,16,44,7,-57,49,30,-52,10,27,33,50,29,23,20,-45]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.81","t":"Jack’s therapist went on to assess his goals for his physical health, emotional health, activities and hobbies, and relationships and social life. When relevant, she encouraged him to compare his current functioning with the goals that he verbalized so the discrepancy was clear to him. She also helped him to frame his goals as ones that he, personally, could achieve (e.g., I hope to have better control over my anger), rather than ones that were about others’ behavior (e.g., I wish my wife would take care of the house better). Throughout the discussion, she linked his goals back to the process of therapy, explicitly stating that the goals were relevant for their work in treatment and could be readily attained through CBT. Later, in the initial phase of treatment, Jack’s therapist reminded him of this discussion as they explicitly formulated goals for treatment (see page 74).","e":[36,24,-148,-23,18,28,-12,-11,60,-15,-45,11,93,43,2,8,28,-43,-34,27,-30,-58,-35,-16,13,26,-41,25,-50,29,39,-17,-38,-41,-38,-36,77,67,-3,-37,17,-18,-33,-115,65,-37,47,25,29,-7,19,-62,-10,-41,143,51,-9,24,19,-69,76,45,-58,53,58,-20,-22,19,-78,23,46,-26,28,31,-33,8,-12,-18,-12,14,39,-29,56,-60,21,28,20,44,-30,55,3,33,27,50,-101,4,-22,-17,12,-16,-99,-23,25,-4,32,44,9,24,1,6,-36,6,-25,4,-14,4,68,-50,13,54,18,10,-8,52,1,56,-76,-8,21,14,-8,-36,-7,9,-20,38,0,-27,-11,3,68,2,6,-1,-1,-34,6,-24,-71,16,2,-6,20,53,32,-44,-35,45,27,26,42,-2,11,29,2,-28,9,24,16,81,-25,-72,-7,-8,83,13,46,2,9,-46,50,-48,62,36,-11,17,25,-31,-24,-33,13,40,-76,-14,-44,-28,39,-39,0,-20,-26,31,-43,11,-60,63,-2,6,-12,-50,44,-17,-45,26,-41,-11,3,-8,-72,11,-2,1,-12,-18,4,7,-38,-11,-23,37,-8,-74,47,24,9,38,8,38,29,96,-15,21,52,16,-71,35,14,-50,-11,44,28,33,6,-3,19,-43]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.81","t":"Consequences of Psychological Symptoms A second motivational enhancement strategy is to work with patients to identify the consequences of their psychological symptoms. Patients often are not cognizant of the effects that depression and anxiety have on their close relationships, work functioning, parenting, and enjoyment of recreational activities Patients often are not and hobbies, in part because they are struggling just to make it through cognizant of the effects that each day. Although identifying the consequences of depression and depression and anxiety have on anxiety can be painful for some patients, it often motivates them to their close relationships, work continue with treatment to prevent further life interference. Jack was functioning, parenting, and diagnosed with major depressive disorder, but he was convinced that he enjoyment of recreational was not depressed and that others were the problem. However, he activities and hobbies, in part admitted that his anger and irritability have caused problems for him. because they are struggling just Thus, Jack’s therapist focused on the consequences of his anger and to make it through each day. irritability rather than his depression per se, in order to facilitate a collaborative relationship rather than one that is adversarial.","e":[60,23,-163,-41,42,7,26,-6,59,-28,-9,15,64,43,12,22,-3,-40,-22,33,-46,2,-61,-18,14,65,15,-46,-39,56,36,-7,-30,-60,-78,-1,68,79,50,1,12,-22,26,-86,-18,-37,65,66,39,-7,43,-70,8,-43,105,27,6,38,54,-56,80,39,-45,33,55,-32,-23,26,-46,1,51,1,32,33,-31,33,9,15,-3,40,50,-25,55,-59,73,-24,20,34,-15,79,22,42,19,55,-117,2,0,-16,0,-25,-51,-3,28,11,9,2,2,15,10,19,-46,44,-16,-19,37,-5,28,-51,-1,42,8,24,13,58,23,33,-34,-6,46,14,-23,-28,-27,32,5,25,-8,-10,-6,0,72,-8,-9,17,-43,-44,2,-31,-59,24,-8,1,29,39,32,-63,-70,9,55,21,71,28,-8,67,4,-47,28,29,2,66,-50,-54,-9,-31,82,19,68,-20,22,-23,9,-35,48,13,3,-14,36,-13,-58,-27,16,42,-60,-23,-77,-79,46,-20,28,-47,-27,27,1,-18,-27,86,-2,-22,-19,-56,11,-42,15,25,0,-1,-21,-18,-11,9,12,-11,-28,-5,7,18,-13,-5,-33,7,-18,-101,80,14,18,29,-34,-1,34,42,-4,22,23,44,-46,9,-8,-32,2,26,33,23,0,13,55,-1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.81","t":"Therapist: You mentioned earlier that you could stand to learn how to manage your anger and irritability. I’m wondering if you can tell me a little more about that, Jack. How have your anger and irritability caused problems for you? Jack: I’m just really angry all the time. People have really gotten on my nerves lately. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 65","e":[30,7,-177,-49,67,30,5,-29,67,-23,-24,28,31,47,43,-14,30,-42,-11,29,-40,-56,-20,-42,32,64,-34,28,-38,35,33,-19,-20,-22,-51,-49,50,16,23,10,64,-35,8,-98,7,-3,74,69,18,4,32,-123,-12,-51,105,12,7,18,2,-53,79,16,-58,58,26,-19,-47,28,-57,-38,85,-37,55,9,-61,13,-33,-1,-5,35,60,-20,57,-84,77,-18,2,29,-11,62,27,26,-8,45,-71,6,-29,13,-47,-66,-58,-16,-6,-6,18,39,2,-33,-2,-20,-77,27,-17,-14,18,45,48,-46,-2,50,13,13,-15,11,17,21,-29,9,39,7,-6,-26,-25,-12,5,26,-34,-21,-11,14,103,-1,3,21,10,-28,-10,-43,-79,-8,2,16,10,-1,48,-50,-65,33,59,4,34,3,-42,32,19,-37,-23,67,24,58,-44,-43,-3,-24,76,29,50,2,11,-66,33,-45,48,19,-15,-9,15,-46,-61,-21,1,41,-33,-14,-29,-71,39,-38,0,-15,31,19,-22,32,-70,44,-9,-6,-11,-44,56,-16,-13,5,-7,6,33,-30,-52,14,16,-3,-27,-10,10,9,-16,13,-19,-2,-30,-103,70,17,20,32,5,42,6,47,8,39,39,31,-74,46,28,-33,4,16,4,-13,4,0,0,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.82","t":"Therapist: Yes, it certainly seems like you’ve had quite a few conflicts with others recently. [reframes question] I’m wondering if your anger and irritability somehow make these conflicts even worse than they already are. Jack: I don’t know. I think people get what they have coming. Therapist: [offers a menu of choices] When you have a problem with others and get very angry and irritable, do you usually achieve the end result that you were hoping for, or is the end result not particularly satisfying for you? Jack: [sighs] I guess most of the time the conflicts just go unresolved. I don’t give in, and they don’t give in. Therapist: And how does that affect you? Jack: It does wear you down, I’ll say that much. Therapist: What would life be like without the anger and irritability? Jack: [demonstrating ambivalence] Sometimes, I think it would be nice just to say, “Screw it. Who cares?” and just kick back, relax, and be done with it. But it’s not that easy. I’ve always had to fight for everything I have coming to me—promotions, raises—hell, even respect from my own family. Therapist: What I’m hearing you say is that the anger wears you down, that you wish you could let some of it go and just relax. Is that right? Jack: Yeah, but like I said, then I’ll be letting others get the best of me. Therapist: [linking the consequences of Jack’s symptoms to treatment] I wonder if we could put our heads together to figure out a way in which you wouldn’t feel quite so angry and irritable all the time while ensuring that you are getting what you feel is coming to you. Jack: That would be nice, I guess—if it were possible.","e":[60,22,-133,-37,48,34,-20,-26,70,-24,-32,4,-5,45,15,3,54,-50,-29,39,-72,-60,-4,-7,4,54,-27,-17,-79,23,43,-33,-35,-46,-90,-10,66,41,27,-6,90,1,26,-110,39,-65,33,48,25,-17,22,-116,-24,-12,78,34,24,35,7,-77,36,-15,-51,51,32,-14,-54,3,-38,-48,62,-16,52,-18,-23,47,-1,-4,32,29,43,-30,48,-100,43,-13,39,35,-11,93,40,9,5,10,-55,1,-15,-8,-39,-45,-61,-10,-2,-13,34,27,-3,8,-13,-13,-55,-3,-7,-26,34,6,55,-47,14,36,1,23,-52,3,45,34,-33,3,1,25,-25,-32,-6,16,-32,53,27,-34,-16,13,124,8,-22,12,17,-36,-19,-35,-54,41,4,1,2,33,21,-27,-46,24,61,12,15,-24,-18,32,20,-19,1,68,11,56,-19,-44,-18,-37,57,26,46,-31,-8,-53,33,-21,74,-26,37,25,25,-46,-18,-43,8,32,-58,4,-8,-65,38,-55,-3,-37,23,15,-12,37,-63,50,-9,22,-10,-53,58,-18,5,24,-35,-5,48,-3,-46,19,38,1,-17,-21,6,-5,-36,19,-57,5,-45,-91,69,10,51,41,-5,31,-7,78,-18,31,7,39,-67,38,27,-39,3,27,29,1,44,-3,12,-35]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.82","t":"Notice that Jack still seems ambivalent about giving up his anger and irritable style of interacting with others because he is concerned that it would leave him vulnerable to being taken advantage of by others. The therapist made several attempts to illustrate the adverse consequences of his anger and irritability while, at the same time, validating his concern about getting what is coming to him. Below we list several questions therapists can ask to assess the consequences of patients’ psychological symptoms (Zanjiani et al., 2008).","e":[60,19,-155,-49,42,55,0,-5,71,-2,-29,37,40,74,15,-2,35,-58,-4,37,-72,-39,-40,-18,23,34,13,-10,-45,23,35,-15,-44,-57,-79,-32,79,44,26,-9,19,2,25,-94,30,-26,49,71,29,2,36,-103,-19,-49,129,41,13,42,19,-75,36,20,-39,43,53,-1,-40,16,-45,-16,58,-20,47,-11,-13,47,20,-17,21,48,40,-22,54,-73,75,-7,20,24,-15,80,35,12,25,30,-95,19,-42,1,-12,-44,-70,-8,23,-7,11,17,-18,32,21,-6,-36,39,-9,-21,50,-12,43,-45,9,50,4,19,-50,57,-4,51,-34,3,16,9,-27,-31,-11,10,-1,36,-7,-41,-7,4,83,23,-2,13,6,-33,3,-41,-53,9,13,15,23,37,23,-54,-43,29,49,33,37,-7,-4,39,-16,-48,7,43,7,52,-27,-36,16,-16,61,11,48,-33,36,-50,10,-51,59,6,33,-1,42,-22,-39,-45,9,49,-49,-20,-24,-80,33,-27,-4,-16,4,14,-16,14,-77,52,2,16,-22,-64,40,-27,-4,2,-16,17,26,-20,-37,22,10,3,-24,-18,-9,6,-33,5,-28,-3,-47,-105,67,24,32,26,6,47,15,27,-27,27,15,38,-64,17,9,-72,7,26,-2,23,7,12,19,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.82","t":"Strategic Questions for Assessing Consequences of Psychological Symptoms What problems have [symptoms] caused you recently? What effects do [symptoms] have on your life? Do [symptoms] get in the way of doing things you normally do? Like what? Do you avoid doing certain things because of your [symptoms]? Like what? How do [symptoms] affect your work? Your relationships? Do [symptoms] reduce your life satisfaction? Have other people noticed [symptoms]? Have they expressed concern that [symptoms] are problematic? What would life be like for you without [symptoms]? CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 66","e":[33,-9,-133,-54,76,11,51,-31,78,-37,0,10,31,22,6,-62,-13,-50,12,29,-11,-32,-71,-24,14,59,-17,6,-21,10,35,19,8,-49,-62,-34,39,65,8,21,45,-27,17,-102,9,-27,80,58,37,-43,47,-86,17,-25,93,-5,15,13,27,-75,97,38,-56,54,47,-68,-58,24,-54,-16,44,10,13,19,-67,19,-10,33,-20,36,-1,-21,71,-49,56,4,6,0,-1,88,0,46,7,28,-111,4,-15,-34,6,-32,-26,-13,4,-3,27,19,6,-2,7,8,-90,40,-15,9,19,-2,45,-40,-20,77,35,42,10,58,14,24,-51,-1,41,18,10,-14,-26,29,-3,35,-22,-18,8,-19,83,-28,-5,47,-40,-50,0,-18,-43,-20,-16,5,0,11,60,-49,-62,39,47,-9,56,22,-30,69,4,-31,8,45,33,60,-54,-64,12,-1,92,6,60,1,24,-25,5,-40,48,6,-6,-38,32,-32,-55,-22,14,43,-50,-23,-63,-88,32,-21,39,-59,-6,26,-19,23,-13,48,-32,-2,-14,-64,40,-59,38,4,-22,4,8,2,-16,40,4,-17,-63,20,5,23,-32,-24,-10,-5,-23,-86,87,10,11,15,-9,19,44,27,28,15,45,51,-38,9,-23,-39,-4,23,23,23,10,33,41,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.83","t":"Benefits of Reducing Psychological Symptoms It is logical to encourage patients to identify the benefits of reducing their psychological symptoms after considering their deleterious consequences. This will help them to see that there is a “light at the end of the tunnel” and that there is hope that their lives will improve. Patients who are depressed and anxious often feel overwhelmed when presented with the option of psychotherapy, perceiving that it will require more energy and effort than they have to give. By identifying the benefits of reducing psychological symptoms, many patients begin to view the long-term benefits as outweighing the short-term costs. Because patients in the midst of a depressive episode often think in general terms and have difficulty generating specific pieces of information to solve problems (Williams, Barnhoffer, Crane, & Duggan, 2006), it often is helpful for therapists to provide a menu of choices (below) so that patients can select from a wider range of benefits than they might identify on their own.","e":[37,56,-129,-52,64,-13,27,22,49,-20,-10,29,50,23,-8,-7,-24,-61,-5,16,-31,-15,-60,-39,-19,47,20,0,-27,27,56,-21,19,-33,-58,-29,81,82,21,7,38,-22,46,-93,-6,-29,73,16,32,-17,58,-43,-22,-15,114,-6,8,25,54,-60,88,55,-52,42,76,-46,-29,9,-17,-22,48,12,-4,26,-26,14,-15,21,32,19,53,-38,32,-48,43,43,43,-2,-19,73,-10,16,16,49,-102,45,19,-21,-14,-40,-29,12,15,-25,16,23,-19,2,8,24,-66,23,-3,-32,23,-31,76,-47,5,54,-5,48,1,59,45,43,-40,-21,55,4,-12,-17,-46,37,6,71,5,-5,6,13,49,26,-9,9,-47,-35,-7,-19,-42,23,-26,-3,33,41,37,-71,-26,-12,44,16,42,23,-17,46,-7,-35,46,12,-7,21,-33,-38,4,-11,86,16,99,-39,19,-21,24,-31,55,35,30,-29,42,-29,-60,-38,-5,15,-57,-15,-75,-64,39,0,-1,-45,-29,3,1,-12,-24,57,12,-20,-18,-55,32,-47,29,16,-22,15,-22,-25,-2,22,25,5,-15,-8,17,10,-43,-9,-19,-4,-1,-73,75,-4,20,-7,-36,0,5,47,4,1,48,56,-61,8,-12,-26,-28,43,1,25,2,47,67,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.83","t":"Benefits of Reducing Psychological Symptoms Happiness Relaxation Increased productivity Increased confidence Take better care of self Enjoy life more Lowered stress Physically feel better Easier to deal with Ease in speaking one’s Mentally feel better people mind Exercise and eat better Avoid legal problems Sleep better Feel in control Enhanced sexual Safer More energy performance Better memory and Able to enjoy Better relationships with concentration pleasurable activities family and friends Better able to achieve Better able to deal with Have more hope for the my goals problems future Note: From Zanjani et al. (2008).","e":[19,26,-132,-8,53,-12,41,13,60,-35,-1,26,31,32,-18,0,-31,-59,-8,19,-30,-49,-38,-28,-4,96,2,-1,-8,20,62,-16,6,-9,-14,-16,78,93,32,3,10,-26,45,-89,30,-45,88,28,56,16,47,-81,-20,-2,132,-21,10,-8,43,-58,74,39,-41,59,88,-27,-6,48,-49,23,17,0,-26,18,-33,8,-5,0,22,38,21,-37,45,-36,50,27,7,-23,-33,46,24,14,12,59,-55,34,31,-35,6,-30,-11,-4,47,-19,30,7,-7,-7,-21,56,-40,16,5,-19,40,-28,67,-57,13,71,-17,50,-3,60,18,14,-37,-33,49,0,-2,-19,-58,63,-24,52,-31,-14,17,-25,66,8,-15,31,-71,-51,15,-10,-58,23,-19,-35,40,13,28,-100,-51,19,46,13,34,-5,-12,56,-8,-24,26,21,-12,52,-25,-29,-20,-4,70,-24,58,-20,6,-54,25,-23,41,42,20,-37,46,-8,-67,-18,0,4,-62,-55,-56,-87,16,9,0,-28,-41,-15,18,-47,8,40,-16,-31,-8,-21,16,-32,46,-18,-5,1,-16,-29,7,7,10,-10,-34,3,37,33,-26,-13,-32,-1,-4,-75,70,-15,2,-25,-9,18,16,24,3,35,15,30,-55,25,-42,-34,-38,34,22,52,23,26,62,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.83","t":"Like many depressed patients, Jack had difficulty identifying specific benefits for attending treatment and reducing his psychological symptoms. Jack’s therapist knew it was important for Jack to clearly articulate some benefits because he expressed resentment that he was the one in treatment when so many others were causing problems for him—a belief that surely would decrease his motivation for treatment. When Jack reviewed a list of potential benefits of getting treatment and reducing his psychological symptoms, he indicated that being better able to achieve his goals, having an easier time dealing with people, and sleeping better were the three most relevant benefits to him.","e":[19,35,-141,-45,21,32,-12,15,64,-23,-35,11,62,24,-15,-5,4,-44,-15,28,-43,-38,-71,-41,-2,49,-23,2,-51,53,63,-36,-34,-42,-45,-19,81,100,20,9,-5,-23,-3,-104,46,-31,59,48,24,-32,41,-81,-25,-31,129,13,2,21,43,-49,75,35,-52,48,70,-18,6,35,-64,16,42,-5,10,10,-34,24,-12,9,8,9,45,-32,54,-58,45,32,17,5,-18,61,-1,30,22,77,-96,25,-15,-25,6,-29,-53,-15,17,-5,37,50,12,21,9,6,-37,0,-5,-38,17,-16,64,-50,13,28,-32,48,-19,72,9,57,-15,10,52,22,-8,-34,-34,50,-1,53,-24,-32,-12,-4,71,12,-10,15,-23,-54,-14,-13,-71,15,24,4,39,27,15,-73,-37,-2,43,52,32,-6,-2,31,13,-39,21,29,7,71,-11,-60,-8,-18,88,14,84,-35,18,-35,49,-46,39,40,8,4,40,-31,-55,-54,-5,17,-45,-26,-63,-43,46,-9,-9,-19,-27,5,-5,-10,-41,67,7,16,-1,-27,24,-33,15,21,-21,5,-17,-26,-20,19,-6,3,-24,-14,18,16,-33,-20,-45,5,-41,-87,76,14,15,9,-15,22,31,55,-23,24,46,21,-59,35,-16,-43,-18,27,5,51,-8,6,64,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.83","t":"Attitudes and Expectations Toward Treatment Attitudes and expectations toward treatment can have a powerful influence on the • Attitudes and degree to which patients are actively engaged in the therapy process. Research shows expectations that patients with higher expectations for treatment are more likely to recover from toward their mental health problems and report fewer psychological symptoms (Shapiro & treatment Shapiro, 1997), in part because the therapeutic relationship is stronger in patients with higher expectations for treatment (Meyer et al., 2002). Furthermore, patients who report a neutral or negative attitude about talking with a therapist about their CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 67","e":[28,9,-167,-32,76,30,19,10,48,-15,14,41,51,26,17,-2,17,-28,-35,49,-54,-44,-46,-77,-4,45,-34,-7,-32,19,34,4,0,-21,-62,-60,56,37,32,-23,48,-17,0,-64,11,-40,85,50,26,-3,29,-65,-8,-8,117,17,17,46,9,-43,75,25,-69,52,61,-1,-37,37,1,-38,38,42,5,24,-34,-15,-13,-28,-15,22,45,-21,49,-56,36,28,40,14,-5,91,35,19,22,22,-119,7,-29,-55,-40,-24,-35,0,22,-8,17,25,7,30,-36,8,-63,56,-22,-29,-15,-16,49,-43,19,56,18,5,-7,59,21,40,-31,10,9,-1,24,-17,-22,19,-20,43,0,-20,23,43,93,14,25,36,1,-64,0,17,-47,-3,8,10,35,33,-8,-52,-42,26,35,28,65,34,-22,40,-12,-73,29,42,-5,33,-27,-33,-1,7,89,11,70,-13,29,-37,-4,-35,35,2,-13,-45,35,-33,-72,-41,-1,29,-43,-5,-52,-41,22,-9,53,-25,-3,25,-23,32,-40,68,-16,-12,-13,-54,27,-30,-2,21,18,1,-21,-4,-34,17,31,-47,-25,18,22,-17,-31,8,-5,15,-22,-77,65,19,4,6,-34,18,59,32,0,54,26,37,-67,7,-14,-7,-6,45,0,65,13,-18,45,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.84","t":"problems report more depression and suicide ideation than patients who report a positive attitude 12 months after beginning treatment (Wenzel, Jeglic, Levy-Mack, Beck, & Brown, 2008). On the basis of this body of research, we encourage you to assess attitudes and expectations for treatment in the first session. If patients report low or negative attitudes and expectations, we encourage you to take time to understand the rationale behind these beliefs, provide psychoeducation to correct incorrect assumptions about treatment, and use the motivational enhancement strategies described in this section to overcome these beliefs and create a context in which patients decide to commit to treatment.","e":[36,7,-175,-47,59,17,38,8,21,-37,-13,50,43,28,17,1,20,-57,-51,66,-47,-53,-67,-64,13,68,-44,-7,-49,40,25,-11,-2,-31,-51,-46,55,2,30,-53,40,-32,19,-64,-4,-23,99,16,19,-33,29,-40,-13,1,95,49,-9,15,14,-55,90,22,-54,30,82,1,-15,36,-29,4,20,30,4,22,-21,35,-3,-13,-13,27,56,-29,44,-71,46,15,18,17,-17,85,5,21,0,20,-96,10,-44,-13,-39,-11,-47,-3,-12,-20,14,46,-6,6,9,-15,-56,53,-33,-30,5,-5,55,-48,32,23,-6,3,30,47,30,-7,-16,-17,22,9,4,-21,-54,32,-15,50,27,-31,-3,20,78,24,24,17,-10,-56,3,-17,-18,21,-21,13,51,12,12,-69,-38,-1,58,-12,84,24,-31,38,-8,-45,10,32,13,20,-27,-43,-5,-21,83,11,71,-24,16,-27,31,-44,21,14,2,-39,45,-29,-76,-72,13,46,-56,-6,-69,-32,59,-39,26,-11,13,27,-50,22,-68,66,-4,-11,-22,-45,21,-20,-17,19,-7,0,-5,5,-15,20,21,-23,-19,-28,39,-3,-49,15,-25,-15,-32,-66,39,7,3,-7,-12,5,12,21,-28,46,22,82,-86,-11,13,-24,17,26,2,30,4,2,43,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.84","t":"Assessing Negative Attitudes Toward Treatment Understanding the rationale behind patients’ negative attitudes toward treatment achieves several aims: It communicates to patients that you are taking their views seriously and reinforces the collaborative relationship between you and the patient, rather than a relationship in which your opinions as a therapist are more important than those of the patient. It provides additional insight into the patient’s cognitive processes, thoughts, and beliefs, which can be incorporated into the case conceptualization. It provides information about aspects of treatment that the patient perceives to be unhelpful, which can be considered in developing a treatment plan and tailoring specific interventions to the patient’s clinical presentation and personal preferences.","e":[57,32,-99,-59,75,39,25,18,32,3,17,49,51,41,-13,-34,0,-12,0,51,-47,-23,-33,-73,5,38,-7,1,-66,8,20,0,-1,-35,-62,-69,63,32,-13,-14,39,-8,16,-72,22,-12,88,24,10,-3,43,-62,14,-10,92,14,-6,46,7,-35,53,54,-51,55,75,-26,-26,12,-15,-2,15,27,16,5,-55,11,-1,-14,-10,33,42,-41,73,-60,43,27,25,-1,-14,69,12,23,40,12,-122,41,-39,-29,-78,-36,-48,28,-13,-28,25,27,-16,38,9,18,-52,39,-44,-23,37,-22,64,-67,2,27,44,40,-20,65,5,24,-53,-25,-6,-4,-11,-28,-19,-18,-20,67,8,-41,1,40,85,13,25,30,-2,-42,8,-15,-19,15,-15,3,43,21,58,-56,-36,17,31,7,98,26,-32,55,-22,-27,40,25,0,6,-17,-31,10,1,91,19,74,-3,-6,-18,-14,-15,23,5,22,-39,58,-24,-64,-49,43,32,-37,-3,-48,-69,3,32,62,-47,-13,22,-44,51,-41,20,-8,-22,-13,-23,-2,-29,14,11,-9,-1,5,-4,-47,26,47,-26,-9,19,20,10,-74,34,5,0,-29,-98,29,20,6,3,-8,25,14,59,-15,47,21,35,-59,-1,18,-30,3,44,-17,63,21,-6,51,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.84","t":"In our experience, negative attitudes toward treatment come from two main sources— preconceived notions about what therapy is and is not, and negative experiences with one or more previous courses of therapy. In both instances, it is helpful to educate the patient about the goals, structure, and process of CBT in order to ensure that he has an accurate understanding of what this trial of therapy will be like. For example, therapists will encounter some patients who have never been in therapy and who base their opinion about the usefulness of psychotherapy on stereotypes (e.g., the idea that they will be asked to attend several sessions a week for several years). In other instances, patients will have had a course of therapy that they did not perceive to be particularly helpful, and they expect that CBT will be the same. In fact, Wenzel at al. (2008) found that negative attitudes toward talking with a therapist about one’s problems were associated with more previous experiences with therapy and higher levels of hopelessness before treatment started.","e":[46,37,-124,-50,82,59,29,4,33,1,-17,53,58,33,-15,-36,-10,-17,-9,60,-67,-33,-8,-66,-39,28,-53,13,-24,10,57,-26,-17,-23,-50,-45,55,12,-19,-34,73,0,11,-92,21,-26,96,43,-3,4,62,-60,2,-23,108,21,-4,38,-2,-55,53,42,-61,92,61,-20,-45,40,-18,0,20,23,1,27,-21,-12,-17,-29,-3,57,42,-18,43,-50,62,29,29,9,-20,66,4,0,29,9,-103,21,-47,-28,-63,-20,-40,-6,-8,-28,-1,45,-8,-13,9,7,-86,52,-41,-24,-24,0,55,-58,27,29,12,28,-44,38,15,55,-35,-25,21,-19,-18,-38,-12,-3,2,61,19,-25,1,58,82,-6,22,37,14,-33,-7,-32,-28,25,-7,7,21,32,39,-53,-35,14,65,-2,85,20,-12,17,-12,-38,7,21,5,19,0,-39,-5,-3,89,32,51,-9,12,-44,-22,-4,13,32,44,4,11,-20,-37,-78,22,12,-49,9,-66,-64,11,24,29,-31,-6,32,-22,43,-69,42,-17,1,-10,-31,30,-7,-5,12,-35,-11,6,-11,-42,27,13,-10,-9,-12,22,20,-42,-3,-13,11,-32,-108,56,31,-1,6,8,8,7,47,-15,51,20,60,-70,-29,22,-31,0,24,-28,61,16,-3,31,-1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.84","t":"The following excerpt is an example of the manner in which Jack’s therapist handled his negative attitudes toward treatment. Therapist: [making a periodic summary] So, let’s summarize where we are so far: It sounds like you would like several aspects of your life to be different than they are right now. Your anger and irritability are wearing you down, and you identified three important benefits of reducing your anger and irritability—reaching some of your goals, dealing with people more effectively, and being able to sleep better. Am I on target here? CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 68","e":[27,11,-169,-64,47,34,10,-24,57,-18,-3,30,44,22,27,-19,11,-27,-15,14,-40,-49,-44,-59,35,79,-27,35,-58,28,61,-34,-36,-27,-50,-9,71,63,-6,-18,52,-14,25,-98,20,-29,90,41,13,-25,48,-102,2,-41,122,-27,-5,5,-7,-63,69,23,-76,59,46,-22,-35,29,-59,-27,52,-14,19,14,-59,18,-40,-24,-4,20,39,-19,46,-89,73,-11,20,31,-16,44,16,33,-3,45,-70,25,-12,-23,-30,-35,-56,-22,6,-28,18,50,0,-19,-11,-4,-72,25,1,-31,8,7,63,-55,-14,45,19,15,-21,6,-2,27,-43,13,34,8,-13,-18,-16,17,-1,30,-21,-27,-5,24,101,0,-16,38,-2,-32,-23,-16,-62,-3,5,11,25,11,39,-56,-47,32,47,20,35,2,-32,44,36,-36,-12,61,23,63,-37,-57,-21,-35,75,7,53,-20,-2,-41,19,-36,55,37,9,16,17,-36,-48,-49,5,50,-56,-11,-58,-65,46,-16,9,-33,10,18,-12,16,-56,40,-2,6,-7,-43,46,-26,20,10,-7,5,12,-6,-57,5,23,13,-23,-28,20,9,-12,-21,-28,-14,-33,-105,59,-9,18,23,13,50,12,67,9,55,39,40,-87,47,-7,-47,4,33,13,22,6,-5,29,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.85","t":"Jack: Yeah … I guess so … Therapist: I’m sensing that you’re not convinced that this will be helpful to you. Jack: Yeah. I mean, I’ve done this before, and things are still the same. The problem is more with other people than with me, but yet I’m the one who is stuck going to see a counselor. Therapist: So you’ve been in therapy before. What was that like? Jack: To be honest, I didn’t really get anything out of it. All I did was show up, tell my counselor what happened that week, and leave. Therapist: Were you having the same sorts of problems then as you have now? Jack: Some yes, some no. Things with my wife have been bad for at least 15 years. But at least back then, I had a job. Therapist: So your relationship with your wife was the major issue that brought you into treatment before? Jack: Yeah, that and the problems with my kids. And, I guess, problems with my boss at work as well. Therapist: Did you develop any concrete strategies for dealing with these relationship problems from your previous experience in therapy? Jack: No, not at all! All I did was talk about the relationships, over and over and over. It probably made my anger worse, not better. Therapist: It occurs to me that your previous therapist might have been providing a different type of treatment than the type of therapy that I do. Would you be willing to hear more about the cognitive behavioral approach that I take with the people I work with? Jack: Cognitive what? Therapist: Cognitive Behavioral Therapy—or CBT, for short. It is an active approach to therapy that focuses on helping you to develop strategies to address your current problems. In each session, we’ll figure out the most important topics to cover in order to meet your treatment goals, and then you and I will work actively as a team so that you can start to develop some concrete skills for handling problems differently. In many instances, you’ll try to use these skills in your real life, and you’ll come back to the next session and let me know how it went. What do you think of this so far? Jack: It’s a lot different than I thought it would be. Therapist: In what way? Jack: It sounds a lot more direct than I expected. Therapist: And do you view that in a positive way or in a negative way? Jack: Well, I guess positive because it sounds like we might get a lot done. But I won’t lie to you—it also sounds like a lot of work. I have so much on my mind right now that I really don’t need more work piled on me. Therapist: I understand. Another aspect of this treatment that I should make you aware of is that it is tailored to each person, so that we figure out ways to solve problems that work best for your needs. How does that sound? Jack: It sounds good in theory. But you know how things go—everything is always different than you were led to believe once you get into it. Therapist: I have an idea. What if you were to agree to come in for just four sessions? That should give you enough time to judge whether this type of therapy is helpful for you and whether it requires more effort than","e":[46,25,-108,-75,20,22,20,-40,42,-22,-59,-9,7,39,-21,-30,28,-50,-53,30,-37,-35,-8,-12,-15,44,-88,38,-61,33,71,-29,-38,-22,-86,-8,77,54,4,-25,70,-5,-13,-139,34,-77,89,31,6,-13,11,-58,5,23,96,21,2,74,4,-77,65,25,-48,76,16,-32,-40,52,-61,-30,31,-16,35,18,-44,40,-20,-6,12,17,39,-11,33,-77,5,22,19,51,-10,69,8,24,-9,43,-64,-8,-52,-50,-27,-35,-57,-17,7,9,8,48,-26,-31,-6,17,-65,15,-5,-7,-40,-7,47,-68,40,31,5,16,-54,2,46,68,-57,-3,25,-15,-2,-24,13,28,-7,48,39,-37,-14,14,83,-18,2,14,29,-20,-19,-25,-43,19,25,19,1,51,40,-56,-56,-2,55,32,38,-12,16,12,18,-6,2,78,4,56,-1,-66,-5,-30,46,43,73,-24,-8,-21,68,6,45,-2,24,16,22,-31,6,-52,14,6,-71,6,-51,-44,49,-33,-3,-28,-1,50,-21,50,-37,55,-16,4,-44,-32,55,-33,-22,46,-42,-10,22,-2,-62,39,4,9,8,6,11,24,-31,4,-23,35,-51,-93,36,24,13,12,-16,11,3,97,12,53,7,10,-63,-2,15,-34,28,8,38,23,28,-30,23,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.86","t":"you are willing to give. At the end of the fourth session, we can re- evaluate. Jack: Four sessions…that’s it? I don’t have to commit to anything more than that? Therapist: And in the fourth session, we’ll look at everything we’ve done together and decide together whether it has made a difference in your life. Jack: OK. Four sessions it is.","e":[48,39,-166,-58,28,13,-7,-10,37,-1,-74,-7,2,47,-11,-17,28,-84,-11,33,-52,-64,-63,-17,6,58,-28,27,-54,15,51,-44,33,-17,-33,-40,59,40,-14,-68,-6,9,-27,-60,65,-64,82,14,37,-25,28,-29,-42,-14,99,59,-20,50,5,-33,95,1,-41,77,77,-24,-46,57,-17,-30,41,-6,35,10,-35,48,-12,14,-20,8,27,-16,71,-34,35,20,19,26,-1,81,23,10,16,40,-60,11,-17,51,-19,-46,-90,2,-2,-38,28,30,13,16,0,-18,-52,15,-25,18,-41,-21,55,-60,33,48,-2,-11,-18,58,-12,74,-17,18,-5,-11,0,-8,1,30,10,44,3,-80,-26,18,35,8,-7,15,-4,-41,-4,-36,-39,22,45,24,23,36,22,-89,-20,-14,46,53,29,-11,-15,23,-21,-3,9,59,7,29,-16,-72,9,-21,50,7,44,-43,-6,-21,68,-22,31,19,15,-2,41,-42,-13,-56,2,23,-28,-19,-33,-45,37,-38,15,-8,8,18,-31,28,-35,106,-45,37,-41,-43,92,-20,-19,31,-26,-15,24,0,-48,82,22,30,4,-44,2,10,-44,-23,2,17,-42,-109,16,16,1,34,-20,15,14,40,-4,25,17,-9,-58,17,21,-39,27,25,41,27,16,9,23,0]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.86","t":"Notice that when Jack’s therapist attempted to describe CBT, she stayed away from technical terms and jargon as much as possible. Once patients commit to treatment, it is important that they understand what is meant by cognition and behavior, as these • Commitment constructs lie at the heart of CBT. However, when patients are ambivalent about to treatment treatment, they will likely tune out information that seems foreign to them or difficult to understand. Thus, when therapists use motivational enhancement to increase patients’ commitment to treatment, they focus on concrete aspects of treatment and the manner in which they will affect patients’ lives.","e":[42,59,-144,-48,89,13,19,22,48,-7,-40,12,52,5,7,0,-14,-50,-10,64,-45,-5,-3,-33,-28,25,-26,24,-45,29,60,-12,-5,-33,-42,-43,83,55,-2,-26,15,-15,-4,-99,-8,-31,82,5,36,-12,9,-66,-14,-36,147,41,-16,60,-3,-58,90,61,-40,49,44,-24,-44,60,-72,8,26,-10,20,54,-25,1,-24,-15,-11,14,58,-31,56,-51,61,20,10,22,-20,85,13,-35,21,42,-116,-14,-34,-40,-20,-28,-106,-10,13,-14,1,28,17,15,19,8,-30,19,-28,-1,-31,6,42,-43,30,-4,53,-14,3,52,-10,65,-36,-28,30,-30,-9,-35,-9,1,-27,64,-16,-34,-6,26,54,-4,26,8,-28,-24,-11,-33,-10,18,35,22,14,13,65,-54,-9,-8,28,37,48,26,-23,7,4,-21,21,36,2,53,-24,-28,-9,19,99,52,53,-10,19,-34,13,-14,22,18,-10,-1,18,-46,-32,-47,8,40,-31,7,-95,-47,43,-18,46,-32,-24,20,-36,6,-56,75,-15,8,-48,-49,38,-18,-25,34,-24,-20,3,-16,-62,26,41,-9,39,-18,-10,-1,-32,-1,12,21,-12,-58,35,35,29,44,-22,35,19,54,13,55,25,10,-45,-6,18,-41,-11,29,9,12,4,-13,40,1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.86","t":"At the end of this dialogue, Jack still was not convinced that he was willing to participate in CBT. It is not uncommon for patients with negative attitudes toward treatment to be hesitant to commit to an entire course of psychotherapy. In this case, Jack’s therapist made use of a strategy called the behavioral experiment. Briefly, a • Behavioral behavioral experiment requires that a patient try out something (e.g., four sessions of experiment treatment) and evaluate the outcome based on the “data” he collected experientially. This is one of the most powerful approaches to modifying maladaptive thoughts and beliefs, as patients experience the costs and benefits in their lives rather than evaluating them hypothetically. This behavioral experiment, as applied with patients like Jack, is an effective tool for getting patients’ “feet in the door” without creating a context in which they resent having committed to more than they had anticipated.","e":[41,58,-154,-55,48,18,18,-2,75,-20,-30,13,64,43,-39,-46,16,-51,-18,8,-48,-9,-25,-38,0,16,-47,29,-47,40,40,-32,-3,-26,-64,-42,57,27,-21,-31,-12,19,15,-99,48,-24,109,31,18,-10,44,-38,34,-37,132,35,-17,56,4,-79,84,7,-52,38,55,-12,-64,54,-43,-4,60,-3,24,12,-11,32,-8,-32,7,44,19,-36,53,-40,71,-2,14,21,-25,55,2,-6,42,40,-110,20,-51,-16,-19,-30,-74,5,4,11,-17,47,-11,29,7,-2,-60,29,-8,-37,-14,17,40,-56,34,13,24,14,-35,23,-17,69,-53,10,35,-21,-25,-12,0,-13,-11,33,17,-41,-6,20,51,-6,7,54,14,-23,-3,-31,-21,30,22,15,40,34,21,-65,-30,13,34,60,50,-18,-13,15,-11,-38,16,53,35,36,-35,-97,4,-4,68,30,47,-27,-3,-21,32,-16,24,18,6,12,24,-13,-25,-73,25,16,-56,-17,-86,-57,57,-17,21,-26,2,21,-12,29,-66,40,-37,13,-35,-41,56,-2,-26,43,-35,-7,25,-5,-42,28,23,7,-20,-6,20,10,-22,-26,-18,17,-38,-76,41,10,22,55,-20,22,18,41,-25,45,13,34,-69,-9,-17,-25,29,13,9,40,11,-25,52,9]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.86","t":"Obstacles to Participating in Treatment In addition to negative attitudes toward treatment, there are several other barriers that prevent patients from attending their sessions on a regular basis or otherwise actively engaging in treatment. Some of these obstacles are logistical in nature, such as living far away and having trouble arranging for transportation, not having resources for childcare, having other medical problems that interfere with attending sessions, and • Obstacles to working during business hours. Other patients have few logistical obstacles but, participating in treatment instead, have difficulty attending sessions and/or engaging in treatment because of decreased energy and motivation, concurrent substance use, other crises that demand their attention, and generally chaotic lifestyles. Many of these barriers can be identified in advance during the initial sessions before they disrupt the course of treatment.","e":[17,78,-127,-34,44,55,33,15,53,-25,-10,13,31,30,12,-35,16,-39,-44,44,-62,3,-11,-65,-15,51,30,-22,-33,34,31,-26,40,-57,-26,-41,64,39,25,2,55,-16,0,-90,-4,-34,66,20,20,-48,60,-82,-67,-16,86,-1,5,46,29,-24,123,28,-60,54,57,-45,-28,31,4,-3,29,32,26,-1,-26,9,-11,17,-17,23,20,3,57,-63,67,32,0,17,-19,72,-21,14,26,9,-115,23,-39,11,-47,-23,-23,-17,17,13,3,2,36,32,0,20,-46,48,-25,-43,25,-32,73,-53,19,15,-19,-1,-9,53,15,62,-26,-31,56,7,6,-27,-41,5,3,18,-4,-35,20,10,94,11,21,23,-4,-52,2,-38,-37,-1,6,41,19,59,39,-77,4,50,32,23,79,21,-47,20,-14,-51,12,35,6,46,-18,-57,-14,24,85,57,90,-25,-5,-60,2,-55,-2,-8,7,-19,22,-24,-72,-56,12,35,-12,-61,-71,-73,43,31,49,-58,-6,31,-34,37,-6,69,-36,-5,-11,-19,49,-20,-13,2,-11,-24,17,-27,-27,71,23,-53,-12,-13,55,16,-67,17,-20,21,-57,-67,51,-3,10,-1,-5,21,11,14,-10,24,38,27,-44,-11,-22,4,-52,21,2,42,-6,1,35,19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.86","t":"When these obstacles are identified, cognitive behavioral therapists use problem- solving strategies to help patients develop a plan for overcoming them. Not only does this approach increase the likelihood that patients will attend and engage in treatment, but it also models an adaptive problem-solving approach that can be generalized to other problems in patients’ lives. In many instances, it is important to write down the plan to overcome obstacles on a piece of paper so that patients can take these CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 70","e":[35,48,-135,-39,66,1,67,-5,35,-3,-28,-15,53,30,4,-23,-26,-74,-37,5,-4,-16,-5,-4,4,63,-46,27,-31,22,42,-1,-4,-68,-41,-26,72,20,6,-1,29,-12,-3,-113,21,-41,108,9,35,-18,50,-67,25,-38,96,1,-4,23,1,-68,119,50,-43,35,32,-30,-47,68,-74,-9,58,-8,50,14,-56,-4,-20,-11,-25,30,50,-33,38,-51,72,25,12,19,-27,53,-21,24,22,36,-81,26,-38,-32,-23,-37,-52,-15,22,-1,-27,52,20,-3,4,34,-92,41,-10,-20,-8,35,50,-32,23,37,1,1,0,1,12,93,-58,-44,70,-6,-9,-8,1,-20,13,33,-14,-7,14,40,47,-11,6,28,-4,-34,-21,2,-52,-16,-39,44,13,25,64,-43,-11,29,28,3,51,9,-52,27,-21,-32,14,37,11,45,-43,-56,-15,8,98,18,64,-11,-3,-34,22,-31,43,39,-6,-8,29,-25,-39,-39,12,30,-39,-6,-99,-64,38,-5,37,-39,-14,51,-26,10,-30,50,-22,-2,-14,-35,48,-15,9,17,-70,-27,9,-5,-44,29,27,-32,-25,-4,19,18,-55,-5,11,31,1,-89,33,20,79,26,-35,44,27,54,27,21,45,39,-44,44,0,-47,-14,40,25,6,-5,2,32,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.87","t":"problem-solving plans with them and consult them outside of session. In the following dialogue between Jack and his therapist, they identified obstacles that would prevent him from attending treatment and problem solved ways to overcome these obstacles.","e":[24,46,-132,-40,24,28,-8,-24,50,-18,-44,-7,47,35,-13,-14,27,-65,-43,0,-39,-32,-25,9,6,18,-16,-5,-45,16,61,-32,-16,-50,-50,-53,82,42,-11,-26,10,-4,-25,-121,66,-63,85,27,25,-48,61,-66,-31,-25,84,59,26,22,47,-39,100,36,-49,32,53,-32,-48,53,-47,6,56,-15,49,-1,-44,12,14,21,-2,36,23,-12,87,-64,54,53,-12,6,-22,68,-14,30,33,21,-97,32,-34,0,-7,-37,-56,-26,15,-22,18,59,33,20,0,19,-42,27,-37,-29,10,-37,66,-21,59,16,-27,-5,-17,40,20,94,-29,2,46,-10,-11,-17,-15,22,4,63,-2,-36,6,9,78,13,-16,4,16,-50,-7,-13,-74,3,4,40,-26,45,32,-26,-24,23,63,25,52,-10,-32,24,-10,-22,20,40,11,42,-6,-64,10,19,89,47,63,-45,1,-26,40,-53,18,31,-1,-3,23,-42,-17,-56,-2,30,-29,-47,-43,-79,52,-9,23,-13,-19,19,-40,4,-42,72,-19,26,-14,-22,63,-18,-20,16,-33,-47,29,8,-61,39,-10,-13,-56,-36,18,11,-37,5,-38,25,-59,-94,32,34,55,1,1,48,12,56,5,41,28,31,-31,37,19,-41,-15,47,30,36,1,-13,9,-8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.87","t":"Therapist: I’m glad that you have committed to attending four sessions, Jack. I’m wondering, though, if there is anything that might prevent you from attending these sessions or from getting the most you can out of them? Jack: I don’t think there’s anything. Once I set my mind to something, I do it. Therapist: OK. So that means that you have all of the basics in place, like transportation to get you here and time each week to attend sessions? Jack: Yeah, it shouldn’t be a problem. My car’s running good, and I only live a half hour away. No big deal. Therapist: [realizing there are no overt logistical barriers to attending sessions but that there might be other barriers] Sometimes, when people are depressed or angry or irritable, people have the best intentions to go to their session, only to find that when it’s time for them to get ready, they just don’t feel like it. Do you think this will happen to you? Jack: I think our appointments will be at 9:30 in the morning, right? As long as I had a good night’s sleep, everything should be fine. Therapist: [sensing a “red flag” when Jack mentioned his sleep] Jack, I recall that you told me that sleep is a pretty big problem for you. That sometimes you don’t fall asleep until 2:00 or 3:00 in the morning, and then you have trouble getting up in the morning. How often do you have those kinds of nights? Jack: A lot, unfortunately. Four or five times a week. Therapist: So do you think there is a high probability that something like that might happen the night before we have a session? Jack: Now that I think of it, yeah probably. It’s worse whenever I know I have to get up in the morning. Therapist: How should we handle this, to ensure that our sessions run smoothly? Jack: Do you have any appointments in the afternoon instead of the morning? Therapist: Sometimes I do, and sometimes I don’t. When I do, you’re more than welcome to grab one of those appointment times. But what will happen when I don’t have an afternoon available and you have a morning appointment? Jack: I guess I should think about that, huh? Therapist: Yes, I guess you should. But that’s what I’m here for. I can help you figure out possible solutions to these sorts of problems and decide on the best one. So, what would you say are possible ways to ensure that you wake up and can get to a morning appointment? Jack: Well, maybe I should go to bed earlier. I have this thing where I sit on the couch and watch TV until I nod off. Maybe I should just try to get in bed at a decent time. Therapist: That sounds reasonable. Any other ways to address this problem?","e":[-17,30,-151,-47,-24,21,7,-23,44,-19,-32,-26,-1,62,-26,-25,37,-51,-53,-6,-61,-26,-56,-25,-23,77,-24,18,-72,52,91,-56,-18,-56,-49,-24,28,69,-7,-30,51,-17,-5,-106,32,-74,86,31,-10,-52,35,-74,-51,-1,91,37,19,32,39,-8,147,-4,-46,71,44,-11,-29,46,4,-18,43,-13,32,-17,-17,68,-9,-9,3,21,2,4,77,-71,8,22,35,49,20,68,32,17,2,32,-38,16,-3,36,-38,-40,-57,-4,-29,-25,19,24,-16,-1,-19,-35,-49,9,-28,-34,-15,-8,56,-72,32,2,-27,-5,-24,28,41,73,-40,13,2,23,-13,-29,-15,48,-21,43,34,-55,-23,24,57,-3,-13,-23,10,-25,-35,-42,-60,47,29,6,1,58,43,-65,-32,-19,68,56,49,-1,-43,20,8,-24,-6,70,-1,43,10,-48,-23,-23,25,39,74,-46,-5,-30,61,-19,5,-23,-2,-8,24,-70,-8,-67,17,10,-41,-31,-44,-33,49,-20,-2,-4,6,17,-1,20,-15,88,-21,25,-29,-29,65,-23,2,58,-31,-18,26,-22,-30,56,38,-11,-9,-8,11,18,-26,-16,-34,13,-63,-77,25,10,30,48,5,6,27,52,17,39,15,19,-89,-4,3,-30,2,9,45,23,25,-15,44,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.88","t":"Jack: I guess I could set the alarm clock the night before. I haven’t been using the alarm lately because I don’t have to get up and go to work. But I can try to remember to do that. Therapist: Sounds great. So to recap, on the days you have a morning appointment with me, you’ll prepare for that in advance by getting in bed at a reasonable hour the night before and setting your alarm to ensure you wake up. Jack: Yeah.","e":[-22,8,-154,-1,-32,45,-17,-36,57,-34,-45,41,21,88,-27,-11,50,-42,-9,-25,-16,-49,-66,-29,-28,51,16,35,-68,48,82,-24,-13,-65,-34,-73,-33,43,-1,-53,21,10,13,-108,61,-11,71,43,15,-50,19,-65,-32,-42,110,37,48,14,63,-22,129,33,-4,54,38,21,-16,61,-3,3,40,-4,20,-25,-25,42,14,0,-1,50,29,-11,88,-33,4,36,39,1,5,81,47,-3,4,28,-41,23,-23,50,-11,-29,-48,-9,-6,-15,26,35,-8,-42,-14,-44,-45,23,-4,-4,-18,20,101,-83,46,21,-40,-11,-10,33,-30,57,-17,14,44,14,29,-8,-37,35,-4,74,29,-36,7,23,39,-3,-15,-63,-6,12,-25,-34,-44,57,17,8,-1,48,33,-63,-33,-3,49,43,91,-39,-40,8,9,-35,-38,69,-5,53,6,-31,-6,-43,50,26,43,-32,-1,-48,69,-9,3,-2,-53,-67,12,-49,-43,-43,14,44,-36,-26,-49,-29,21,37,10,9,-15,-3,-1,12,-16,84,15,7,-13,-37,45,15,-14,-1,-10,-2,4,-16,-65,44,-26,4,2,-29,26,-12,-10,-3,-10,13,-4,-86,25,41,67,50,17,31,32,45,-1,26,39,12,-63,9,40,-59,2,48,32,2,7,-13,10,-65]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.88","t":"Socialization into CBT Earlier, Jack’s therapist provided him with some information about CBT to show him • Socialization how this course of therapy has the potential to be different than other courses of into CBT therapy in which he participated in the past. His therapist did this for two reasons: (a) to increase his motivation to commit to treatment, and (b) to begin orienting him to CBT structure and process. It is important for therapists to spend time educating patients about CBT so that they have accurate expectations of their role and responsibilities in treatment, the therapist’s role and responsibilities in treatment, and the types of things that will transpire over the course of treatment. Below we list the topics that therapists often cover when they socialize their patients into CBT.","e":[19,43,-132,-45,51,21,17,-12,60,-11,-63,-7,56,36,0,-41,-9,-51,-31,15,-66,-26,-7,-33,-10,40,-45,24,-27,-14,72,-6,-21,-29,-44,-44,69,16,-8,-26,52,-6,0,-115,43,-59,76,22,24,-17,52,-70,-25,-37,156,51,-15,34,5,-53,79,57,-72,53,33,-18,-40,57,-62,45,29,2,62,23,-40,19,-8,-4,-20,28,54,-5,40,-70,42,19,-21,-3,-33,74,25,-10,16,40,-93,13,-51,-23,12,-43,-82,-32,22,16,7,30,-3,-14,10,-4,-61,5,-53,1,-11,14,80,-57,39,34,-1,-5,-25,47,1,87,-22,-22,28,-31,-32,-42,-24,13,-6,40,-10,-47,15,11,67,11,0,14,3,-20,-20,-47,-44,16,20,14,12,39,32,-44,-16,-1,82,34,49,-2,-38,5,-17,-22,29,13,-2,37,-30,-37,-5,16,73,36,39,-30,24,-20,12,-28,36,17,18,-5,32,-52,-36,-43,1,51,-31,-7,-75,-39,49,1,-12,-28,-38,-2,-45,18,-74,65,-19,-10,-33,-61,36,-45,-6,6,-24,16,8,-13,-57,37,22,-22,-22,-11,-14,7,-32,-12,-16,37,-35,-77,30,32,25,36,-3,7,13,52,15,19,43,9,-37,-3,26,-60,-20,25,-10,33,17,-3,9,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.88","t":"Topics for Socialization to CBT Structure, length, and frequency of sessions Rationale for regular attendance, homework, and full participation Goals of CBT and their relation to the patient’s goals and problems CBT model and the manner in which it relates to their problems and subsequent intervention Roles and responsibilities of the patient and therapist Research on the effectiveness of CBT Personal experiences of the effectiveness of CBT with past patients","e":[2,30,-109,-36,44,-13,45,-35,40,2,-38,-39,43,36,-10,-76,-14,-47,-46,19,-50,-13,-2,-39,-20,78,-29,17,-22,-46,35,15,22,-30,-53,-6,44,16,-2,-22,62,-4,25,-94,33,-59,91,12,24,-14,45,-44,-10,-40,128,45,-31,47,3,-14,110,56,-102,62,54,-22,-45,107,-62,19,38,9,67,28,-69,0,-11,-8,10,39,49,-7,51,-68,35,5,-42,26,-37,79,-23,11,38,13,-79,17,-21,-29,-21,-44,-63,-16,49,23,3,37,3,-21,-11,4,-72,6,-44,20,-7,5,85,-28,35,44,5,-12,9,42,-29,66,-63,-11,3,1,-7,-31,-46,15,-13,38,1,-27,29,17,60,-29,-16,31,11,-33,16,-39,-37,26,22,12,6,16,27,-45,-31,-10,67,14,18,-9,-67,19,-17,-12,22,9,13,51,-37,-61,-10,42,69,28,39,-5,-21,-25,9,-33,20,39,-2,-24,57,-47,-39,-29,-6,41,1,-47,-71,-53,53,1,7,-51,-39,18,-19,33,-54,54,-14,-14,-30,-39,36,-38,-3,19,-46,22,-17,-4,-53,34,23,-45,-48,6,2,23,-29,19,-12,47,-44,-73,1,-9,2,40,-2,-9,3,51,12,7,47,17,-49,3,-22,-36,-6,43,-18,35,-3,16,1,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.88","t":"Jack’s therapist provided additional orientation to CBT at the beginning of his third session, after he had made a commitment to treatment at the end of the second session. The following is a dialogue that demonstrates the manner in which Jack’s therapist socialized him into CBT.","e":[22,21,-149,-73,27,35,-5,-27,66,-11,-79,8,47,11,-13,-42,17,-60,-14,23,-56,-17,-33,-32,9,40,-37,37,-45,18,85,-25,-19,-3,-30,-52,61,41,-25,-14,17,-2,-15,-110,36,-68,64,54,15,-12,21,-30,-18,-50,140,47,-8,41,15,-53,52,31,-49,41,61,-24,-37,70,-77,5,47,-17,50,12,-15,28,-6,-35,-38,36,30,-6,53,-54,38,14,-2,41,-20,55,25,12,22,43,-100,2,-33,0,-21,-41,-81,-25,34,-17,26,52,6,-8,8,-5,-63,15,-30,2,-12,-8,49,-73,35,26,14,0,-48,62,-7,87,-38,-8,16,-28,-24,-27,7,9,-11,28,11,-54,5,32,44,-6,11,12,22,-28,18,-28,-39,38,22,17,19,53,21,-67,-23,17,51,45,43,-15,-21,-3,-4,-43,15,35,20,39,-26,-56,-6,5,74,53,37,-28,22,-17,26,-20,23,31,21,-7,8,-31,-33,-61,8,47,-52,-11,-69,-48,58,-9,-6,-10,7,8,-23,15,-71,62,-20,15,-16,-31,50,0,-28,14,-43,19,12,-2,-60,29,14,7,-15,-38,4,20,-40,-16,-11,41,-20,-84,37,23,33,38,1,31,10,48,5,52,33,2,-57,12,20,-51,19,31,15,15,11,10,24,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.88","t":"Therapist: Let’s talk a little bit more about what CBT is all about. Jack: Yeah, that’s good. I forget what CBT even means. Therapist: That’s OK, I realize this is all new to you. CBT stands for Cognitive Behavioral Therapy. Last time, I talked with you about the fact that CBT is an active treatment that is aimed to help you develop strategies for solving problems in your life. Jack: Well, I’ve got a lot of them. Therapist: We’ll be sure to address them in the upcoming weeks. [pause] Did you notice anything about the last session that was different from when you were in therapy previously? Jack: Yeah, you had me fill out that form [referring to the Beck Depression Inventory].","e":[40,18,-134,-65,46,15,33,-20,65,-33,-46,7,49,-2,11,-78,-28,-53,-30,37,-49,-14,-34,-6,-2,41,-62,33,-48,10,66,-14,-1,-12,-56,-28,50,65,-14,4,40,17,-5,-109,51,-48,81,55,30,-35,34,-63,5,-30,119,24,17,37,-16,-33,90,57,-36,70,34,-19,-51,58,-57,-9,70,-21,49,61,-37,-1,-56,-22,19,18,28,-24,36,-45,52,32,-19,40,-5,85,7,-23,1,60,-73,18,-17,-31,-37,-61,-63,3,2,-10,44,83,-34,-48,-32,-30,-52,24,-18,-2,-40,11,61,-55,30,34,9,1,1,36,11,68,-32,-3,32,-39,-30,-25,2,0,9,20,-8,-25,-11,33,51,-4,14,19,22,-33,-2,-36,-24,1,34,15,1,-2,41,-59,-41,8,48,44,40,15,-1,1,-24,-51,-6,33,9,68,-38,-57,-24,-21,66,34,60,-6,12,-45,34,-12,40,31,10,9,2,-48,-9,-33,17,23,-38,3,-58,-25,15,-8,6,-25,-5,37,-42,16,-44,71,-16,15,-17,-40,77,-49,-23,27,-25,-5,15,0,-64,36,14,10,-2,-21,11,25,-8,2,-2,50,-21,-94,19,26,17,45,6,18,15,81,7,42,31,26,-82,31,-13,-30,2,7,-3,17,1,-4,77,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.89","t":"Therapist: You’re very observant. This is something I am going to have you do every week. It will give me an idea of how your mood and other symptoms are changing from week to week. Jack: OK. Therapist: Did you also notice that we set a game plan for today’s session? Jack: Yeah. Therapist: That’s another thing that we’ll do every week. You and I, together, will set an agenda for the session to be sure that we are covering important topics that are relevant to the goals that you’ll set for treatment. Then, we’ll make sure we pace the session so that we cover all of those topics. Jack: OK. Therapist: Another important component of CBT is homework. Jack: [snarls] I always hated homework in school. Therapist: [smiles] Maybe we can call it something different, like “practice.” Jack: That’s a little better. Therapist: I realize that practicing what we have discussed in between sessions is not real attractive to you. However, in my experience, practicing what we have covered in session is more likely to lead to lasting changes in people’s lives. For example, let’s say that we’re talking about getting another job. Your assignment might be to actually submit an application. So, in addition to talking in here about a problem, like needing a job, the assignment helps you to take action. Does that make sense? Jack: Yeah, if all of the assignments are like that, then I guess it wouldn’t be so bad. Therapist: [pause] Another thing about these practice assignments is that I’m not just going to “assign” you something on my own. In fact, the two of us will work together to develop an assignment that both of us think has promise in improving your life situation. Jack: [seems a bit relieved] OK, I like that a lot better than you giving me something that feels like school, like a book to read or something. Therapist: Now, as we said last time, at this point you’ve made the commitment to attend four sessions, after which time we’ll evaluate whether CBT is a helpful approach for you. If you choose to continue, then I would anticipate the entire course of treatment would be around 16 sessions. Jack: There’s actually an end to therapy? Therapist: Yes, we typically find that in approximately 16 sessions, people have learned to address problems in their lives and manage mood problems, like depression, anger, and irritability. However, some patients may stay in therapy for longer periods of time, if needed, or they may also benefit from booster sessions. These are follow-up sessions that are scheduled one to three months after therapy is over. Jack: This is a lot different than other times I was in therapy. Before, it just seemed endless. Therapist: That’s why we describe this type of therapy as one that is active and problem-focused. We’ll be getting a lot of work done in each of those sessions. Jack: And this really works?","e":[37,19,-130,-81,17,-20,21,-39,49,-25,-36,-12,33,38,-12,-37,8,-70,-50,16,-24,-36,-11,-17,-34,61,-57,23,-40,21,59,-53,-19,-7,-64,-31,75,55,-16,-47,62,0,-14,-122,49,-84,105,28,13,-25,20,-63,-14,0,122,51,-5,39,9,-63,108,20,-71,94,28,-19,-50,45,-55,-19,41,-7,50,31,-29,31,-28,-6,-3,19,2,-18,59,-61,39,10,17,38,-31,88,15,-4,1,43,-64,-2,1,-18,-39,-42,-73,2,-11,-27,20,46,-27,-42,2,-1,-52,-5,-34,0,-29,32,59,-61,29,43,17,-2,-16,5,35,70,-50,-9,12,-2,-17,-19,-13,40,-14,60,30,-51,-1,6,58,-4,-19,20,5,-11,-29,-41,-46,34,22,-9,14,37,49,-54,-28,-11,63,51,39,-14,-35,17,-6,-10,10,64,18,48,-32,-64,-16,-7,43,30,64,-14,-10,-24,65,-4,27,-3,11,23,13,-60,-11,-47,20,13,-37,10,-47,-33,56,-53,-23,-23,-15,45,-34,37,-38,73,0,3,-31,-46,76,-13,-20,51,-30,-5,9,0,-74,34,43,9,-10,-18,-7,33,-22,-16,-30,39,-38,-77,44,-6,8,48,-3,23,16,98,14,40,27,5,-86,10,25,-41,7,20,38,7,31,-4,31,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.90","t":"Therapist: In fact, research studies have repeatedly shown that CBT is a very effective treatment for depression. Jack: I guess I didn’t realize this would be so different. Therapist: One thing that makes this approach so effective is that you and I both have distinct roles and responsibilities that we bring to the table. My job is to make sure I’m prepared at each session, that we stick to the agenda, and that I really listen to what you are saying about your problems so that we can be sure the treatment is tailored to your individual needs. You have a few jobs, too, though. Your jobs are to make sure you get to your sessions on time, to participate actively when you are here, and to try out whatever assignments we come up with. Does this sound reasonable to you? Jack: That sounds fine. Therapist: I have a suggestion. I have a short article, Coping with Depression, that I can give to you to read. It provides a brief description of what depression is as well as some strategies that might be useful for treating depression. The article would give you more information about CBT. Would this be something that you would be interested in reading between now and the next session? Jack: Sure. I usually don’t like to read a lot, but this is short, so I’m willing to give it a shot. Therapist: I appreciate your flexibility, Jack.","e":[9,28,-145,-75,27,-2,17,-11,28,-46,-8,-13,37,-3,8,-30,-1,-53,-9,34,-64,-39,-35,-19,-11,53,-62,43,-41,16,54,-26,-21,-17,-49,-5,50,65,8,-11,38,-5,5,-123,53,-58,105,59,-10,-67,24,-89,11,-30,145,12,-19,51,-2,-79,124,47,-53,40,59,-19,-35,64,-60,-7,52,3,45,37,-40,23,-44,-21,1,-2,30,-28,27,-56,40,1,6,1,-31,62,31,-8,3,72,-46,6,-23,-49,-24,-47,-79,-7,2,7,23,53,-1,-44,-17,-14,-45,9,-16,-23,-29,26,64,-54,19,37,-10,42,2,5,23,46,-38,1,35,0,-12,-18,-20,34,-11,61,-7,-32,-21,2,49,7,-11,10,11,-19,-28,-8,-55,22,25,8,34,38,22,-39,-5,-3,53,46,41,-11,-25,22,26,-8,2,58,25,69,-47,-71,-30,-4,63,-2,69,-1,-14,-47,64,-22,28,13,5,16,24,-54,-9,-63,18,12,-21,9,-74,-21,52,-42,-5,-22,-21,54,4,2,-49,76,6,14,-12,-51,72,-27,21,47,-30,7,-22,5,-79,16,22,1,5,-11,14,26,-31,-3,-14,24,-20,-84,30,-8,18,46,2,8,14,98,17,22,40,6,-62,31,12,-34,26,21,14,6,7,-14,40,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.90","t":"Notice that Jack’s therapist assures him that, together, they will develop homework • Bibliotherapy assignments that fit Jack’s strengths and inclinations. One type of homework assignment that is often very useful and effective, especially in the initial phase of therapy, is bibliotherapy. Bibliotherapy consists of recommendations by the therapist for the patient to read published information such as therapy workbooks or Web- based materials. Bibliotherapy resources, which are often based on CBT principles, can help to expand on concepts and reinforce cognitive and behavioral strategies discussed in session. In an effort to promote the use of Bibliotherapy resources, which bibliotherapy, particularly as an adjunct to professional treatment, VA are often based on CBT has developed a VA Bibliotherapy Resource Guide (Karlin et al., 2009), principles, can help to expand which identifies and describes a wide range of print and Web-based on concepts and reinforce materials that therapists may recommend to their patients. Some cognitive and behavioral patients, like Jack, may find extensive reading undesirable, so it is strategies discussed in session. important to tailor homework assignments to their personal preferences. For example, providing Jack with very brief reading assignments and encouraging him to record sessions and listen to the recordings between sessions may be better suited for reinforcing key concepts discussed during sessions than having him read extensive chapters or record a great deal of information. Whether it is through bibliotherapy or listening to audio recordings, clinical experience has shown the value of repeated exposure to expedite learning and increase compliance with prescribed cognitive and behavioral homework assignments.","e":[63,22,-143,-82,11,-26,10,-5,16,16,4,-9,53,25,-30,-27,-8,-44,-18,-14,-55,-26,-46,3,9,52,-48,6,-61,-13,21,-37,-55,-14,-27,-19,80,18,-36,12,-1,-12,1,-76,71,-32,75,19,47,0,36,-94,14,13,146,34,12,10,-17,-65,108,73,-72,45,34,2,-36,51,-52,9,46,7,82,17,-43,7,-24,-33,-7,62,27,-15,57,-22,90,7,-4,37,-20,65,9,15,28,43,-62,35,-19,6,-20,-37,-74,10,35,-11,27,53,21,-11,-19,7,-37,42,-15,-25,16,38,70,-41,54,39,-11,-17,-26,36,-11,77,-94,4,29,-15,-12,-29,-25,27,9,37,-1,-53,0,-15,52,-5,1,39,23,-4,-24,-28,-22,24,-7,21,14,8,33,-23,1,0,55,55,36,-9,-55,40,-3,-12,11,59,28,61,-66,-76,10,6,62,13,47,-10,29,5,24,-48,34,29,-10,6,9,1,-36,-41,4,19,-13,-44,-95,-47,54,-27,7,-26,-22,28,-28,21,-53,82,-14,2,-29,-36,60,-13,-13,39,-16,-30,-39,-7,-68,4,15,-14,22,-35,20,16,-25,-8,-14,33,-54,-71,43,-4,38,6,13,21,5,99,-16,23,37,8,-93,29,17,-67,2,23,12,3,5,0,5,14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.90","t":"In many instances, it is relevant to inform patients of the potential for negative reactions to treatment. Although it is anticipated that patients will benefit in general from a course of treatment, at times, they leave individual sessions with unpleasant emotions because they had discussed difficult topics or because they had difficulty CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 74","e":[24,22,-149,-67,65,42,37,-15,32,-12,1,51,59,12,7,-49,10,-8,-20,30,-45,-32,-44,-37,-7,61,-32,16,-38,34,38,-15,1,-38,-64,-41,47,59,-8,13,77,-20,18,-103,20,-10,87,58,17,-35,54,-88,14,-46,117,-22,-1,24,-2,-63,90,40,-55,58,69,-17,-57,20,-34,3,51,10,9,30,-59,8,-29,-27,-17,16,37,-23,29,-56,94,11,20,9,4,66,10,15,31,30,-122,19,-24,-17,-42,-41,-23,-6,-3,-16,-1,56,0,-18,19,-14,-74,62,-27,-17,26,6,47,-48,-20,49,8,30,-18,27,14,38,-28,-8,53,-30,-17,-48,-18,-22,20,36,-13,-29,10,27,72,11,-20,40,-21,-18,1,-14,-54,-5,-9,5,24,23,48,-55,-30,33,34,10,59,14,-52,30,4,-40,0,38,36,26,-40,-60,10,-24,105,31,48,-1,35,-58,-15,-64,30,8,10,-21,14,-34,-39,-54,12,31,-39,-16,-81,-56,31,18,38,-25,0,41,-30,27,-54,41,-6,-1,-16,-38,40,-29,30,11,-21,-22,5,-9,-39,27,41,1,-18,-16,29,12,-32,-4,-38,1,-23,-87,60,-4,-12,25,13,19,-9,62,15,7,46,38,-97,20,5,-40,-9,26,-10,32,-2,-8,29,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.91","t":"arriving upon a resolution to the problem being discussed. In these instances, it can be helpful to draw an analogy between therapy and exercise. With consistent exercise, patients receive the long-term benefits of being healthier and increasing strength and stamina despite feeling sore after individual workouts. The same is often true of therapy. If patients know this in advance, a negative reaction to a session will not be as alarming as it might otherwise have been perceived.","e":[47,79,-181,-21,23,7,50,12,42,-19,-3,19,39,-7,17,-19,-9,-99,-28,27,-50,-22,-13,-46,-24,34,-16,10,-30,-13,60,-18,60,-34,-32,1,87,63,2,-51,53,-25,37,-37,52,-51,34,19,8,26,18,-85,-27,2,110,0,43,8,17,-69,51,59,-93,27,91,-17,-21,20,-24,-11,54,-45,19,61,-20,2,0,6,-19,13,29,-6,53,-61,73,15,10,11,3,82,6,38,45,70,-105,-30,13,25,-69,-38,-44,16,27,-45,26,21,33,34,-19,19,-54,33,-18,-23,-15,6,60,-87,-8,19,-14,-21,-28,23,13,29,-23,-52,24,-30,-9,-37,-43,20,-1,60,-20,-13,-2,-10,33,-16,-9,15,-13,-11,15,-70,-15,55,-2,24,-13,24,58,-48,-36,11,62,14,56,-14,9,6,-7,-25,-13,53,22,27,-46,-68,-9,-9,76,21,41,-45,-29,-55,15,0,50,12,24,4,42,-13,-82,-52,11,25,-45,10,-73,-27,55,-17,14,-6,5,14,-21,11,-10,52,-41,-24,6,-44,39,15,-11,26,-5,-36,-1,-15,-59,20,54,-15,-21,-34,-2,-5,-25,1,-53,33,-9,-56,86,20,17,13,6,39,-4,40,37,26,16,8,-64,41,32,-29,14,20,12,73,1,-25,32,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.91","t":"Setting Treatment Goals During the initial phase of treatment, the patient and therapist collaboratively agree • Setting upon the overarching problem areas to be addressed over the course of therapy. It is treatment essential for patients to play an active role in the process (and also that they perceive goals that they play an active role in this process) so that they assume ownership over the course of treatment. Once the general problem areas have been identified, therapy can focus on more specific examples of these problems.","e":[33,27,-144,-24,46,6,29,-13,34,16,-1,17,66,34,16,-31,-2,-42,-32,39,-20,-43,2,-23,-5,54,20,-28,-38,5,33,27,20,-49,-20,-91,77,29,-30,-30,8,-22,15,-97,0,-33,46,0,2,-2,40,-41,-59,-35,112,58,-17,49,28,-53,128,55,-72,57,23,-41,-22,4,-41,-4,27,12,52,3,-20,-5,-15,15,-2,20,47,-16,85,-69,46,33,-3,1,-43,59,2,36,-6,3,-126,1,-46,11,-20,-28,-52,-2,7,-2,36,40,36,29,-28,4,-51,44,-8,-5,-4,-5,98,-23,29,37,-11,-32,10,49,23,49,-47,-32,50,36,-15,-21,-37,20,10,53,9,-44,15,19,40,37,-1,18,-7,-20,31,-31,-33,11,-15,16,-3,34,23,-57,-35,17,43,-28,80,24,-40,22,-13,-27,22,17,9,30,-23,-41,-24,21,127,48,87,6,34,-31,3,-49,7,34,-6,9,24,-45,-65,-16,3,71,-26,2,-29,-21,45,-48,28,-43,-34,16,-85,36,-49,100,-11,25,-47,-23,44,-31,-8,11,-53,-34,-5,-2,-49,39,22,13,-11,11,19,3,-67,0,-16,22,-9,-57,46,7,12,-2,-18,25,31,68,-4,28,53,5,-67,60,11,-46,-45,45,11,11,1,2,29,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.91","t":"To develop treatment goals, the therapist works with the patient to generate a list of target complaints that reflect the challenges that the patient is experiencing as well as things the patient hopes to accomplish in therapy. Next, the patient ranks the importance of each of these complaints, which, in turn, is used to identify short-term and long-term goals. Short-term goals are those that can be attained in a period of a few weeks; in our experience, patients’ motivation for and commitment to treatment increases when they see relatively immediate and tangible changes in their lives. It is important to set realistic short-term goals, as inappropriate or overly ambitious goals may set patients up for perceived failure. Examples of short-term goals include “Develop relaxation skills” or “Run two miles twice a week.” Long-term goals, in contrast, are those that the patient hopes to achieve by the end of treatment and even beyond. These goals are typically broader in scope and apply to many problematic areas in the patient’s life.","e":[28,32,-162,-19,-2,1,24,-13,31,-28,-39,34,89,-4,7,-20,11,-65,-34,61,-7,-11,8,-64,-30,49,18,1,-26,23,20,27,-9,-24,-8,-90,69,21,9,-53,8,-37,32,-70,45,-46,35,2,24,-15,13,-45,-23,-15,87,45,-11,4,22,-44,112,37,-50,73,71,-37,-22,8,-30,-11,47,-5,20,45,-32,11,-40,1,-14,34,45,-11,28,-72,42,21,3,57,-22,79,-18,27,8,13,-133,-29,-6,3,-24,-10,-63,-20,33,-42,31,44,8,33,26,4,-46,56,-51,12,-19,31,44,-29,35,38,13,-24,44,40,20,17,-73,-10,47,52,4,0,-84,26,-6,74,33,-28,-12,21,48,-34,16,3,-32,-37,28,-30,-33,35,-6,8,23,31,41,-27,-29,14,43,-23,48,-6,-35,54,-13,-24,15,2,-15,38,-28,-59,7,4,100,38,74,4,-20,-60,25,-55,27,28,-31,23,44,-60,-49,-21,6,20,-52,-16,-55,-39,39,-57,7,-48,-27,30,-79,51,-26,78,0,1,-29,-22,60,-12,-27,14,-39,-28,-24,0,-56,14,46,11,-14,-8,48,-9,-66,22,3,31,-2,-57,19,18,11,-1,-1,0,19,75,1,1,37,24,-58,-7,-7,-10,-19,50,20,32,24,21,20,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.91","t":"A key feature of treatment goals is that they are specific, well-defined, and described in observable and measurable terms. For example, if a patient indicates that she would like to feel happier by the end of treatment, the therapist might ask, “How could someone tell if you were happier?” and then formulate the goal in these more specific terms (e.g., “To be spending more time with friends A key feature of treatment and family, to be exercising at least three times a week, and to resume goals is that they are specific, participation in art classes”). In some instances, it is helpful to reframe well-defined, and described in goals using positive, change-oriented language rather than language that observable and measurable focuses on the patient’s deficits. For example, many patients indicate terms. that they would like to feel “less depressed,” which can be restated as “improve depressed mood and learn skills for controlling my mood.” This places a positive spin on the problem and helps patients to begin to think in terms of change rather than focusing exclusively on areas in which they may be deficient. The use of small behavioral steps affords patients the opportunity to achieve success early on, which serves as mastery experiences on which they can draw later.","e":[16,27,-150,-37,36,-10,8,3,30,-35,1,20,102,30,20,-15,16,-74,-23,76,-23,-36,-17,-51,-14,66,1,15,-52,24,18,4,14,-27,-36,-50,77,54,16,-55,15,13,-17,-77,49,-25,31,-4,31,-13,17,-46,1,-18,133,39,4,11,19,-63,114,49,-65,51,61,-19,-36,7,-59,-14,40,10,-5,48,-36,14,-57,28,-16,3,25,-40,39,-51,54,38,36,24,-22,68,-26,2,4,37,-130,-19,-18,-10,0,-28,-72,-19,13,-28,34,44,3,19,16,-9,-20,45,-30,6,-45,15,61,-49,3,29,15,-33,29,45,22,22,-51,-31,28,37,5,-40,-73,10,-28,72,36,-5,0,20,49,-4,-5,1,-35,-68,46,-4,-13,20,-5,18,19,30,19,-48,-35,30,25,3,66,29,-32,30,-21,-27,13,16,-16,36,-38,-45,-13,2,100,10,80,19,8,-71,15,-45,35,35,-22,16,43,-36,-44,-23,4,21,-33,-8,-45,-26,12,-38,19,-38,-41,39,-66,41,-38,60,17,28,-23,20,53,-24,7,17,-17,-14,-11,2,-36,-2,35,7,1,18,45,5,-55,11,-26,31,-13,-66,47,9,21,4,4,17,32,86,10,-5,37,8,-74,31,-27,-11,-32,61,16,37,14,-8,28,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.91","t":"Exhibit 3.1 summarizes the treatment goals identified by each of the four patients described in this manual. In Jack’s case, you will see that many of his treatment goals follow logically from the issues that arose when his therapist engaged in motivational CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 75","e":[6,19,-174,-43,29,13,23,-28,30,-5,-45,14,65,12,6,-30,-3,-26,-13,27,-33,-44,-62,-47,46,49,-46,34,-35,20,44,0,-25,-28,-29,-40,78,54,-21,3,8,-26,-21,-87,1,-22,67,35,27,-28,29,-53,13,-55,111,12,-45,14,15,-43,99,48,-53,51,82,-29,-20,43,-61,-12,54,9,38,24,-71,2,-33,-3,-32,25,40,1,33,-65,60,-1,11,27,-28,39,-3,37,26,46,-108,7,-29,5,6,-39,-82,-40,22,-18,27,55,43,22,10,-21,-48,30,-29,11,-38,4,58,-26,10,46,20,-19,11,30,-14,23,-57,17,32,15,-1,-27,-38,1,3,29,-36,-40,-17,8,50,-9,-6,31,9,-41,3,-18,-50,3,14,26,32,16,27,-67,-52,5,3,21,57,-6,-7,51,10,-27,5,42,22,60,-21,-67,-11,-5,96,8,47,9,2,-39,45,-57,45,51,-11,4,12,-38,-32,-40,6,58,-42,-31,-58,-33,47,-29,25,-32,-4,27,-35,16,-64,56,-4,19,-14,-22,21,-32,-6,19,-18,-9,22,1,-50,0,1,12,-13,-18,13,16,-24,-33,6,12,-23,-69,36,-6,-3,27,-8,35,25,64,-13,29,42,17,-58,34,-30,-40,18,62,13,21,-1,10,39,-36]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.92","t":"enhancement strategies. Thus, although the initial phase of treatment usually ends with setting treatment goals, in reality, the patient and therapist form treatment goals throughout the entire initial phase of treatment.","e":[36,35,-158,-11,65,3,12,5,36,10,-19,10,76,44,15,-23,15,-76,-13,61,-35,-44,-30,-30,7,33,7,-7,-34,25,36,7,19,-12,-7,-53,53,23,-17,-61,21,-23,31,-66,-5,-23,33,19,20,-7,44,7,-32,-27,121,62,-20,33,27,-56,112,59,-67,43,50,-29,-13,13,-48,-44,42,6,26,7,-4,-5,-31,-18,-13,34,37,-39,56,-48,63,50,20,13,-43,77,-14,31,14,23,-160,-26,1,5,4,-45,-52,-10,49,-49,28,43,27,9,-15,6,-58,44,-16,1,-28,7,75,-15,25,27,20,-27,19,35,19,66,-49,-22,42,5,-1,-17,-31,13,11,67,26,-36,19,18,2,-6,-8,-8,-37,-40,45,-12,-31,16,3,26,27,36,33,-64,-19,11,28,-1,65,-12,-18,46,-12,-39,20,0,4,30,-13,-31,-10,21,100,58,83,-22,25,-24,9,-29,1,59,-3,-42,27,-18,-67,-30,26,61,-48,-11,-61,-18,67,-51,23,-26,-10,40,-85,24,-69,84,-9,27,-46,-5,35,-14,-10,8,-53,-6,-12,-10,-30,27,20,8,-24,5,16,-8,-57,-4,-33,15,-20,-67,36,-4,17,-11,-1,11,25,55,-3,19,23,11,-75,37,14,-35,4,32,34,28,7,22,30,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.92","t":"Exhibit 3.1. Treatment Goals for Sample Cases Jack’s Treatment Goals Kate’s Treatment Goals Reduce anger and irritability by Improve depressed mood by engaging decreasing conflicts with family in at least one pleasurable activity each members and co-workers and sleeping day and sleeping no more than eight at least seven hours per night. hours per day. Improve relationships with wife and Re-negotiate a satisfying relationship children by increasing the frequency of with children, including daily telephone spending time with wife, engaging wife and biweekly in-person contacts. in family problem-solving, and speaking Improve adaptive functioning by getting with children on the telephone every a new job, paying bills on time, and week. maintaining frequent contact with Improve quality of life by getting a new family members and friends. job, contributing to a retirement fund, adhering to medical advice, and participating more frequently in recreational activities.","e":[-2,14,-173,-12,-20,10,-17,-31,53,-8,-39,-11,91,54,-26,5,-6,-3,-68,58,-6,-38,-32,-34,38,79,10,50,-42,46,25,-14,-45,-43,-32,-20,106,37,-8,-43,52,-7,12,-50,43,-74,67,23,24,-4,7,-51,9,-29,100,47,-23,9,5,-38,104,24,-78,58,67,-31,-25,34,-60,16,21,1,31,2,-33,5,-28,-14,-12,45,53,-24,53,-80,33,-10,18,23,-17,40,20,35,15,45,-53,34,-20,-1,8,7,-88,-22,35,4,-8,76,-3,52,10,-12,-54,1,-23,-28,14,-14,22,-44,5,-4,18,-16,5,30,11,40,-86,28,12,17,-31,-10,-52,31,5,36,2,-10,-20,2,55,21,-3,8,-24,-37,7,-27,-51,21,-3,-7,48,3,14,-62,-55,29,32,16,64,9,-22,63,-4,-2,7,55,5,71,-38,-93,-24,-11,52,2,50,-25,-14,-47,62,-76,62,50,-33,29,2,-40,-47,-34,22,34,-55,-22,-36,-28,45,-17,-27,-42,-23,5,-30,33,-20,59,33,7,26,-13,25,-19,-16,8,0,7,20,-37,-53,-10,5,-5,-39,0,38,-2,-10,7,-39,-2,-52,-73,23,-1,5,24,0,25,-8,61,-39,49,17,13,-53,69,-18,-5,-24,64,15,35,22,-22,65,-36]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.92","t":"Michael’s Treatment Goals Claire’s Treatment Goals Decrease suicide ideation by developing Decrease anxious and irritable mood by reasons for living and decreasing self- decreasing conflict with others. reported hopelessness. Diversify engagement in pleasurable Improve depressed mood by increasing activities by initiating social interaction engagement in pleasurable and and engaging in recreational activities at mastery-oriented activities every day. least once a week. Improve coping with cognitive Improve coping with physical limitations limitations from IED explosion by from airplane crash by tolerating tolerating frustration and identifying a frustration and, if necessary, identifying new career path. a new career path.","e":[26,-12,-151,-5,35,-13,20,21,31,-8,-33,-14,104,52,23,2,-31,-39,-50,28,-65,-57,-39,-8,36,96,12,36,-61,60,25,-7,-39,-28,-25,-11,31,80,22,-20,14,-2,22,-82,10,-43,73,-40,30,-54,45,-45,16,-44,94,11,-5,5,31,-66,110,35,-35,59,52,-39,-56,3,-36,-5,64,-17,8,35,-38,29,-23,-34,-4,-10,21,-35,64,-52,44,29,45,39,-43,49,-1,36,1,37,-80,19,-4,7,-30,11,-62,-12,22,-9,10,86,15,11,7,13,-48,13,-38,-24,19,-8,43,-54,25,14,6,-24,15,17,4,7,-42,10,15,20,-51,-12,-53,31,-5,42,0,-25,-23,17,40,5,-28,5,-71,-45,31,11,-53,-27,-24,21,71,5,16,-51,-66,18,19,4,41,18,-42,60,-10,-35,29,38,13,40,-34,-44,-39,6,90,8,45,5,-28,-65,50,-39,69,35,-19,3,32,-18,-73,-58,-3,42,-35,-3,-44,-18,42,-37,5,-30,-59,17,-15,16,-42,74,21,-30,8,-2,36,-37,14,-2,-29,9,-18,-27,-21,17,18,-5,-35,3,22,39,-35,3,20,-36,-6,-37,29,0,0,9,-13,20,-14,81,-36,52,43,-3,-55,34,-10,14,-34,61,10,26,1,22,23,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.92","t":"Suicide Risk Assessment and Safety Planning Veterans who are seeking mental health treatment, including CBT, in the community or VA health care facility may be at risk for suicide, and it is typically recommended • Suicide risk that a suicide risk assessment be conducted during the initial phase of treatment. We assessment have already suggested that a suicide risk assessment may be conducted if patients endorse a 1 or higher on the suicide item of the BDI. There may be other reasons for conducting a suicide risk assessment, such as the patient’s report of suicide intent or plan, a recent suicide attempt, new or increased severity or frequency of suicide ideation, threat or other behavior indicating imminent risk, uncertainty that the patient can control his impulse to harm self or others, an abrupt positive or negative change in clinical presentation, lack of improvement or worsening despite treatment, significant loss, or other negative life event. Thus, although we recommend that the risk assessment be completed during the initial phase of therapy, it may be completed during any phase of treatment as indicated by warning signs or other risk factors as","e":[45,-4,-157,-37,82,21,30,-1,32,0,-28,33,48,19,-14,-59,22,-66,-32,-16,-78,-75,-53,-20,42,64,-10,31,-52,33,42,18,16,-42,-34,-89,37,55,-12,-37,24,-15,17,-95,-2,2,125,22,73,-34,54,-45,-2,-18,86,-17,-22,11,-39,-76,74,48,-47,-3,65,-9,-57,3,-8,33,43,-12,35,29,-72,60,-11,-16,-43,40,26,-3,76,-52,47,32,24,3,-10,68,-5,30,1,47,-102,20,-55,17,-22,-15,-58,-28,-5,-20,-21,25,-1,-12,7,1,-30,23,-58,-34,55,18,80,-30,32,62,-17,-21,24,58,-41,59,-49,1,43,-11,-18,-26,-45,-6,14,54,-11,5,5,8,60,11,6,12,6,-35,26,-3,-56,-44,-19,51,5,0,-1,-49,-49,43,49,32,57,29,-38,33,-33,-52,7,-2,22,8,-52,-37,36,-17,79,-7,59,-20,18,-6,-2,-43,48,3,-13,-41,38,2,-38,-39,28,55,-45,-30,-84,-34,60,-27,23,-23,-4,55,-79,28,-44,82,-31,2,-37,-56,64,-51,-12,-1,-4,-11,10,16,-31,24,15,-20,-9,-43,-15,33,-66,-29,13,-5,-15,-58,26,-4,-17,26,13,1,15,20,12,32,51,39,-62,14,-11,-44,8,39,-12,0,13,15,29,-24]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.93","t":"Below is a list of risk and protective factors for suicidal behavior that is often considered in the context of a suicide risk assessment. The therapist may assess for these risk factors by the Veteran’s verbal self-report as well as by other sources, such as completed measures, medical record, other therapists, or family members. The therapist should note whether each risk factor is present or absent. Although a detailed description of specific strategies for conducting a comprehensive suicide risk assessment is beyond the scope of this manual, additional information can be found in Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors (American Psychiatric Association, 2003).","e":[59,-6,-160,-37,68,45,31,-2,31,-8,-36,3,61,19,-8,-35,35,-59,-9,14,-54,-86,-46,-8,38,53,-28,33,-55,5,3,25,10,-43,-33,-56,33,86,4,-21,4,23,6,-81,-2,-27,69,-8,64,-4,38,-67,-11,-16,66,-46,-10,25,3,-83,62,47,-84,-26,64,14,-79,47,-38,25,34,3,30,22,-60,42,5,-5,-6,41,58,7,87,-49,28,39,1,22,-2,68,-11,57,29,41,-89,15,-44,17,-49,-22,-50,-2,6,-22,39,3,17,-16,3,17,-46,55,-47,-15,59,-9,69,-40,26,60,-30,1,18,63,-58,40,-52,37,15,-19,22,-43,-41,-3,18,63,-26,0,-2,-2,64,31,-10,8,19,-38,10,-11,-44,-35,14,68,-18,13,5,-59,-57,6,34,30,48,43,-10,60,-18,-26,0,22,20,18,-33,-42,41,-14,78,-15,71,-35,18,-17,8,-49,53,0,-18,-65,44,-6,-61,-19,18,49,-15,-42,-51,-60,35,-33,40,-32,-32,35,-74,38,-58,70,-40,-12,-34,-56,45,-46,-5,15,-18,-19,-20,9,-49,10,7,3,-10,-29,-8,35,-86,23,35,28,-16,-75,23,1,-19,11,-5,54,13,23,4,30,48,23,-59,-4,-37,-31,40,40,-13,14,4,20,-4,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.93","t":"Potential Risk Factors History of single or multiple suicide Current severe hopelessness attempts (lifetime and especially in the past Current major depressive disorder 30 days) Current psychosis (especially command History of non-suicidal self-injury behavior hallucinations to kill oneself) History of aggressive or violent behavior Traumatic images toward others Current mania or other highly impulsive Preparations to kill self (purchased a gun, behavior wrote a suicide note) Relapse or current substance abuse (illicit Current wish to die, or wish to die drugs, alcohol, and/or medication) outweighs wish to live Exacerbation of physical pain or other Current suicide ideation with intent to kill serious medical problem (e.g., Chronic oneself Obstructive Pulmonary Disease) Current specific plan to kill oneself, lethal Current agitation or acute anxiety method currently or easily available Current perceived burden to the family Reluctant to reveal suicide ideation Current homicidal or aggressive ideation Regrets surviving a previous attempt A problematic treatment history, including Any recent stressful life event such as a job hopelessness, indifference, or loss, break-up of a relationship, dissatisfaction about current treatment, interpersonal conflict history of treatment noncompliance, Any abrupt negative or positive change in current unstable or poor provider clinical presentation relationship, or other problem interfering with treatment Potential Protective Factors Current hopefulness Current engagement in treatment and/or Current reasons for living emotionally connected to the provider Current wish to live outweighs wish to die Current supportive social network Current perceived self-efficacy in the Current fear of death, dying, or suicide problem area Current belief that suicide is immoral Current responsibility to children, family, Current lethal method of suicide unavailable others, or pets Current participation in religious or spiritual Current living situation with dependents activities After the risk and protective factors have been assessed, the therapist determines whether or not the patient is imminently or highly dangerous to himself. The reasons for this determination should be noted on the medical record.","e":[47,0,-167,-30,52,26,4,17,25,-33,-35,14,74,25,7,-23,47,-32,-17,48,-76,-86,-41,-26,-3,72,0,-20,-37,20,17,-1,2,-28,-56,-67,56,79,67,-23,30,1,23,-96,-35,-20,88,12,57,-62,15,-58,11,-28,53,5,3,23,-18,-82,79,43,-36,2,72,-41,-67,58,1,-10,44,11,4,29,-19,62,-21,-7,16,14,46,4,96,-41,17,0,4,38,1,40,-15,39,24,29,-92,14,-40,24,-55,-5,-41,-51,-3,7,28,17,35,-5,-27,12,-56,62,-41,-9,49,-29,50,-42,32,48,-36,-15,40,54,-19,30,-26,17,42,-14,-2,-31,-35,37,26,60,-3,-3,-29,-13,103,-3,14,0,-22,-44,24,-31,-54,-24,-3,40,-16,21,-9,-43,-48,2,31,1,10,31,-52,70,-27,-50,9,40,8,32,-42,-46,39,16,97,-12,68,-31,-2,-65,44,-52,58,6,-15,-12,23,3,-36,-9,-11,44,-25,-31,-39,-53,49,-34,17,-53,-17,42,-66,54,-24,79,-14,3,-7,-37,54,-48,-10,-3,-10,-15,-25,-8,-47,26,34,0,12,-16,-14,35,-60,-11,7,-1,-46,-77,69,-8,-43,24,-11,-11,0,45,-33,29,16,30,-45,-22,-37,-29,-9,47,-8,26,-2,27,-5,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.93","t":"Next, the therapist chooses an appropriate action plan given the Veteran’s level of suicide risk. Although this is not intended as an exhaustive list of possibilities, one or more of the following action plans may be implemented by the therapist: CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 77","e":[2,3,-160,-53,73,23,17,-30,45,-3,-46,4,48,-3,1,-46,8,-58,-26,-5,-40,-58,-52,-14,49,68,-13,48,-60,13,41,4,19,-32,-23,-65,50,59,6,-29,-1,-18,11,-81,7,-38,126,30,39,-31,62,-79,-7,-43,78,-31,-4,9,-1,-82,85,69,-62,14,53,-3,-66,53,-36,-27,44,-14,32,19,-79,14,-54,0,-15,9,8,-16,82,-70,49,7,16,25,-20,52,-12,56,9,50,-93,-2,-21,-8,-31,-73,-58,-30,11,-34,16,43,17,-28,-4,16,-55,27,-21,-2,6,5,65,-28,24,69,14,-11,12,18,-25,26,-52,0,22,-18,10,-11,-20,9,-13,24,-40,-23,3,-8,60,-13,-13,23,-13,-21,10,7,-53,-22,5,34,11,14,36,-65,-35,28,33,21,57,23,-54,49,-3,-31,-3,48,32,8,-48,-65,-16,-5,94,-8,28,-18,20,-14,2,-24,59,34,-28,-40,23,-52,-47,-31,9,58,-1,-26,-67,-39,52,-25,26,-36,1,55,-44,21,-53,62,-20,29,-2,-44,73,-47,10,8,-38,-1,14,6,-66,6,39,14,-28,-21,-2,21,-52,-22,40,7,-4,-66,29,-15,5,15,-20,37,25,46,28,36,75,54,-68,65,-17,-46,16,43,-5,-5,-9,2,2,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.94","t":"(a) If the Veteran is determined to be at high risk for suicide, the Suicide Prevention Coordinator is consulted. (b) The Veteran should be placed on the High Risk List and the Enhanced Level of Care process started. This includes the development of a safety plan, frequent visits, and/or hospitalization and treatment plan modifications. (c) Veterans may be hospitalized if the therapist or another clinician determines that they are at a high or an imminent risk for homicide or suicide or are otherwise a danger to themselves and cannot be safely treated on an outpatient basis.","e":[24,8,-180,-26,87,38,-14,11,54,-9,-52,5,50,5,15,-55,20,-44,-38,-33,-71,-72,-59,-18,48,67,13,33,-37,50,41,22,17,-39,-4,-70,19,74,13,-30,17,15,22,-118,-33,-4,80,4,63,-40,44,-76,-50,-19,52,-34,22,3,-1,-78,101,43,-18,-13,29,26,-60,51,-8,-21,14,-26,5,-6,-75,70,1,8,-18,30,54,10,99,-61,24,34,22,9,-32,53,-33,44,0,62,-95,12,-17,15,-20,-41,-51,-47,19,-19,2,29,31,13,19,0,-46,36,-37,-38,30,3,69,-25,29,41,-22,-5,31,57,-28,32,-27,27,29,-17,15,-20,-12,17,0,39,-25,-10,-6,3,69,26,17,1,-30,-37,33,0,-48,-42,-12,77,-13,-17,8,-37,-40,40,65,41,57,27,-77,62,3,-41,-10,24,-9,29,-25,-48,34,-6,96,-18,41,-55,28,6,-11,-42,70,24,-21,-16,32,-10,-59,-24,7,61,-9,-56,-71,-19,61,-35,23,-45,-8,27,-50,37,-54,68,-33,8,-42,-26,38,-42,-5,-11,-9,-4,5,22,-43,22,11,-27,3,-37,-3,-6,-53,-33,22,1,8,-45,43,-12,-45,1,-6,51,34,3,34,9,46,13,-41,28,3,-44,-8,39,-13,-20,-6,7,19,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.94","t":"The therapist may complete a safety plan with the Veteran for any level of risk. A safety plan is a prioritized written list of coping strategies and sources of support that patients can use during or preceding suicidal crises. The intent of safety planning is to provide a pre-determined list of potential coping strategies as well as a list of individuals or agencies that Veterans can contact in order to help them lower their • Safety plan imminent risk of suicidal behavior. It is a therapeutic technique that provides patients with something more than just a referral at the completion of suicide risk assessment. By following a pre-determined set of coping strategies, social support activities, and help-seeking behaviors, patients can determine and employ those strategies that are most effective in managing acute distress. It is strongly recommended that therapists consult the following VA manual, Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version (Stanley & Brown, 2008) for a full description of the safety plan protocol.","e":[23,45,-159,-39,81,21,35,-24,60,8,-59,-28,52,-10,7,-29,22,-45,-26,-39,-38,-59,-32,-3,47,66,3,16,-27,-7,61,19,-2,-20,-45,-104,9,60,-34,-36,-18,14,26,-93,4,-3,90,-20,32,-20,72,-29,-43,-29,105,-51,40,10,-52,-72,61,80,-62,-19,56,-13,-82,36,-4,-3,45,-9,15,2,-68,30,-7,37,-16,64,20,-60,41,-41,32,31,19,-5,-22,63,-19,54,5,20,-93,40,-40,-10,-18,-42,-38,-64,20,-22,-20,33,2,-5,30,28,-22,33,-16,-16,39,-9,82,-15,60,40,6,-13,15,15,-28,34,-15,28,23,16,-23,-28,-43,-5,-10,56,-22,-7,15,27,68,-14,-17,-38,-16,-63,3,-8,-55,-57,-13,41,-18,33,20,-28,-23,60,64,23,67,28,-46,27,-21,-14,4,-12,6,18,-42,-43,24,-12,82,-23,60,-49,2,-8,-9,-30,72,9,-34,-30,36,-7,-39,-50,35,34,-20,-43,-54,-49,36,-15,32,-22,-24,56,-71,17,-47,77,-43,9,-10,-26,54,-36,28,4,-34,-44,17,18,-45,-16,8,-19,-28,-26,5,15,-42,-44,16,-4,-36,-63,21,-3,14,15,4,40,25,-9,24,20,41,40,-51,58,2,-46,16,59,-6,-13,-6,-28,16,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.94","t":"The Veteran may also be referred to another provider or agency, or the therapist may assist with the coordination of care, including referral to a VA clinic or agency, to a physician for a medication evaluation, to a Suicide Prevention Coordinator, or to the emergency department or urgent care service. The Veteran’s agreement to go for additional consultation should be noted, and the method of transporting the patient to this evaluation should also be disclosed. Regardless of the referral options provided, therapists should be familiar with and follow specific guidelines established at their local facility.","e":[-20,10,-170,-62,95,15,-2,-4,80,4,-21,-13,39,5,-9,-55,33,-49,-11,-14,-76,-71,-32,-4,41,29,17,47,-56,5,83,18,34,-28,10,-50,9,70,-12,-15,12,9,5,-87,-2,-35,64,1,25,-19,43,-64,-52,22,84,-57,31,17,8,-50,82,29,-62,-1,61,-17,-54,44,-8,-22,23,-15,44,0,-65,47,-22,-43,-26,22,72,-8,78,-33,10,18,19,33,-13,65,-15,59,6,41,-88,0,-27,10,-14,-47,-57,-27,15,-36,59,35,35,16,-7,-13,-73,-5,-36,-29,42,-26,72,-74,2,35,-7,-13,-11,38,2,25,-47,-4,-7,17,8,-44,-15,-7,-15,17,-15,-25,15,18,37,8,1,-4,-20,-28,9,-9,-30,-15,22,76,-14,18,19,-68,-12,36,38,18,50,45,-36,41,29,-33,5,24,3,29,-8,-42,8,6,112,0,49,-32,22,4,7,-51,25,1,-21,-7,2,-33,-44,-64,22,56,-10,-28,-77,-5,39,-27,19,-52,-13,51,-20,39,-34,67,-58,4,-43,-30,57,-44,9,25,-47,-7,10,12,-51,34,31,2,32,-46,-13,-7,-66,-7,21,17,7,-45,24,14,8,3,-31,59,13,38,31,16,72,28,-79,45,9,-16,26,29,-6,5,-13,2,22,-39]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.94","t":"Finally, the therapist identifies follow-up procedures. These may include ensured continuation of care in the days or weeks following the suicidal crisis or plans to conduct a follow-up risk assessment (interview time and date are noted), examining the medical record (especially from any recent hospital admissions), contacting a provider or agency also responsible for the patients care, or contacting family members or other responsible individuals (especially to alert them of increased suicide risk). CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 78","e":[35,-30,-170,-76,63,16,37,-16,47,-15,-59,-1,59,-9,13,-42,24,-64,-40,15,-46,-33,-50,-14,12,69,-8,61,-30,6,58,16,24,-49,-29,-55,55,59,11,-19,32,-18,10,-127,-20,-44,97,16,33,-57,45,-37,-8,-46,79,-32,1,27,-5,-83,111,52,-43,18,52,-35,-75,54,-36,-5,25,14,31,54,-48,17,-31,7,-24,16,26,4,64,-79,31,6,2,17,1,79,-1,21,-2,58,-87,6,-19,-22,-18,-43,-44,-39,-8,-54,21,53,16,-8,12,-11,-54,38,-30,-9,35,1,47,-58,0,51,-17,-8,16,30,-10,25,-28,22,10,13,5,-15,-34,49,14,34,-12,-23,3,1,46,-16,-15,23,14,-20,15,-14,-50,-39,13,41,14,23,56,-52,-47,6,49,21,76,13,-54,56,0,-36,10,20,35,35,-36,-69,4,-25,90,13,46,-36,45,-32,16,-31,74,40,-7,-23,9,-55,-17,-42,37,61,-9,-6,-72,-25,50,-28,0,-37,-11,56,-56,23,-57,69,-24,-10,-41,-36,55,-31,33,14,-35,-8,0,-3,-49,12,10,15,5,-60,7,28,-53,-17,32,2,-12,-54,29,-18,13,49,-12,55,26,51,16,22,53,46,-65,37,-16,-17,26,29,9,-3,4,19,26,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.97","t":"During the middle phase of treatment, the patient and therapist work together to address the treatment goals established in the initial sessions in a systematic, strategic manner. The therapist uses a combination of cognitive and behavioral strategies as indicated by the case conceptualization. However, the therapist also continues to remain cognizant about the strength of the therapeutic Many Veterans achieve the relationship and balances relationship-building strategies with greatest amount of success cognitive- and behavioral-change strategies, as necessary. In this part, when they first make tangible we describe a number of standard cognitive and behavioral strategies behavioral changes in their that therapists can apply in their work with individual patients. We lives, which puts them in a describe behavioral strategies first and cognitive strategies second better place to examine and because, in our experience, many Veterans achieve the greatest amount evaluate their thoughts and of success when they first make tangible behavioral changes in their beliefs using cognitive lives, which puts them in a better place to examine and evaluate their thoughts and beliefs using cognitive strategies. Although these strategies primarily occur in the middle phase of treatment, we encourage therapists to use them when relevant in the initial phase of treatment so that patients notice symptom change as immediately as possible.","e":[21,-4,-158,-28,68,-22,34,-29,54,10,-24,-8,39,42,10,-41,-11,-44,-16,45,-82,-31,-24,-31,4,54,-38,23,-25,23,90,48,24,-38,-54,-63,34,23,-24,-30,17,20,26,-88,5,-34,49,-10,2,22,36,-25,-5,-15,114,-3,3,43,15,-84,122,48,-67,64,29,-16,-60,34,-61,-45,44,-12,42,18,-27,21,-22,-17,-21,32,45,-74,60,-37,45,29,12,16,-34,91,-11,23,-2,42,-107,2,-39,-16,-6,-29,-64,-7,5,-24,13,62,0,6,-21,24,-96,34,-15,-4,-2,12,57,-30,30,34,6,-10,5,9,10,72,-79,-50,35,3,-2,-13,-22,11,8,64,23,-18,-3,18,36,-26,17,5,-19,-20,22,-30,-23,-6,-9,42,32,30,45,-63,-22,28,30,30,40,15,2,48,3,-45,21,19,16,9,-15,-50,-17,8,117,31,79,-15,4,22,11,-19,8,27,9,-13,48,1,-92,-22,3,39,-47,17,-86,-50,15,-49,34,-46,-27,9,-59,52,-57,80,-6,9,-55,-11,50,-17,6,27,-67,11,-1,-16,-35,50,27,7,-11,20,10,-2,-49,15,32,25,0,-67,54,22,27,5,-23,46,53,73,5,31,17,40,-85,70,-15,-42,-10,59,26,27,-5,-17,43,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.97","t":"Behavioral Strategies As you have undoubtedly seen in your previous clinical experience, many depressed patients claim that they lack the motivation and energy to engage in activities that were once pleasurable and meaningful to them. Some depressed patients spend most of their time doing things that give them little sense of Behavioral strategies can be pleasure or accomplishment. Not only does engaging in few positive used to help patients re-engage activities provide little enjoyment or reward, it also serves to reinforce in their environment, become pessimistic and self-defeating cognitions that contribute to depression. more active, and attend to the Other depressed patients actually are engaging in activities that give fact that they are engaging in them a sense of pleasure and accomplishment, but they view these pleasurable activities, all of activities through a negative lens and focus more on failures than on which can be associated with a successes. Behavioral strategies can be used to help patients re-engage significant improvement in in their environment, become more active, and attend to the fact that mood. they are engaging in pleasurable activities, all of which can be associated with a significant improvement in mood.","e":[18,43,-172,-23,61,12,66,-41,42,-37,-37,11,70,29,-1,-15,-19,-45,-36,42,-39,-18,-31,-25,3,72,-12,-26,-28,50,6,-14,7,-17,-45,24,46,63,37,2,3,8,30,-76,24,-31,79,-14,24,-40,55,-55,9,-49,127,2,6,14,9,-49,113,25,-18,47,63,-36,-50,42,-50,-12,76,18,15,-10,-53,57,-5,-18,-1,-11,56,-57,48,-54,89,3,24,11,-17,46,23,3,49,58,-140,24,-1,-7,-7,-24,-47,-1,-4,-10,32,46,-12,5,4,24,-36,45,4,-59,3,37,40,-40,-4,60,-6,17,13,14,37,68,-3,-32,36,18,-25,-41,-46,-7,15,3,0,-30,1,0,62,3,-11,23,-41,-42,-14,-31,-24,21,-7,20,60,9,34,-80,-20,37,22,-3,76,0,-11,24,5,-16,31,24,10,27,-51,-66,-14,-30,87,-3,58,-35,-18,-52,20,-18,24,7,7,-1,47,-7,-72,-51,13,57,-25,-26,-94,-33,14,-9,33,-22,-23,2,-8,5,-47,57,-20,-1,-20,-31,24,-14,12,13,-36,10,-18,-22,-11,-22,29,-21,-45,13,58,22,-46,14,-40,19,-31,-93,45,-2,26,15,-31,4,16,49,-12,15,40,33,-56,40,-55,-7,0,32,43,34,2,-1,85,-8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.97","t":"Activity Monitoring One of the core components of CBT involves working with the patient, in a structured way, to identify, plan, and carry out pleasant activities and activities that provide her with a sense of mastery or accomplishment. This behavioral component of CBT often begins early in the treatment, particularly with patients with moderate to severe depression, to activate the patient and engage her in treatment. This process involves • Activity two related strategies: Activity Monitoring and Activity Scheduling. Activity Monitoring Monitoring is typically done before Activity Scheduling in order to collect accurate data about the manner in which patients are spending their time. This exercise gives patients and their therapists a baseline assessment of their engagement in pleasurable and meaningful activities. It requires that, in the time between sessions, patients write down the activities in which they engage, no matter how trivial or mundane. In CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 79","e":[7,-7,-193,-49,47,-42,94,-42,50,-26,-27,27,81,-8,1,-69,-29,-37,-86,-10,5,-11,-16,-16,16,60,-7,11,-11,19,43,5,-5,-39,-29,-59,46,61,-31,-1,25,-17,11,-91,23,-31,98,22,-2,-3,7,-43,-17,-44,153,12,-20,32,0,-54,159,40,-44,48,43,-28,-32,33,-46,0,28,-10,40,47,-16,19,-29,3,3,12,45,-15,71,-41,98,2,-11,18,-34,68,29,8,37,35,-114,18,-26,8,-10,-24,-36,-30,-9,-21,10,24,2,-33,-1,-5,-25,29,-6,-15,-17,23,74,-22,-13,37,7,-11,-3,15,0,69,-23,-3,22,13,-10,-4,-18,-4,12,44,-9,-44,3,0,4,-22,-13,26,-12,5,4,-42,-29,14,-3,22,10,14,47,-63,-46,2,51,53,52,-11,-29,23,-18,-48,7,50,40,9,-59,-69,-39,-40,83,45,46,-6,46,-46,-4,-25,23,32,-20,-48,23,-51,-36,-38,7,22,-39,-36,-92,-14,42,-4,24,-48,-19,11,-49,22,-30,75,1,11,-13,-35,73,18,7,14,-29,14,-3,-11,-20,-1,35,-26,13,-22,30,18,-36,-6,-18,18,-21,-55,14,17,22,43,-31,39,22,50,7,22,40,3,-52,27,-16,-6,-18,18,-1,10,-9,-11,61,-46]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.98","t":"addition, patients are asked to provide three ratings: (a) the amount of pleasure [p] that they obtain from each activity (0 = no pleasure; 10 = a great deal of pleasure); (b) the amount of mastery/accomplishment [m] that they obtain from each activity (0 = no mastery/accomplishment; 10 = a great deal of mastery/accomplishment); and (c) their overall mood for the day (0 = depressed; 10 = happy). This process is demonstrated in the following dialogue with Kate.","e":[32,58,-192,-55,44,29,20,-13,39,-27,-30,34,57,38,3,-5,-10,-71,-35,43,-41,-35,-49,-30,31,72,-17,-47,-82,24,-10,10,10,-13,-56,-24,41,99,-14,-18,56,-17,39,-20,10,-15,70,8,33,12,-9,-64,19,18,105,49,-2,-24,61,4,65,-10,-2,78,84,-4,-28,67,-43,-4,21,-29,14,20,-70,40,-27,-14,34,11,66,-14,87,-13,70,-35,-3,-6,-12,69,13,2,54,19,-102,3,2,10,-11,-23,-48,-6,-4,-47,30,52,14,18,7,-10,-46,36,-11,-34,24,-10,48,-49,-23,40,21,24,9,54,-5,48,-19,30,6,-16,4,-40,-34,28,-7,76,8,0,-21,-9,32,-1,-27,12,-35,-36,43,-14,-7,54,31,3,43,-1,-3,-82,-19,3,9,27,57,3,-50,62,5,-46,16,23,-15,12,-19,-74,12,-40,41,-17,45,-2,11,-39,52,-34,41,7,-9,-49,22,-25,-70,-22,20,44,-26,-39,-70,-13,23,-3,25,-43,-7,32,-22,2,-59,73,2,32,-3,-16,22,-32,-23,22,-23,-46,7,-32,2,-1,20,-27,-10,-26,36,26,-29,0,-56,41,-12,-89,39,-9,3,17,-26,40,16,63,-3,15,1,24,-91,30,-26,-18,-9,48,-22,21,40,9,72,-6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.98","t":"Therapist: From what you have told me, it sounds like you haven’t been enjoying yourself much recently and getting much done. Is that correct? Kate: Yes, I would say that’s correct. Therapist: I’m wondering if we may be able to monitor your activities, say, over the next week to see how you are spending your time. You can also rate how much pleasure and sense of accomplishment you get from the activities in which you engage. Kate: Alright. What kind of activities? Therapist: Well, right now, I’m interested in how you’re spending your time, no matter how that may be. I think this will be helpful information for us. Kate: Actually, I never really looked that closely at what I do. How do I do that? Therapist: This sheet is called the Activity Monitoring Form. It’s kind of like a weekly calendar. Right now, it’s blank. Throughout the next week, I’d like for you to write down what you do each hour of the day, however big or small it may be. Kate: OK. You know, I’m not working or doing much these days. So, do you want me to include things like watching TV, eating, taking naps? Therapist: Yes, whatever it is. Kate: OK, I can do that. Therapist: It would be good if you could also rate how much pleasure or enjoyment you received from the activity on a scale of 0 to 10, with 0 being absolutely no pleasure and 10 being the most pleasure you could imagine. Kate: OK. Therapist: So what might be an activity you would rate a 0? Kate: Hmm. Probably going grocery shopping. Therapist: So, you get no enjoyment whatsoever out of going grocery shopping? Kate: Well, I kinda like walking down the aisles, mainly in the frozen section because of the ice cream, and reading the magazines. But it’s standing in line and unloading groceries that I hate. Therapist: So, it sounds like maybe there is some small enjoyment you get from that activity. Kate: Yes, I would say more like a 3 or 4. Therapist: That’s good to know. What do you think would be a 0, then? Kate: Going to the Unemployment Office. That would definitely be a 0. Therapist: Now, what might be something you would rate a 10? Kate: A 10? It’s been a long time since I have done anything like that. Let me think for a minute. Therapist: Take your time. Kate: When I used to go to the park with my kids. That would be a 10.","e":[14,39,-172,-47,-14,5,69,-47,70,-46,-44,0,59,38,-32,-7,-3,-69,-43,38,1,-29,-6,-14,-18,51,-12,4,-67,46,22,-37,-31,-2,-61,-34,61,80,-15,-39,50,22,16,-79,32,-85,101,-11,-7,-17,-6,-83,-14,35,114,-2,7,-25,22,-23,107,-6,-33,103,45,-4,-55,46,-50,-38,45,-21,27,39,-52,53,-26,-20,45,36,23,-9,59,-35,45,-35,17,26,16,76,6,21,51,7,-68,0,10,13,-18,-19,-72,8,-12,-6,58,34,-16,-53,-6,2,12,20,4,-25,-2,24,54,-77,28,44,-5,24,-12,14,23,46,-51,35,-29,14,4,-31,-17,32,4,78,36,-28,-8,2,71,-17,-42,-7,-9,-24,-16,-33,-8,33,5,9,2,15,46,-82,-11,-1,52,15,74,19,17,41,12,4,7,41,6,5,-11,-76,-14,-56,5,-11,30,-22,0,-40,67,-12,28,-26,-3,-24,25,-33,-16,-24,39,-1,-44,-53,-77,-15,38,-45,-5,-34,-29,5,-47,18,-30,60,-10,12,-31,-40,86,-16,-12,50,-26,-34,11,-1,-48,12,28,-24,20,-22,35,21,-38,2,-43,24,-51,-64,24,22,27,37,-46,14,10,64,15,31,17,5,-73,4,-8,14,-8,30,19,37,40,-5,75,-6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.99","t":"Therapist: I think you’ve got down the pleasure rating. There is another rating that I’d like you to make—the mastery rating. The mastery rating refers to the degree of mastery or accomplishment you received from the activity. We’ll use a similar 0 to 10 scale for mastery, with 0 being no sense of mastery or accomplishment at all, and 10 being the highest level of mastery or accomplishment you can imagine. Kate: Like, if I did something that required effort or some achievement I felt proud of? Therapist: Exactly. It could even be something small, even a household chore. Kate: OK. Therapist: What do you think would be a 10? Kate: Cooking a full course meal. Or, when I was working, I would feel great when I really helped a patient. Therapist: Those sound like good examples from your life. What do you think would be a 0? Kate: Umm, lying on the couch in the middle of the day. It seems pretty useless and unproductive. Therapist: So, lying on the couch provides you with no sense of mastery or accomplishment? Kate: Yeah. Therapist: Good, so that would be a good example of a 0. You seem to be getting the pleasure and mastery scales. For each activity, I’m going to ask you to record your pleasure and mastery ratings next to or under the activity. You may use P as an abbreviation for pleasure and M as an abbreviation for mastery. Let’s see how we would do this for today, as an example. Kate: Where should I start? Therapist: So, today is Tuesday. Let’s start with this morning before you came in today. What did you do this morning? Kate: Well, my alarm clock rang at 7:00 am, but I didn’t want to get up, so I stayed in bed for about two hours and watched TV. Therapist: Go ahead, write stayed in bed and watched TV between 7 and 9. How would you rate your pleasure from that activity? Kate: I would say that was a 2. Therapist: It sounds like it wasn’t very pleasurable. Kate: No. Therapist: OK, then go ahead and write down P = 2. Kate: OK [writes down “P = 2”] Therapist: How about mastery? Kate: Mastery? That was very low; in fact, I would rate that a 0. I was just lying there. Therapist: So you can go ahead and record M = 0. Kate: OK, M = 0. Got it. [writes down “M = 0”] Therapist: What happened after that? Kate: I ate some cereal. I don’t have much in the house today. Therapist: Was that at 9:00 am? Kate: Yes, because it was right after the Today Show. Therapist: Go ahead and write that down.","e":[58,47,-173,-55,4,24,3,-11,44,-40,-53,-1,55,55,-19,-29,28,-69,-44,24,-37,-56,-41,3,5,46,-37,-44,-58,20,-3,-24,-20,-21,-49,-12,30,87,-48,-56,59,-14,45,-51,5,-40,77,-7,-7,31,19,-83,52,5,103,4,0,-17,51,-31,76,17,-22,98,50,-5,-45,77,-54,-38,15,-48,29,20,-70,23,-23,-61,47,16,8,-1,75,-3,31,-44,1,37,3,97,14,-8,30,0,-66,7,11,8,-31,-8,-62,0,-16,-33,61,90,37,-24,-15,1,8,27,-24,-27,13,-31,71,-78,-2,31,7,26,-10,21,18,82,-47,4,-16,-5,-6,-16,-35,39,11,113,28,-32,-15,-12,32,-13,-28,-25,-19,-5,33,-19,-33,53,35,-1,19,16,39,-60,-12,-21,48,24,38,32,-32,31,27,-32,-6,26,-12,-12,-7,-72,5,-27,-25,9,35,-7,4,-17,90,5,66,-19,-12,-26,11,-30,-19,-14,36,28,-41,-16,-88,-21,46,-15,-12,-57,-32,14,-14,12,-53,58,-17,40,-20,1,27,-13,-19,50,-41,-22,-7,-19,-17,8,21,-18,15,2,1,9,-41,7,-42,28,-17,-79,22,18,21,28,-38,36,3,89,3,-1,0,17,-93,30,0,-14,-1,40,17,41,56,5,53,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.100","t":"Kate: OK [writes]. I would say that pleasure was a 3 and mastery was a 2. [writes] Therapist: Was that right before you came here, then? Kate: Yes. Therapist: So, would you like to continue with recording the therapy session? Kate: OK. Therapist: How would you rate the session in terms of both pleasure and mastery? Kate: This has been pretty good. I wasn’t sure what to expect today, but I think I would rate my pleasure a 5 and mastery a 4. Therapist: Let’s go ahead and record the numbers. Kate: Should I finish this for the rest of the day? Therapist: Yes, it would be helpful to complete this today and continue for the rest of the week until we meet again next week. How does that sound to you? Kate: I can do that. Therapist: At the bottom of the column for each day, you can also rate your overall mood for the day, just as you’ve been keeping track of your mood until now, on the 0 to 10 scale, with 0 being depressed and 10 being happy. Kate: Just do it on this same form? Therapist: You got it. Are there any things you can think of that might get in the way of doing this? Kate: Umm [pause], I might forget to record the activities, or I might forget later what the activity was. Therapist: Good point. What might help you with this? Kate: [pause] I guess I could keep this monitoring sheet in my purse and do it right away. Therapist: Sounds like that could be very helpful. In fact, it is best to record the activity on the chart as soon as possible after it happens. This also will allow you to most accurately rate the degree of pleasure or mastery because you aren’t having to think back your experience after the fact. Kate: I’m not exactly clear on how all of this will be helpful to making me feel better. Therapist: I’m glad you brought that up. It’s important to me that you understand why we do the things we do in here. Knowing how your activities affect your mood—both in a positive and a negative way—will help us come up with some activities that you might enjoy and feel a sense of accomplishment. It’s very effective in treating depression. Are you willing to give it a try? Kate: OK. I’m willing to give it a try. Therapist: One final thing—shortly before we meet again next week—say in the morning or the evening before, do you think you would be able to review the Activity Monitoring Form and see if you notice any patterns in terms of the activities you engaged in and in the ratings? Kate: Yeah, I can do that. Therapist: Terrific. Do you want to summarize what we discussed doing, then, over the course of the week?","e":[29,14,-170,-67,9,9,46,-29,43,-43,-37,9,69,24,-6,-17,30,-75,-62,61,-43,-66,-49,-8,0,69,-28,-39,-66,36,21,-28,-24,-2,-69,-21,36,75,-41,-42,82,-2,35,-67,14,-61,90,-20,0,14,12,-48,26,4,125,23,4,-22,30,-59,92,-4,-20,81,53,-14,-65,78,-70,-43,32,5,32,15,-50,43,-10,-52,36,2,32,-10,84,-39,51,-40,12,22,-8,82,2,-4,35,18,-55,1,-2,-6,-17,9,-67,-6,-15,-4,33,57,3,-41,-6,-14,-2,0,-11,0,15,-3,33,-61,-16,43,-1,33,-10,22,32,48,-25,11,-6,-1,-30,-29,-45,49,8,102,28,-20,-21,-9,35,-5,-30,-8,-21,-15,19,-24,-28,20,24,-29,25,26,14,-75,-34,-11,58,42,52,24,-11,33,44,-18,22,7,5,-9,-33,-77,4,-67,12,-2,34,-13,28,-27,84,-10,42,-42,-12,-20,8,-24,-27,-8,44,5,-65,-8,-74,-28,63,-26,-13,-27,-42,38,-35,-13,-65,67,18,17,-22,-32,56,-12,-6,52,-30,-8,16,-25,-9,5,7,8,6,-13,0,20,-54,7,-37,15,-30,-79,7,-7,18,47,-47,22,1,75,15,-3,29,30,-88,40,-22,8,21,45,14,26,52,-6,84,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.101","t":"Kate: OK. [pause] I’ll complete the Activity Monitoring Form for the week and review it for patterns. Therapist: This is a big assignment because it requires that you write down many things each day. What’s the likelihood that you’ll do it? Kate: I’d say 90%. You’re right, it seems like a lot of work. But I need to do something to start feeling better. Therapist: Tell me in your own words why you think this will be a useful assignment. Kate: I think this will show me how little I’m really doing to take care of myself. Therapist: [asking a question that will instill hope] And how will that information be important? Kate: Maybe I can figure out things to do that will make me happier. Therapist: Yes, Kate, that’s exactly it.","e":[-9,10,-156,-42,4,-9,62,-16,53,-33,-47,-3,101,29,-41,9,23,-77,-56,35,2,-50,-28,1,17,58,-17,-16,-54,24,41,-54,-22,-47,-62,-57,51,71,-47,-39,69,11,-5,-111,31,-80,90,1,5,-42,-18,-67,-14,37,120,53,31,-8,4,-60,117,5,-75,93,29,-22,-42,36,-52,-11,34,13,55,18,-44,36,-27,-7,41,31,47,-13,71,-27,51,15,10,42,-11,98,26,18,38,17,-55,19,2,9,-57,-32,-74,4,-34,-20,36,31,-20,-34,-10,-1,-11,24,-22,-5,3,13,70,-74,19,24,-1,1,-15,20,4,56,-49,45,2,-10,-9,-22,-36,20,-2,67,-25,-44,0,-8,34,27,-23,3,-13,-23,12,-17,-16,16,5,-24,0,-16,51,-54,-21,-7,57,38,53,10,-11,35,-6,-20,12,52,17,3,-33,-63,27,-27,32,4,30,-24,47,-29,82,-38,51,-25,-12,-6,10,-48,-52,-24,15,0,-34,-15,-53,-9,49,-46,-16,-5,-30,10,-57,9,-30,52,17,-4,-35,-56,94,-14,-18,53,-5,-30,-6,-12,-62,18,25,-17,20,-18,0,34,-47,-13,-32,1,-28,-78,47,15,31,43,-24,31,10,54,7,21,51,-22,-51,42,3,-13,-6,37,18,7,26,-11,54,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.101","t":"When reviewing the pleasure and mastery scales, it can be useful to ask the Veteran for specific examples of activities that she would rate at different points on the scales to assess understanding of the scales and the rating process, as the therapist did with Kate. Also, it is useful to note that when the therapist initially asked Kate for an example of an activity that she would rate a 0 on pleasure, she responded “going to the grocery store.” However, when they looked more closely at this activity, she noted that there were things about this activity that she liked and revised her pleasure rating. This is fairly common with depressed patients. Failing to recognize positive aspects of activities or situations is often part of the negative bias of depression, which can lead to inactivity. Finally, as described previously when discussing homework assignments, the therapist assessed the likelihood that Kate would engage in Activity Monitoring and tried to identify and problem solve any barriers to engaging in this activity.","e":[30,32,-193,-54,34,60,29,-13,52,-8,-14,22,78,51,-18,-26,16,-48,-34,32,-16,-48,-40,-16,20,60,-8,-29,-59,35,-3,-5,-1,-40,-48,-14,70,74,-13,-22,45,14,42,-60,35,-20,76,13,36,18,31,-65,26,-4,109,11,25,-7,29,-45,68,-1,-28,80,58,-15,-46,58,-44,-1,24,2,8,20,-74,30,-15,-34,-13,8,37,-15,75,-20,64,-21,10,22,4,59,11,6,42,20,-101,35,-5,10,-26,-8,-51,-13,-16,-10,44,54,18,0,-4,-4,-29,30,-17,-24,47,-17,49,-67,-26,32,-3,23,-9,38,3,55,-40,9,-1,-13,-14,-25,-36,16,12,62,3,-22,-8,-12,57,-7,-17,9,-13,-37,31,-36,-38,13,1,12,22,3,23,-82,-22,27,58,3,79,41,0,40,21,-29,14,35,24,11,-55,-80,18,-59,45,-5,49,-19,16,-34,41,-52,57,0,1,-21,14,3,-64,-32,31,27,-53,-21,-87,-46,39,4,4,-44,-39,19,-44,17,-75,53,-21,10,-18,-32,43,-18,-11,29,-29,1,3,-16,-20,-8,12,-11,-1,-19,44,21,-40,-15,-34,10,-20,-90,48,6,-4,11,-5,31,-4,43,-5,5,33,44,-60,45,1,-3,9,41,-8,48,9,14,66,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.101","t":"Exhibit 4.1 displays the Activity Monitoring Form that Kate completed between her third and fourth CBT sessions. Note that her mood was very low (i.e., ratings of 0 or 1) early in the week, on days in which she did little more than sleep, watch TV in bed, and eat light meals. Although she attempted to get out of the house and go for a walk on Saturday, her mood improved very little. Kate’s therapist speculated that sitting on • Activity a park bench and watching children play had an adverse effect on her mood because Monitoring this activity activated negative thoughts and beliefs about the implications of her Form husband taking her children away. However, Kate’s mood improved on Sunday and Monday, when she woke up at a reasonable hour, showered, and left the house for activities such as church, a haircut, and lunch with a friend. On the basis of this exercise, Kate’s therapist hypothesized that a lack of engagement in pleasurable and meaningful activities was contributing to Kate’s depression and that there was the potential for her mood to improve if she scheduled more of these sorts of activities into her daily routine.","e":[7,10,-198,-35,-4,53,61,-8,42,-52,-63,20,89,40,-31,-4,-7,-33,-55,39,-24,-9,-35,-16,38,78,-12,26,-34,37,29,-51,-13,-57,-53,-10,83,49,-29,-15,64,9,16,-35,0,-69,92,31,1,-23,-14,-47,16,-52,109,47,10,-6,9,-24,115,14,-45,81,49,-31,-42,53,-68,-17,45,8,14,30,-15,24,-6,-21,-28,30,39,8,52,-27,80,-6,1,11,13,36,25,2,31,12,-72,25,4,27,-39,-10,-86,-32,-23,-2,10,37,-19,-15,-12,4,-54,2,-22,-9,8,7,22,-75,22,-5,14,17,-10,44,20,49,-52,21,3,-24,-20,-21,-19,11,6,44,-7,-9,-18,13,49,16,-7,0,-5,-22,20,-44,-29,20,5,-31,15,22,46,-72,-37,41,36,18,77,15,-9,38,-18,-19,11,71,14,22,-70,-85,-42,-42,12,0,19,-45,13,-62,53,-12,10,17,16,-22,9,-31,-45,-67,4,21,-87,-50,-72,-38,32,6,13,-19,-10,6,-30,26,-37,62,-10,-12,12,-75,59,-2,-17,16,-23,-6,17,-23,-34,23,-11,-3,-31,-20,35,33,-22,-20,-37,-9,-35,-64,18,11,3,48,-37,-18,-8,18,-12,41,12,1,-29,33,-8,9,1,40,5,34,36,-17,84,20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.102","t":"Exhibit 4.1. Kate’s Activity Monitoring Form Wed Thurs Fri Sat Sun Mon Tues 7–8 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep M=0 M=0 M=0 M=0 M=0 M=0 M=0 P=5 P=5 P=3 P=3 P=2 P=3 P=2 8–9 am Woke up; lay Showered in bed M=0 M=0 P=0 P=0 9–10 am Went to Showered Showered church M=1 M=1 M=2 P=1 P=1 P=5 10–11 am Ate cereal Ate cereal Went for a Got hair Therapy M=0 M=0 walk cut appointment P=0 P=0 M=2 M=2 P=4 P=3 11am–noon Tried to pay Looked Sat on park Went to bills online for bench Mom’s house M=0 jobs watching for lunch P=0 M=1 kids play M=0 P=0 M=0 P=4 P=0 noon–1 pm Ate cereal Mom visited Watched Made lunch Met friend M=0 M=0 movie on TV M=0 for lunch P=0 P=2 M=0 P=0 M=2 P=3 P=7 1–2 pm Watched TV Nap Looked in bed M=0 online for M=0 P=2 jobs P=0 M=2 P=0","e":[-21,2,-189,23,-9,19,27,-64,60,-43,-69,24,106,79,-60,-59,-14,-39,-39,54,6,-32,-63,-32,35,72,-9,17,-40,39,52,-23,-11,-79,-57,-69,35,22,-23,-2,83,-11,7,-1,19,-53,76,22,36,-15,-16,-38,12,-14,76,12,14,-34,49,6,151,21,-53,50,42,-2,-10,70,-49,14,28,28,28,-23,-21,8,-20,-22,-18,71,45,31,74,-15,44,-13,-1,23,13,30,14,25,42,-7,-43,33,-8,24,-49,-6,-55,-17,9,-13,50,52,-17,-2,-19,-12,-40,-12,-29,19,-9,-34,76,-63,42,-4,32,-20,-12,38,-13,25,-49,40,1,-21,36,-21,-28,29,4,57,-19,-39,24,-17,24,14,-6,-61,-28,-8,34,-44,-6,29,30,-19,-23,19,32,-90,-47,17,36,70,59,-5,-43,46,-32,-31,-10,94,-1,10,-49,-43,-30,-36,-2,5,-12,-34,32,-10,66,-20,37,7,-44,-72,12,-41,-69,-28,6,22,-34,-44,-10,-3,45,15,28,-19,-26,-6,-59,29,9,77,4,35,16,-31,49,-1,-14,14,-16,5,11,-25,-48,17,-2,-26,-1,-29,49,17,-23,11,9,-2,-19,-46,18,-5,19,47,-7,30,-8,8,-15,21,19,-50,-30,30,-4,18,-21,73,27,58,33,5,58,-33]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.103","t":"Wed Thurs Fri Sat Sun Mon Tues 2–3 pm Nap Ate Revised Looked M=0 sandwich resume online for P=2 M=0 M=4 divorce P=2 P=2 attorney M=3 P=0 3–4 pm Nap Nap Watched TV Watched M=0 M=0 in living TV in P=2 P=2 room living room M=1 M=1 P=4 P=4 4–5 pm 5–6 pm Called kids Light Called kids Called kids Dozed off M=1 Cleaning M=1 M=2 on couch P=5 M=2 P=3 P=5 M=0 P=0 P=0 6–7 pm Made frozen Made frozen Watched TV Watched TV Cooked light Tried to dinner dinner in living in bed dinner call kids – M= 0 M= 0 room M=0 M=3 no luck P=0 P=0 M=0 P=1 P=4 M=0 P=2 P=0","e":[-7,16,-166,14,-9,19,-34,-67,33,-46,-81,24,23,86,-46,-80,-10,-45,-33,55,-25,-52,-34,-52,18,26,-11,28,-23,40,29,-22,14,-62,-74,-87,64,33,27,-32,38,10,6,-26,54,-46,30,32,46,-48,41,-53,-19,-72,55,-12,11,2,69,65,118,44,-32,68,30,17,-14,92,7,-5,31,-13,13,-7,-27,-7,-27,-10,-16,69,20,9,55,-19,14,-8,6,18,35,63,18,11,10,13,-46,57,0,38,-37,-26,-9,-31,24,-27,79,68,10,1,13,13,-81,21,-14,12,-7,-38,97,-52,58,60,6,-14,6,17,20,41,-42,9,2,-39,5,-6,-22,1,5,58,4,-51,59,-10,25,-6,28,-73,-47,-13,28,-57,-5,66,45,-7,-10,35,50,-76,-44,17,56,49,-5,-31,-72,16,-16,-19,0,84,-22,12,-64,-27,-6,3,-14,32,2,-51,-11,13,45,-18,31,-16,-40,-69,19,-47,-55,-18,-8,62,1,-68,-33,-14,23,42,48,-50,-28,-26,-14,25,16,86,-15,11,12,38,38,6,-22,15,-15,27,-17,-15,-47,47,-3,-19,-12,-45,42,-10,-4,32,3,45,-7,-99,62,38,9,27,0,35,-8,18,-21,22,21,-4,-41,38,5,-26,-48,55,42,60,3,26,29,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.105","t":"After patients complete their Activity Monitoring Form, it is important for therapists to review the results at the following session. We encourage therapists to approach this review from a collaborative stance, sitting alongside the patient The goals of reviewing the while reviewing the form and actively asking questions to supplement Activity Monitoring Form are the information on the form. The goals of reviewing the Activity to (a) help patients recognize Monitoring Form are to (a) help patients recognize the link between mood and the activities in which they engaged, and (b) begin to identify the link between mood and the activities associated with a sense of pleasure or accomplishment that activities in which they can be scheduled more frequently in upcoming weeks. Special attention engaged, and (b) begin to should be given to the identification of specific types of activities identify activities associated associated with increased ratings of pleasure, a sense of mastery, or the with a sense of pleasure or patient’s mood rating. Observations about the degree to which the accomplishment that can be patient is engaging in pleasurable and meaningful activities should be scheduled more frequently in linked explicitly to the behavioral model. The information gathered on upcoming weeks. an Activity Monitoring Form often facilitates subsequent behavioral change because patients are faced with “hard data” indicating that the activities in which they are currently engaging are not particularly helpful for them.","e":[7,20,-173,-39,21,-43,102,-18,75,-42,5,28,99,10,10,-50,-4,-76,-63,-8,-7,-27,-28,4,15,66,10,-29,-20,22,32,6,-5,-33,-41,-64,59,64,-76,17,36,18,-5,-87,43,-19,75,-31,17,-22,-1,-29,-25,19,153,24,0,2,26,-68,128,18,-45,48,39,-46,-19,-8,-38,24,2,23,31,49,-25,39,-11,-15,9,7,56,-15,73,-48,64,-13,-3,20,-27,81,30,-3,65,4,-120,27,-16,17,-8,0,-68,9,5,-8,37,28,-18,6,-11,-5,-15,37,-6,14,1,-4,71,-14,-1,59,9,-24,-3,12,3,28,-24,-12,19,12,-11,-23,-27,-1,31,54,-8,-31,18,-11,29,-11,2,27,-11,-27,31,-42,-9,24,-26,-7,2,-7,53,-69,-45,-8,51,36,65,7,-28,56,-21,-35,24,-7,12,1,-48,-39,-5,-37,64,13,32,-25,26,-54,20,-72,34,29,6,-35,41,-33,-56,-3,19,26,-52,-44,-48,-7,21,-12,4,-47,-61,-6,-67,-3,-38,55,10,6,-41,-38,37,-21,4,37,-29,-3,-5,-5,-16,14,24,-26,4,-23,3,12,-51,-13,-26,17,-17,-63,21,21,9,3,-11,42,37,27,-12,30,55,-10,-57,34,-14,11,-12,56,29,41,10,0,72,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.105","t":"CASE EXAMPLE: KATE Before completing the Activity Monitoring Form, Kate believed that sleeping was helpful for her, claiming that she had always enjoyed sleeping and that it helped to refresh her. However, her ratings suggested that she did not derive as much pleasure from sleeping that she would have predicted, and in fact, she discovered that she derived less and less pleasure from sleep as the week went on. Without the information recorded on the Activity Monitoring Form, Kate might not have altered her view that sleeping improves her mood, rather than maintains her depression.","e":[18,27,-176,-5,10,52,11,-46,59,-51,-66,5,115,67,-43,-23,-9,-41,-55,25,-29,-23,-51,-8,18,73,14,-23,-43,54,53,-34,12,-43,-60,-37,41,59,-37,4,56,0,25,-30,18,-43,69,5,-1,-30,8,-44,13,-14,131,39,23,-9,5,-42,106,5,-22,68,46,-36,-38,64,-40,8,36,25,-13,12,-30,47,-10,-12,-23,37,88,-30,68,-24,75,24,22,-1,6,62,34,-3,50,11,-63,13,10,12,-41,29,-61,-34,4,6,42,41,-38,-20,1,-1,-24,2,-2,-17,15,-9,67,-47,-14,6,-37,17,0,44,5,66,-18,17,13,-25,-7,-23,-38,48,20,56,-11,-29,3,12,50,-8,-22,-13,-27,-21,6,-18,-29,36,-5,-18,9,10,24,-67,-28,3,50,28,94,5,-15,40,-9,-16,2,52,-3,1,-62,-58,-23,-37,66,17,51,-35,35,-40,48,-26,10,3,13,-57,12,-12,-95,-45,-19,13,-68,-34,-87,-8,51,42,11,-5,-44,-16,-40,0,-19,56,-6,0,11,-32,59,9,-8,19,-15,-8,-5,-13,-32,-5,-3,-13,-12,-16,38,-24,-26,-11,-50,-13,-18,-110,37,27,-1,31,-24,22,11,9,-22,20,12,-26,-31,44,-15,-3,-20,59,8,49,25,-14,92,-33]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.105","t":"Activity Scheduling After patients complete the Activity Monitoring Form, they often collaborate with • Activity their therapist in the process of Activity Scheduling. Once patients have an Scheduling understanding of the manner in which the activities they engage in relate to their mood, they can work with their therapists to identify activities that gave them a sense of pleasure and/or accomplishment and brainstorm ways to work them into their daily and weekly schedules. Veterans may have difficulty Once patients have an identifying activities that they find enjoyable. It may have been a long understanding of the manner in time since they have engaged in such activities. If this is the case, it can which the activities they be helpful to ask patients what they previously enjoyed when they were engage in relate to their mood, happier. In addition, it can be useful to provide patients with a checklist they can work with their of pleasant activities, such as the Pleasant Events Schedule described in therapists to identify activities the subsequent section, to help patients recognize activities that provide that gave them a sense of them with pleasure and mastery. After patients have identified themes pleasure and/or or activities of interest, their therapist works with them to plan activities accomplishment. that they commit to engage in during the week at specific times.","e":[-1,5,-186,-47,12,-46,55,-56,62,-44,-35,19,68,10,-22,-28,9,-47,-74,11,0,-16,-25,-7,5,55,-7,-9,-38,9,20,16,12,-32,-13,-68,35,52,-26,1,38,11,1,-81,42,-57,82,-19,1,-31,7,-39,-35,-1,125,30,21,32,37,-29,130,33,-24,59,41,-13,-30,35,-36,-15,4,6,36,35,-32,68,6,-12,2,3,55,-9,70,-50,65,-7,7,19,-11,82,14,8,36,34,-135,19,-14,35,-30,-34,-47,-10,3,-34,16,28,-18,-9,11,9,-19,21,-21,-5,25,25,59,-56,14,64,1,-10,-17,34,19,60,-33,-16,11,-4,17,-22,-31,26,4,33,28,-41,21,-13,49,-2,-31,1,-32,0,-20,-50,-25,35,-18,21,20,20,18,-87,-53,8,45,38,70,8,-21,29,-3,-24,29,38,-2,-9,-37,-64,-10,-38,75,12,37,-4,43,-39,-5,-54,19,-20,-18,-45,38,-36,-50,-27,16,37,-38,-53,-79,-34,29,-8,0,-28,-36,9,-57,18,-20,89,5,-19,-29,-29,61,-21,-21,16,-46,13,-1,-4,-32,13,53,-30,-10,-34,15,25,-47,28,-46,18,-19,-61,11,7,41,9,-14,40,19,61,8,1,47,10,-87,34,-19,-16,-8,53,14,-1,10,-5,45,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.105","t":"It is important to be as specific as possible when planning activities. It is also recommended that therapists begin with activities that can be easily achieved, especially with severely depressed patients, in order to increase the likelihood that they will actually engage in the activities. In addition, achievable activities can make a substantial impact on depressed patients and on their level of confidence in CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 87","e":[5,33,-161,-38,57,27,60,-5,34,-11,-36,20,69,-6,10,-18,-7,-67,-38,25,-34,-44,-25,-19,2,28,-11,6,-55,17,55,-26,15,-33,-26,-42,61,64,34,-21,15,-15,2,-102,-9,-36,112,7,7,-38,51,-72,1,-41,103,-1,-6,9,8,-63,118,53,-81,49,5,-20,-53,29,-42,-22,56,-33,60,41,-56,15,-25,-29,-20,0,25,-22,57,-66,51,5,17,10,16,65,23,16,18,87,-102,9,-27,13,-8,-52,-28,-18,10,-17,-6,15,2,-11,13,5,-42,62,-32,-37,1,42,60,-33,13,53,11,-6,14,36,-10,61,-23,3,34,-16,-18,-24,-17,11,-6,11,-11,-19,6,-2,31,22,-33,5,-13,-18,-6,-13,-49,1,-7,31,22,7,40,-71,-17,22,58,1,45,34,-31,25,-1,-21,17,30,31,24,-50,-54,-20,-6,85,-7,47,-3,21,-61,17,-35,23,24,-23,-10,27,-51,-66,-53,21,59,-11,-28,-95,-36,68,-12,21,-29,-12,58,-29,41,-64,78,-1,8,-27,-38,62,-47,5,25,-16,-10,-27,-6,-50,1,41,-11,-17,0,6,26,-53,-14,8,9,-9,-76,49,-10,20,14,-32,24,37,77,31,6,61,23,-75,37,-11,-30,-3,19,-3,16,-10,-5,34,9]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.106","t":"treatment. As they implement the activity schedule, they continue to monitor their activities and mood. Within a short time, patients can typically see, through their own • Socratic empirical data, a close relation between the nature and frequency of activities they questioning engage in and their mood. Patients can recognize this relation through the process of indirect questioning, known as Socratic questioning. Socratic questioning is a key skill used by cognitive behavioral therapists that can be employed in the implementation of all of the strategies described in this manual. The When patients make purpose of Socratic questioning is to help patients make important discoveries or realizations on realizations on their own. When patients make discoveries or their own, they are much more realizations on their own, they are much more likely to remember them likely to remember them and and this discovery will have greater impact than when information is have greater impact than when told or suggested to them. Socratic questioning is discussed further in information is told or suggested relation to cognitive strategies in CBT on page 109. The following to them. dialogue demonstrates the process of Activity Scheduling with Kate.","e":[61,6,-156,-50,47,-16,78,-28,31,41,9,7,100,30,-36,-66,10,-60,-47,46,-55,-29,-29,35,33,36,-5,-5,-7,-13,36,10,13,11,-47,-62,89,20,-54,6,8,-48,31,-97,52,-46,66,-11,-4,-66,1,-62,-1,-18,70,38,49,52,2,-36,91,11,-19,39,32,4,-33,44,-75,17,54,3,56,33,-35,28,-2,14,0,22,53,-60,58,-37,60,59,4,-8,-2,50,13,-30,48,41,-83,51,-19,-21,-4,-2,-74,-38,-10,8,7,25,-13,-6,10,17,-42,49,-30,-10,9,11,38,-33,32,-15,-2,8,-1,45,15,105,-52,16,2,-23,-4,-31,-27,0,-18,52,8,-25,2,7,38,0,-7,11,9,7,3,-43,-47,-12,-33,3,-13,6,48,-38,-26,16,34,51,48,-14,-41,33,-30,-17,34,20,4,7,-69,-76,-19,-9,64,38,69,-71,43,-10,17,-31,34,-2,2,-20,45,-5,-11,-40,6,1,-54,3,-96,-52,46,-18,5,-21,-8,7,-55,17,-34,74,0,-22,-18,-31,87,-14,9,18,-33,-3,32,-20,-22,14,17,-57,-28,17,-9,15,-66,8,-19,55,-49,-97,33,14,31,53,-4,23,38,29,6,21,22,22,-67,13,3,-24,-3,27,-23,35,-18,-18,62,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.106","t":"Therapist: So, Kate, were you able to complete the Activity Monitoring Form we discussed last week? Kate: Yes, I think I pretty much got it all. I kept a note by my bed to remind me to do it. I also kept it with me when I went out. Therapist: That’s good, Kate. Did you have a chance to look it over before session today? Kate: Yes, I looked over it yesterday. Therapist: Did anything stand out for you, or did you notice any patterns? Kate: Actually, I did notice that I spend a lot of time on the couch watching TV. Therapist: How much pleasure and sense of mastery did that provide? Kate: I rated it quite low, usually 2 to 3 for pleasure and 0 for mastery. Therapist: That’s good information. This is a fairly common activity of depressed individuals that is usually rated quite low and often contributes to their depression. Did you notice anything else? Kate: [looking at form] Yeah, I don’t go out much. Although, on Wednesday I went to the grocery store and on Friday I went to the Women’s Clinic at the VA. Therapist: How did you find those activities? Kate: The grocery store I rated as a 4 on pleasure and 4 on mastery. It was actually my highest rated activity for both pleasure and mastery that day. For the visit to the Women’s Clinic, I rated a 6 on pleasure and 5 on mastery. Therapist: It sounds like these were fairly positive activities. Tell me more about them. Kate: At the grocery store, it kinda felt good to be out of the house. I also kinda like looking at the different foods and magazines. I got a lot of stuff I had been putting off for weeks, so it felt good to get that done. Therapist: How about the visit to the clinic? Kate: Well, I saw Wendy, a friend of mine who goes to the same clinic. I haven’t seen her in a while. We’re about the same age. Therapist: How was it talking to her? Kate. It was pretty good. She said she has had some health stuff going on. it was nice to focus on someone else’s problems, rather than my own.","e":[4,27,-181,-57,6,10,58,-45,71,-43,-45,-8,75,18,-22,-25,-3,-63,-59,35,-51,-60,-37,-18,6,68,-20,9,-61,47,38,-62,-9,-35,-55,-20,49,99,-47,-15,75,43,-5,-90,7,-66,70,-7,9,-16,-14,-47,-6,19,121,-11,15,6,12,-55,102,3,-40,75,48,2,-51,60,-69,-30,30,-10,30,2,-39,50,-28,-36,6,22,31,-1,59,-47,52,-20,40,46,18,74,39,13,18,38,-63,22,16,11,-35,-30,-54,1,-24,5,63,45,-9,-43,-19,19,-7,-5,-10,-17,9,-20,50,-73,15,15,-8,27,-6,13,36,39,-47,2,-10,10,-1,-46,-31,38,13,55,20,-23,0,-3,39,13,-26,-30,-3,-31,21,-35,-17,2,-2,-3,-13,19,42,-77,-34,-6,66,46,48,38,5,16,23,-27,9,55,29,5,-48,-68,-10,-69,11,-9,14,-26,20,-34,65,-23,43,-9,14,-21,18,-31,-32,-28,4,9,-71,-12,-67,-2,47,-21,7,-39,-34,12,-35,2,-35,66,-6,5,-21,-39,60,-9,1,46,-19,-15,11,-14,-40,-5,39,-18,17,-14,20,28,-43,18,-51,9,-51,-54,33,16,-1,36,-59,18,14,60,2,15,12,9,-65,32,-10,20,-3,42,19,39,34,-14,81,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.107","t":"Therapist: Any other observations about the week? Kate: I noticed that my mood ratings were better on Wednesday and Friday, but I’m still feeling pretty depressed most of the week. Therapist: Do you mind if I take a look at the form with you? You’ve done a really nice job with Activity Monitoring, Kate. I noticed, just like you did, that on most days, you do activities that don’t provide you with a lot of pleasure or sense of accomplishment. This doesn’t seem to help you to feel well. And, in fact, over time the lack of activities may make you feel worse. Kate: Yeah, I feel just “blah” when I’m always on the couch. Then, later, I feel worse because I didn’t do anything I wanted to do. I usually then just bum around because I have little energy to do anything else. Therapist: Sounds like you get caught in a pretty vicious cycle. Kate: Yeah, that’s how I feel. Therapist: What I also have learned from your Activity Monitoring Form is that when you went out, your sense of pleasure and mastery, and your mood, increased. You feel somewhat better when you break this cycle. Kate: Yeah, but I can’t seem to do anything consistently. Therapist: We’ll get there, but now we are recognizing some important patterns. As I mentioned last week, we are going to start working on increasing the number of activities you engage in that provide you with pleasure and a sense of accomplishment. Kate: How are we gonna do that? Therapist: Well, first, it’s important to identify activities that you enjoy. What are some activities that you like doing? Kate: I don’t know. Therapist: What about from this past week? Kate: Umm, well, I kind of liked talking with Wendy. Therapist: Yeah, and in fact, from what you’ve said previously and today, it seems like you enjoy socializing with others even though you can be shy. Would you say that’s accurate? Kate: I guess so. But I don’t do much of that anymore. Therapist: Are there other activities, either with other people or on your own, that you enjoy doing or enjoyed doing in the past? Kate: Umm, nothing specific really comes to mind. Therapist: I know this can be difficult, especially when it’s been awhile since you’ve engaged in these activities. I have an idea of an exercise that may help. It involves closing your eyes and thinking back to a time when you were happy. Would you be willing to try this? Kate: OK. Therapist: Go ahead and take a couple of deep breaths. Now close your eyes. Now think back to a time when you can see yourself feeling happy and doing things that you enjoyed… Kate: I can’t think of anything. Therapist: It’s OK. It doesn’t always come right away. Just relax and try to focus on a time in your life when you were particularly happy. What do you see?","e":[11,22,-168,-47,0,9,61,-47,58,-59,-51,14,51,40,-10,3,2,-69,-73,57,-39,-30,-15,-8,-19,94,-29,4,-44,47,16,-61,-18,-9,-64,7,58,84,-12,-19,64,25,8,-87,9,-106,85,-9,-19,-15,8,-73,-26,-10,108,18,21,-12,33,-52,82,-2,-30,97,29,-15,-62,35,-69,-53,62,-5,30,31,-43,61,-1,-46,37,10,29,-11,46,-57,61,-13,8,44,8,83,33,2,30,34,-74,-7,18,5,-44,-35,-61,18,-34,-16,51,26,-51,-44,-1,6,-25,14,-6,-32,-5,8,37,-78,16,20,5,26,-27,18,61,52,-36,-5,-10,11,1,-36,-50,56,-3,62,29,-27,8,-5,54,2,-24,-22,-16,-20,-5,-43,-27,31,2,-9,-3,14,43,-71,-31,18,66,5,56,22,11,16,28,-6,9,37,7,9,-35,-66,-43,-45,15,18,29,-31,2,-51,66,-7,38,-32,18,-23,26,-48,-44,-42,26,-4,-55,-22,-62,-13,51,-49,-2,-19,-24,9,-20,19,-19,74,2,-14,-24,-48,75,-25,-10,42,-26,-12,14,-14,-27,-3,38,-1,-22,-24,7,30,-31,10,-42,16,-51,-83,31,15,22,41,-49,15,10,64,21,39,-2,7,-65,26,-9,5,11,18,38,35,45,-18,78,4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.108","t":"Kate: Umm. Actually, I used to like gardening. It’s been a long time since I did that. I used to grow these really large zucchinis, which I would use to make zucchini bread. Therapist: You mentioned previously that you used to enjoy cooking. Is there anything else, whether recent or a long time ago, that you enjoyed doing? Kate: I used to really like going to the park with my kids. Therapist: Those were very happy times for you. Kate: Yeah. [tearing up] Therapist: What did you do at the park? Kate: Play Frisbee, have a picnic, and just be with my kids. I felt more connected to the outdoors and my life. Therapist: How did that feel? Kate: Much better than my life now. Therapist: OK, feel free to open your eyes. It sounds like these activities brought you great joy and a sense of meaning. Kate: Yes. Therapist: It also sounds like relationships were very important to you. Kate: Yeah, I kinda lost that in my life. Therapist: Well, you and I can work on rebuilding that together, if you would like. Kate: OK. Therapist: Thank you for engaging in that exercise with me. I think some important work we can do together that can make a big difference in your life and help you feel better is to work on increasing pleasant activities in your life. As we identify activities you enjoy and that are associated with a sense of accomplishment, we’re going to schedule some of these activities to create what we call an activity schedule using this Activity Schedule Form. [gives Kate the form] Kate: It looks like the Activity Monitoring Form I completed this past week. Therapist: Yes, it looks very similar. But we’ll use this form to schedule pleasurable and meaningful activities over the course of the next week. I’m wondering if we can maybe start today with scheduling two pleasant activities for this next week. How does that seem to you? Kate: OK. How? Therapist: Well, let’s think of a couple of pleasant activities. You mentioned earlier that you saw your friend Wendy this past week. And you liked talking with her? Kate: Yeah, I did. Therapist: Would you have any interest in calling her to continue the conversation over coffee or something? Kate: Yeah, I could do that. Therapist: When do you think would be a good time to do that? Kate: Maybe on Sunday. She’s most likely to be home. If I plan to do it at noon, it may get me out of bed before my normal 3:00 pm on Sunday. Therapist: Scheduling activities can help get you going. Is there anything else you would like to schedule, perhaps something pretty straightforward?","e":[8,46,-175,-16,-27,13,16,-56,34,-41,-44,-21,77,45,-61,20,1,-61,-69,46,-9,-35,-3,6,-29,37,-15,40,-75,24,36,-39,-29,26,-52,-13,50,77,-19,-75,68,48,13,-66,43,-144,115,-14,-17,-25,-22,-57,-38,-8,78,26,71,2,43,-22,94,44,-45,76,19,23,-66,47,-63,-46,31,-20,51,42,-1,57,-25,-44,38,13,4,3,54,-49,9,-25,37,28,-19,73,8,16,17,17,-61,0,-7,24,-38,-26,-48,-6,1,4,39,14,-12,-45,-17,24,-6,11,-31,-6,-10,5,37,-85,65,39,11,7,-10,-4,39,78,-61,5,-17,-10,-3,-5,-25,56,-14,52,26,-33,14,-15,57,-5,-23,-36,5,25,-6,-38,-5,18,-8,1,-3,31,45,-80,-31,-9,69,25,51,23,-1,21,29,25,26,29,-5,21,-30,-76,-35,-53,-16,-33,29,-27,7,-52,58,-25,33,-11,-16,-13,24,-36,-33,-38,-6,5,-55,-13,-57,-24,42,-39,-6,-4,-28,21,-62,30,-17,70,6,4,-15,-38,69,-15,-12,27,-31,-24,12,-12,-51,15,36,-18,5,-22,2,28,-7,24,-58,28,-57,-40,14,3,33,61,-22,21,1,38,20,4,13,7,-54,35,14,2,-13,45,59,17,31,-14,42,-8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.109","t":"Kate: Umm, let me think… Well, you asked me to complete this checklist of pleasant activities. Maybe I could go sit in the park and do this. Would that count? Therapist: Nice idea. Do you have any thoughts on when you might do this? Kate: Well, I could do this on Tuesday at 2:00, to spread things out a bit. Therapist: Tuesday at 2:00 pm, it is. Kate: Should I write it down on the Activity Schedule Form? Therapist: Yes. So, Sunday you are going to call Wendy and on Tuesday you are going to go to the park? Kate: Yes, that’s it. Therapist: Are there any things that you think might get in the way of you doing these things? Kate: The only thing I can think of is if it rains on Tuesday, I won’t want to go to the park. Therapist: Maybe we can think of a contingency plan if that happens. Kate: OK. Maybe I could go to the coffee shop. I used to do homework there when I was in nursing school. Therapist: So, coffee shop is the contingency plan. Kate, do you have any questions? Kate: Uh, no, I don’t think so. Therapist: Do you think you could also continue monitoring your activities each day over the next week, as you did the last week? Kate: You mean using the Activity Monitoring Form you gave me? Therapist: Yes. Here are a few more copies if you in need them. Kate: Yes, I can do that. Would I include these activities on there when I do them? Therapist: Yes. Kate: OK. Therapist: To recap on our work today, we started by reviewing your Activity Monitoring Form from the past week and learned that you’re engaging in few pleasant or meaningful activities, and that a good amount of your time is spent in bed or lying around the house. We then talked about Activity Scheduling and identified activities you enjoy even if it’s been a while since you’ve engaged in these activities. You identified a couple of activities you used to enjoy and we went ahead and scheduled some over the next week. Does that sound right? Kate: Yeah, you got it. Therapist: How do you feel about how this exercise went? Kate: This makes sense. I’m beginning to understand how things I do, or don’t do, impact how I’m feeling. I’ve never talked about this kinda stuff before or made a plan from week to week. Therapist: Is there anything you did not like about this exercise? Kate: Umm, I was unsure at first about closing my eyes, but when you explained to me what we’d be doing, that helped. That exercise helped me connect with the side of me who used to enjoy more pleasant activities, um, that’s gotten lost. Therapist: I think this process will help you get that side back, Kate.","e":[13,31,-167,-30,-19,16,45,-39,54,-42,-38,-25,58,35,-58,3,10,-69,-58,17,-13,-28,-22,4,-20,48,-18,8,-86,41,40,-38,-23,-24,-51,-26,51,48,-46,-70,52,18,11,-72,42,-130,121,-4,-13,-14,-6,-53,-34,27,69,45,70,4,19,-30,122,31,-37,77,30,-13,-71,53,-55,-27,41,-3,47,25,5,66,-1,-26,42,33,-8,6,73,-32,45,-2,28,11,-15,75,-20,21,34,15,-42,-3,1,20,-45,-17,-82,-5,-19,4,54,18,-22,-33,11,3,12,25,-33,-4,-6,20,37,-89,60,37,13,-6,-15,7,53,48,-79,3,-6,-18,-12,-2,-46,56,-33,49,35,-32,6,-11,34,3,-29,-17,2,10,0,-57,-4,3,-12,0,-7,18,56,-68,-34,12,90,22,69,21,0,28,-5,9,10,43,4,-2,-13,-80,-31,-48,-10,-11,12,-28,2,-36,73,-8,11,3,-10,-28,2,-34,-36,-57,5,4,-52,-16,-73,-27,52,-28,0,-10,-19,22,-55,25,-23,76,8,20,-9,-39,90,-8,7,33,-39,-30,21,-6,-55,17,15,-4,2,-13,9,37,-41,11,-31,10,-47,-47,-5,-2,40,37,-34,16,13,36,29,28,24,6,-62,26,14,-7,-13,37,46,9,28,-19,57,30]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.110","t":"In the preceding dialogue, the therapist and Kate began the session by reviewing Kate’s Activity Monitoring Form from the previous week. In reviewing the form, the • Guided therapist used Socratic questioning to help Kate recognize her baseline activity discovery functioning (or lack thereof) and make connections between her behaviors and mood. Guiding patients to make discoveries on their own (often referred to as guided discovery) is usually much more effective than directly lecturing patients. In this example, Kate made two key discoveries: (a) she spends a great deal of time in bed or on the couch, which provides her with little pleasure or sense of mastery; and (b) when she goes out of the house, she tends to feel better. After reviewing Kate’s Activity Monitoring Form, she and her therapist began the process of Activity Scheduling by identifying a few activities that provided Kate with pleasure and a sense of accomplishment. Kate initially had some difficulty identifying such activities, so the therapist used an imagery exercise in which she asked Kate to imagine a time in her past when she was happy and activities she enjoyed. This helped Kate to identify pleasurable activities as well as connect with a side of herself she had not seen in some time and to recognize that there are things she can do to feel happier.","e":[28,36,-182,-63,22,2,74,-23,47,-7,-43,-5,128,61,-53,-28,19,-52,-58,34,-54,-12,-38,34,17,36,-7,-19,-15,10,51,-35,10,-5,-51,-58,69,44,-69,-9,29,-2,12,-82,27,-83,73,-21,1,-24,1,-19,-5,-18,102,48,31,24,20,-50,108,12,-48,48,41,-11,-51,53,-53,8,51,-10,71,43,-44,42,-6,-2,-3,23,48,-36,63,-57,77,22,10,21,-10,47,21,-18,50,27,-73,36,3,0,-29,-18,-79,-12,-15,0,32,36,-6,-16,-3,6,-9,24,-35,-12,4,-17,79,-49,34,-11,-3,16,-18,18,21,93,-51,-8,-8,-13,5,-43,-37,27,14,79,-1,-18,-7,2,11,-3,-28,-8,4,-6,14,-41,-29,16,-5,8,-23,9,50,-67,-18,1,43,17,61,-6,-21,40,-10,-7,29,6,11,-11,-53,-69,-15,-27,32,41,46,-65,36,-23,54,-54,38,21,19,-16,21,-37,-29,-46,1,7,-61,-12,-75,-41,56,-20,5,-22,-34,14,-55,19,-50,58,-2,0,-10,-39,82,-9,6,28,-23,-17,29,-13,-37,-6,12,-25,-15,-6,3,23,-50,-4,-33,19,-56,-79,30,15,42,39,-24,18,12,33,-11,26,20,-6,-69,33,8,2,-26,44,5,43,20,-31,73,-8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.110","t":"When introducing the Activity Schedule Form, it can be helpful to begin completing a few of the items in session to get the process started and pique interest in the patient, • Activity which seemed to occur with Kate. The exercise concluded by scheduling a couple of Schedule Form very simple pleasant activities Kate could engage in for homework.","e":[-5,42,-155,-15,9,-2,41,-47,40,-30,-53,3,112,54,-36,-37,8,-67,-60,37,-4,-44,-31,-14,5,40,3,-19,-39,12,43,-21,32,-37,-4,-71,54,19,-74,-32,25,-16,4,-26,57,-63,67,10,-23,1,-10,-35,-37,-11,94,79,25,-4,55,-13,117,34,-47,81,26,1,-38,67,-26,28,18,-10,104,2,-20,33,9,-16,10,48,26,2,83,-23,67,12,18,4,-28,67,-1,16,37,25,-82,23,-20,44,-47,-14,-58,-19,18,-5,4,28,-2,1,10,9,-17,51,-35,9,9,23,63,-35,33,35,-22,-63,21,38,-1,52,-53,-6,51,-37,-2,-21,-53,14,7,40,-22,-49,17,-19,20,18,-34,-19,-17,29,17,-35,-15,15,-12,-19,15,18,36,-66,-8,-12,58,22,85,-20,-44,24,-32,-13,23,54,13,-7,-29,-55,-23,-31,35,4,48,-2,47,-44,31,-43,4,1,-27,-53,15,-23,-75,-31,-4,15,-12,-31,-60,-23,55,42,-13,15,-38,1,-72,1,-17,85,-10,14,5,-47,84,12,-42,16,-13,24,-7,-8,-74,38,28,-19,-15,-32,35,33,-24,12,-58,-13,-63,-61,-13,-10,35,6,-1,22,-15,17,-40,25,61,-25,-62,20,-18,-10,-30,47,9,-18,4,-5,43,2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.110","t":"Exhibit 4.2 displays an excerpt from the Activity Schedule Form that Kate and her therapist created during a subsequent session, with the intention that it would help Kate increase the frequency of pleasurable and meaningful activities in which she engaged. On the basis of the Activity Monitoring Form she completed during previous weeks, Kate realized that her mood improves when she has interactions with others, such as with her best friend. Thus, she took care to include these interactions in the activity schedule for the following week. In addition, she noticed that her mood was quite low on days she took naps and watched television, particularly those days in which she watched television in bed. Kate’s therapist helped her to brainstorm inexpensive activities Kate had previously enjoyed, such as going on walks, reading, and watching particularly pleasurable television shows (versus those she watched to numb her mind).","e":[-7,20,-193,-40,-2,19,38,-29,44,-51,-64,17,100,55,-20,-3,-5,-28,-69,35,-35,-45,-24,-4,8,75,-8,-3,-32,28,42,-57,-2,-45,-41,-45,71,61,-60,5,46,18,3,-30,22,-77,66,-6,0,-30,-1,-25,2,-32,117,42,15,-8,21,-29,109,29,-36,77,50,-9,-42,80,-58,-6,24,-7,26,15,-7,42,3,-21,-15,38,44,-20,64,-40,75,-7,15,19,7,51,38,22,35,34,-65,28,12,21,-45,-13,-83,-23,24,-1,33,29,-12,-4,1,18,-36,6,-16,-13,6,-5,39,-56,30,18,0,3,-13,37,6,65,-54,9,-2,-21,-3,-24,-26,29,2,53,9,-33,-14,10,42,14,-35,-11,-37,-17,4,-55,-22,13,8,-15,-4,20,38,-71,-32,11,35,32,63,-1,-2,30,-25,-4,34,68,7,9,-68,-68,-33,-17,16,0,33,-43,31,-45,44,-57,8,-16,1,-25,21,-26,-60,-48,-15,17,-66,-42,-76,-26,32,-2,6,-21,-44,-12,-49,21,-30,88,-23,-9,2,-56,63,13,-11,28,-26,1,2,-26,-40,20,19,-11,-24,-28,22,15,-25,0,-45,-1,-48,-69,15,19,10,25,-32,15,-4,9,-20,25,19,-7,-46,30,-19,-9,-16,68,15,11,30,-15,81,-8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.111","t":"Exhibit 4.2. Excerpt from Kate’s Activity Schedule Form Tues Wed Thurs 7–8 am Get up and have Get up and have breakfast breakfast 8–9 am Shower Shower 9–10 am Request Contact references transcripts 10–11 am Therapy Go for a walk Go for a walk appointment 11am–noon Grocery shopping Sort through mail Pay bills noon–1 pm Lunch Have lunch with Lunch friend 1–2 pm Pay bills Window shopping Read 2–3 pm Work on finances Get car washed Read 3–4 pm Go for a walk Come back home & Write a letter to read Grandma 4–5 pm Submit online Read Look for more jobs application online 5–6 pm Call Mom Call Mom Call kids 6–7 pm Cook and eat Cook and eat Meet Mom for dinner dinner dinner 7–8 pm Call kids Call kids Dinner with Mom 8–9 pm Watch favorite Watch movie Watch TV show on TV","e":[-51,3,-157,12,-28,15,5,-44,32,-27,-65,-4,93,91,-59,-40,-5,-10,-64,82,23,-28,-42,-3,19,63,-14,48,-50,19,16,-32,10,-71,-50,-46,60,-1,-27,-38,82,-7,4,3,31,-95,85,27,-2,-29,-29,-36,-29,5,56,26,29,-15,47,-5,163,37,-54,63,48,17,-36,92,-51,0,29,-5,46,-33,-6,8,-2,-21,15,58,17,26,53,-26,35,-5,-9,45,52,42,1,20,23,29,-46,49,-10,38,-38,-25,-58,-34,23,-22,24,33,13,19,-7,-11,-13,-5,-25,8,1,-7,47,-69,46,-5,22,-28,-13,22,-4,25,-61,32,-3,-15,29,-2,-44,31,-14,42,-5,-20,8,-22,19,15,-3,-35,-5,13,21,-61,18,31,20,-9,-20,27,44,-92,-44,9,44,59,51,6,-26,48,-40,-15,-15,88,24,5,-37,-52,-31,-30,-2,-20,26,-39,21,-33,54,-41,26,14,-53,-35,18,-13,-43,-40,-18,33,-17,-31,-18,-33,29,-3,-25,-13,-23,-3,-61,37,19,106,10,7,25,-46,70,-11,-16,10,-3,8,5,-29,-67,50,3,-16,-15,-26,42,22,-7,23,-15,-6,-40,-39,-11,-24,28,38,-11,24,-20,15,-21,45,71,-14,-38,35,13,15,-9,65,18,39,30,10,59,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.111","t":"Pleasant Events Schedule In some instances, depressed patients have difficulty identifying pleasurable and/or meaningful activities, even when they are prompted to identify the activities they had enjoyed doing in the past. As stated previously, depressed patients sometimes have difficulty remembering details from their past (Williams et al., 2006), and this can interfere with the ability to remember the activities they pursued during happier times • Pleasant Events Schedule (PES) in their lives. In these cases, it can be helpful to provide a menu of choices for patients to consider, such as MacPhillamy and Lewinsohn’s (1982) Pleasant Events Schedule (PES). The PES has been slightly revised for Veterans. To complete the PES, patients are instructed to rate how often each event happened in the past month. Thus, each item is rated on the Frequency Scale (Column F):","e":[13,32,-201,-66,30,-6,35,-32,53,-55,-1,13,45,2,-25,-24,-19,-54,-58,60,-2,-30,-77,-10,40,98,-5,-13,-53,28,12,3,17,-30,-4,-17,28,53,31,-8,40,-1,22,-75,43,-41,49,19,13,-23,33,-35,-8,-2,94,42,53,23,50,-11,104,20,-15,54,37,-10,-42,34,-15,-16,15,13,-6,26,-18,46,-47,-29,-3,-5,38,-5,74,-61,76,2,8,-8,-29,79,-29,-4,50,63,-98,54,-8,11,-37,-13,-36,-16,18,-32,40,17,-33,11,19,-38,-21,64,-16,-32,24,2,70,-39,-3,59,-35,-8,19,78,9,58,-1,-24,56,-34,-10,-26,-29,17,21,42,24,-25,22,9,65,13,-44,-51,-22,-22,4,-43,-30,22,20,9,39,-12,-7,-77,-52,8,28,41,77,24,-1,40,4,-27,-13,54,3,13,-28,-95,7,-21,62,-5,37,-12,46,-43,-5,-59,32,23,-20,-35,31,9,-19,-38,-6,16,-76,-37,-73,-55,27,-12,-1,-14,7,12,-16,8,-30,72,-1,-6,-16,15,64,-28,-2,3,-40,15,-18,-8,-9,17,22,-18,-5,-22,42,17,-9,26,-67,16,-47,-72,37,14,16,28,-16,19,31,20,3,-15,28,28,-85,27,-19,-28,1,24,-6,-16,-2,13,56,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.111","t":"0: Event has not happened in the past 30 days 1: Event happened a few times (1 to 6) in the past 30 days 2: Event happened often (7 times or more) in the past 30 days Next, the patient rates how pleasant, enjoyable, or rewarding each event was during the past month. To do this, each item is rated on the Pleasantness Scale (Column P): 0: This was not pleasant—use this rating for those events that were either neutral or unpleasant. 1: This was somewhat pleasant—use this rating for events that were mildly or moderately pleasant. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 93","e":[41,-15,-202,-91,58,35,51,-53,30,-60,-21,47,49,6,2,-58,11,-53,-41,62,2,-18,-45,-38,22,91,-25,12,-65,26,4,10,6,-45,-31,-18,34,45,37,-50,65,20,27,-63,44,-15,77,59,-2,-31,-6,-35,20,-18,101,18,13,9,23,22,82,-1,15,48,57,-30,-49,57,-22,-14,28,-4,-6,46,-71,22,-60,-21,-37,3,34,0,84,-39,90,-20,-11,10,-29,72,-14,-3,35,36,-75,8,-43,-1,-42,-12,-26,-10,6,-9,31,53,-48,0,-6,-39,-70,66,4,-19,6,7,46,-42,-5,58,-16,14,0,57,9,38,-10,19,27,-50,6,-25,2,14,15,47,26,-12,18,25,86,-8,-30,-7,-27,-18,27,-28,-14,19,16,4,34,10,-1,-65,-29,15,23,12,65,16,-10,44,9,-48,-22,38,6,36,-33,-87,23,-40,46,12,20,-4,9,-42,-13,-43,44,12,-16,-61,31,-17,-22,-23,10,14,-88,-21,-83,-55,44,24,11,-68,16,26,-18,46,-61,74,-10,14,-5,-5,60,-36,-28,11,-52,-4,13,-4,-6,1,11,-11,-19,-12,48,35,-11,14,-43,0,-32,-80,11,-9,2,36,-8,1,41,21,27,6,20,36,-83,6,-21,-23,52,47,-10,-4,20,25,44,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.112","t":"2: This was very pleasant—use this rating for events that were strongly or extremely pleasant. There are three PES scores: Mean Frequency Score, Mean Pleasantness Score, and Mean Cross-Product Score. To compute the Mean Frequency Score, add the frequency ratings in Column F and divide by the total number of items (i.e., 320). To compute the Mean Pleasantness Score, add the pleasantness ratings in Column P and divide by the total number of items (i.e., 320). To compute the Cross-Product Score, multiple the score in Column F by the score in Column P and enter the score in Column F x P. Then add the F x P scores of all items, and divide this total by the number of items.","e":[21,52,-216,-41,57,-15,66,-5,8,6,-2,6,46,-5,-24,-15,7,-71,1,50,-32,-45,-41,-47,61,58,-67,-6,-69,-3,-10,4,-2,-32,-27,-4,15,60,4,-9,26,-9,58,-22,57,-26,48,-2,48,1,-27,-11,29,27,81,12,10,-24,102,22,45,25,-35,35,51,-4,-37,67,-30,-2,16,4,48,-1,-59,-20,-60,-55,5,41,37,8,110,-19,50,-41,-27,-28,-52,36,-19,12,61,41,-70,39,-37,21,-32,-43,-6,26,4,-44,8,31,22,19,3,-30,-52,41,-8,-26,8,-4,54,-29,8,63,3,-12,13,61,8,36,-26,8,43,-66,12,-39,-23,-31,0,72,-4,14,-7,-2,63,0,-6,-42,-36,-56,10,-48,0,7,41,10,23,-2,-5,-76,-13,4,23,29,89,-7,-1,59,3,-29,-33,37,3,34,-31,-87,26,-16,0,-27,32,-44,55,3,24,-33,58,41,-14,-46,10,10,-44,24,21,20,-81,-42,-50,-19,20,-2,28,-42,-5,0,1,15,-46,78,-11,39,-15,51,32,-45,-19,29,-36,-1,-25,-43,-20,38,-11,-10,11,4,34,45,-20,22,-26,18,-31,-87,25,-6,-9,24,-2,31,29,26,30,-3,35,2,-76,28,6,-17,33,41,12,24,15,14,21,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.112","t":"There are three distinct patterns that may be observed when using the PES: Pattern 1: Low frequency/low pleasantness: The patient is not engaging in many of the activities on the list and is not enjoying the activities in which she is engaging. Pattern 2: Low frequency/average or above-average pleasantness: The patient is not engaging in the kinds of activities that have the potential to be enjoyable for her. Pattern 3: Average or above-average frequency/low pleasantness: The patient is engaging in activities but is not deriving much enjoyment from them.","e":[13,62,-205,-68,39,32,81,-33,37,-38,1,21,37,18,-44,-20,-9,-69,-7,25,-33,-7,-48,-41,65,72,-14,-23,-48,-27,12,-26,23,-55,-17,-26,38,57,4,47,40,-31,32,-42,-5,-32,30,39,3,-18,31,-40,-8,16,102,17,32,20,35,-30,44,26,-60,81,37,-26,-57,24,2,-23,3,-12,-16,4,-33,6,-26,-42,23,34,-3,46,81,-12,89,-3,-11,-31,-20,63,-31,10,72,11,-108,39,5,-3,-46,-45,-31,9,19,-36,-8,41,4,6,4,-30,-19,58,-2,-31,1,-32,42,-37,21,38,14,-23,18,75,-11,51,-9,-6,37,-45,15,-13,-27,-30,-5,62,16,0,22,8,50,-2,6,-79,-21,-21,22,-33,0,2,19,17,20,6,-12,-64,-19,28,14,10,81,-21,-35,77,-18,-48,-15,57,23,23,-11,-85,2,-10,32,7,41,-86,34,-22,7,-23,26,2,-12,20,28,-26,-69,-30,17,2,-66,-70,-51,-12,12,2,8,-18,32,-14,-4,-5,-45,49,-27,42,-13,38,28,-22,4,9,-21,-12,-6,-3,-36,22,26,-46,-22,-14,43,3,-30,-16,-83,2,-47,-99,68,0,-6,2,11,-1,29,-9,-19,37,22,-1,-43,0,-35,-37,1,36,15,28,-9,-5,67,3]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.112","t":"Recognition of these patterns helps to determine whether a behavioral intervention would help the patient increase the number of pleasurable activities in which he engages or would help the patient change the types of activities in which he engages in order to increase the amount of pleasure derived from them. MacPhillamy and Lewinsohn (1982) provide additional information on the administration, scoring, and interpretation of the Pleasant Events Schedule. Consider the following dialogue that Kate’s therapist had with her when she had difficulty identifying pleasurable activities:","e":[7,69,-189,-50,40,-3,60,-12,57,-32,-33,20,84,51,-16,-44,-16,-73,-59,15,-17,-7,-37,-6,14,48,23,-18,-40,-8,24,2,24,-19,-21,-36,58,49,-14,-1,18,26,31,-81,36,-45,66,-9,24,-5,50,-39,8,2,131,43,36,-1,32,-38,113,20,-27,36,23,11,-68,38,-41,-21,22,-14,-1,24,-45,7,-10,-2,-18,2,39,-19,72,-37,66,6,29,1,-14,61,19,12,38,29,-116,24,-2,2,-26,-32,-58,4,33,-26,30,30,2,41,-1,-8,-22,40,-11,-32,-8,-28,57,-44,13,82,-26,-19,-19,55,9,34,-33,-2,12,-46,-3,-23,3,-5,18,30,41,-34,31,15,48,27,-52,0,-47,-20,7,-19,-14,25,6,34,13,5,-7,-76,-52,12,34,44,92,-32,-14,31,-18,-10,30,13,20,11,-24,-65,-8,-26,56,10,32,-32,56,-48,-3,-60,31,2,-10,-32,23,-22,-56,-38,15,13,-57,-33,-64,-34,39,-2,-5,-47,-18,12,-46,14,-45,78,-5,3,-38,-19,67,-31,4,12,-55,6,-3,-18,-25,3,35,-7,-38,-25,21,18,-25,-6,-49,17,-35,-57,12,1,43,23,18,35,7,-1,-10,-6,31,16,-53,26,-21,-39,-11,57,8,14,3,-2,69,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.112","t":"Therapist: Do you think you could try to identify activities that you find enjoyable or meaningful for homework over the next week? Kate: I guess so, but I’m not sure if I’ll be able to come up with anything. Therapist: Well, I have a checklist of activities that may help you. Would you be willing to learn more about it? Kate: OK. Therapist: [gives Kate a Pleasant Events Schedule] This form includes a long list of activities that some people find enjoyable. Not everybody finds all of these enjoyable, but usually people can find several that resonate with them. This list includes activities both small and large. Next to each activity, it asks to indicate how frequently you engage in the activity: 2 if it happens often (about 7 times or more in the past 30 days); 1 if it has happened a few times in the past 30 days; and 0 if the activity has not happened at all in the past 30 days. You can record your frequency rating under the column labeled “F”. Kate: OK.","e":[24,29,-171,-52,20,-10,45,-45,39,-53,-38,-2,82,55,-49,-20,1,-83,-57,46,1,-23,-24,4,4,72,-8,-17,-56,12,7,-26,-22,-46,-36,-48,44,36,-28,-29,46,31,-6,-70,71,-80,82,-9,3,-18,-8,-56,7,32,104,73,24,-10,33,-13,106,22,-54,75,23,-2,-54,65,-49,-21,19,-17,55,29,-46,50,-27,-22,27,43,18,13,96,-38,66,9,5,46,3,83,-6,11,36,19,-56,15,-6,9,-70,-28,-61,6,5,-13,44,19,-32,-11,-5,0,-24,36,-13,1,0,13,43,-74,35,53,-19,-32,7,42,5,44,-52,20,-8,-18,-4,-44,-15,30,3,59,14,-27,-1,-13,72,2,-28,-23,-8,9,-10,-55,0,31,7,16,7,-2,42,-58,-31,-11,56,39,83,-4,-10,63,-11,-1,6,47,-5,24,-45,-75,19,-27,17,-17,22,-18,44,-11,39,-40,38,0,-18,-36,17,-12,-44,-18,8,0,-49,-32,-60,-47,26,-25,-2,-36,-27,21,-48,24,-42,77,7,5,-40,-21,103,-13,-27,55,-41,-14,-22,-4,-46,18,27,-19,-4,-39,24,45,-46,1,-34,27,-47,-82,10,-9,39,24,-17,6,27,51,-5,26,34,-8,-73,3,-14,-14,15,60,11,-8,20,15,36,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.113","t":"Therapist: It also asks you to rate how pleasant or enjoyable you found the activity or would find the activity: 2 if very pleasant; 1 if somewhat pleasant; and 0 if not at all pleasant. You can record your pleasure rating under the column labeled “P.” If an event has not happened to you during the past month, then rate it according to how much fun you think it would have been. Does this sound like something you would be willing to do as homework over the next week? Kate: Yeah. Therapist: Would you like to record it in your homework sheet? Kate: OK. [writes it down] Therapist: How about we do the first few together? Kate: Alright. Therapist: The first item is “Being in the country.” How frequently have you been in the country in the past 30 days, using the ratings we went over at the top? Kate: I haven’t been in the country for some time, so not at all. Therapist: What would we write down in the Frequency column? Kate: 0? Therapist: Yes. Now, how pleasant or enjoyable do you think you would you find that activity? Kate: I used to love the country; that’s where I grew up. I would say 2, very pleasant. Therapist: Good. So, let’s go ahead and write that down in the Pleasure column. [Kate writes down 2] The next activity is “Wearing expensive or formal clothes.” What would be your frequency rating for that? Kate: I haven’t dressed up in the last month, so I would say 0. Therapist: OK. How pleasant would this be for you? Kate: I hadn’t really thought about this. But in doing so, I would say somewhat pleasant. When I get dressed up, it’s kinda nice, though I rarely do it. Right now, I just lay around the house in sweats and a sweatshirt. Therapist: OK. How about one more? “Making contributions to religious, charitable, or other groups”? Kate: I didn’t do this at all. Therapist: If you were to do it, how pleasant would it be? Kate: In theory, a 2, but right now I can’t imagine doing it. It would be way too overwhelming for me. I just really need to take care of myself right now. Therapist: So does that mean that you’d rate it a 0 right now? Kate: Yes, I probably would. It would just stress me out. Therapist: Good, you seem to get the gist of this. Do you have any questions? Kate: No, I don’t think so. I think I can do it over the week.","e":[21,36,-190,-65,-1,20,49,-31,58,-39,-44,-7,40,34,-34,-10,19,-68,-21,41,-42,-52,-13,-3,23,52,-25,-18,-82,10,-3,-28,-34,-16,-46,-14,35,50,-24,-46,61,16,25,-64,55,-66,98,-23,12,5,-5,-68,8,39,123,-9,24,-17,36,-10,74,-7,-29,80,43,3,-53,67,-42,-22,16,-4,20,10,-78,45,-37,-40,47,25,31,-9,74,-36,55,-30,21,16,-31,69,-14,-10,52,13,-30,5,-11,-14,-29,-15,-37,-2,-7,23,24,33,0,-22,-8,-26,-11,65,-3,-19,-5,19,34,-79,27,75,-21,3,-8,27,12,41,-50,33,-8,-6,-8,-43,-12,23,-3,81,41,-44,2,3,75,-8,-41,-6,-21,-19,-6,-31,1,25,10,-2,35,4,11,-57,-5,-2,47,42,58,-2,10,48,42,8,-2,35,-1,10,-11,-86,27,-50,10,-43,22,-4,10,-38,47,-24,33,-14,-22,-35,22,-2,1,-35,41,1,-84,-41,-79,-50,31,-26,-7,-32,-18,15,-28,6,-41,85,-5,9,-29,-15,96,-38,-20,55,-20,-17,2,-5,-38,11,23,-17,26,-1,33,34,-62,12,-55,18,-36,-77,15,15,17,52,-26,13,10,29,6,-2,24,11,-72,11,-23,-6,17,34,23,20,31,2,40,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.113","t":"Alternative Activity Scheduling Strategies At times, patients find it aversive to schedule every hour of their day with pleasurable activities or activities that will give them a sense of accomplishment. For these patients, there are viable alternatives that achieve the same aim. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 95","e":[-11,28,-187,-53,23,-7,38,-78,59,-11,-16,13,69,27,-15,-20,-25,-44,-63,6,6,-27,-32,-12,15,37,-5,7,-34,30,6,-3,30,-37,-9,-26,36,48,-4,0,27,-23,31,-46,30,-53,85,50,3,-52,26,-63,-13,-50,124,-7,-22,34,5,-15,152,37,-35,59,50,-36,-42,49,-30,-8,35,-27,41,29,-54,35,-46,-22,-8,21,37,-22,65,-38,80,-21,28,15,-13,70,-8,-11,27,36,-114,25,-8,18,-27,-33,-45,-17,4,-18,-4,10,3,-17,-16,21,-29,48,-25,-40,24,25,54,-57,1,42,-3,-15,-11,7,-7,76,-38,-3,27,-16,2,-1,-9,13,-16,-1,-16,-49,10,15,20,-15,-22,23,-36,21,-30,-43,-55,18,-9,24,35,28,32,-70,-38,31,24,41,49,-9,-66,31,-14,-28,-3,82,15,14,-52,-69,-26,-30,98,0,17,3,14,-50,9,-25,28,44,-22,-27,22,-27,-42,-30,17,43,-17,-33,-97,-39,57,6,4,-31,6,34,-27,4,-13,75,-7,0,7,-49,90,7,7,22,-42,8,0,-5,-36,33,47,-39,-1,-14,28,23,-38,-3,-8,34,6,-84,15,-12,21,23,7,73,25,27,33,20,48,13,-76,17,-9,-26,-8,25,7,21,-17,-17,54,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.114","t":"CASE EXAMPLE: CLAIRE Claire was hesitant to schedule pleasurable activities into concrete time slots, indicating that she wanted to reward herself with these activities after she accomplished a set amount of studying and practice exercises. She was unable to estimate the precise number of hours she would devote to studying each day, claiming that it varied as a function of the particular module on which she was focusing that day. Thus, her therapist suggested an alternative approach to Activity Scheduling, such that they would create a list of activities that Claire finds pleasurable. To do this, Claire and her therapist reviewed each item of the Pleasant Events Schedule, and Claire rated whether she thought the event would be not at all pleasurable, somewhat pleasurable, or definitely pleasurable. Then, Claire and the therapist discussed which of the pleasurable items could be worked into the activity schedule. To do this, Claire made a list of the pleasurable events and made a check mark whenever she participated in one of these activities in the days between her therapy sessions.","e":[53,38,-166,-55,19,-12,49,-51,36,9,-51,-22,106,62,-38,-42,-10,-61,-62,-21,-48,-22,-72,3,20,31,7,6,-78,20,-2,-8,-4,-53,-30,-26,7,66,-26,-11,38,34,26,-50,34,-65,92,-11,3,-30,28,-31,-12,-7,143,55,21,40,58,-32,127,32,-14,61,27,-15,-14,35,-19,-18,26,-9,26,33,-33,39,-26,-2,-14,-6,26,-37,68,-27,61,22,38,11,-18,71,2,24,41,28,-89,16,22,15,-60,-1,-46,-28,18,-10,6,1,-21,5,-18,2,-10,33,-45,2,32,10,66,-70,14,52,-39,-4,-24,41,19,52,-67,-5,2,-13,-25,-8,-20,22,-10,48,41,-38,13,12,25,-19,-51,-21,-43,-4,-20,-30,-38,15,-8,26,31,26,30,-41,-49,16,11,44,69,-20,-24,37,-37,5,14,65,18,15,-59,-67,-22,-31,71,-1,59,-4,11,-42,14,-39,21,6,5,-48,43,13,-51,-70,-14,20,-57,-33,-89,-37,39,-4,15,-27,-41,14,-35,35,-36,71,-2,-15,-16,-19,71,-2,-9,57,-39,-4,-32,-14,-20,43,22,-46,-3,-11,17,14,-19,20,-31,-9,-42,-72,13,-2,10,25,-38,42,-1,19,-4,12,17,-15,-40,4,8,7,-25,46,1,17,33,9,40,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.114","t":"There are many instances in which Activity Scheduling does not go as smoothly as it did with Kate and Claire. Some patients have negative beliefs about their ability to attain a sense of pleasure or accomplishment from daily activities; others have inaccurate predictions about the degree to which Activity Scheduling will improve their mood. These are instances in which therapists can use some of the cognitive strategies described in the next section (“Cognitive Strategies,” pp. 101–139) to enhance patients’ commitment and motivation to implement behavioral strategies. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 96","e":[8,12,-172,-29,37,17,49,-45,35,0,-21,4,78,24,-8,-23,-13,-17,-48,26,-17,-22,-52,-19,18,74,-34,2,-60,25,49,-1,-13,-50,-35,-23,58,35,-23,-18,43,9,41,-75,10,-44,114,23,-8,-37,19,-59,0,-43,126,18,-12,37,-10,-44,127,36,-35,68,37,-19,-50,66,-56,-12,24,-9,40,16,-53,35,-31,-20,-17,25,43,-28,48,-60,77,25,43,23,-4,84,2,7,29,55,-90,30,-26,-9,-25,-17,-72,-13,-20,-17,-6,39,-12,-10,-13,29,-46,42,-23,-20,9,25,47,-39,-2,23,31,-15,-5,22,4,74,-60,-6,29,-22,-30,-7,-25,17,-13,18,-7,-22,-2,21,34,-8,-12,10,-38,-6,-13,-24,-50,-9,-9,5,26,8,43,-56,-25,44,28,27,70,15,-36,33,-4,-21,26,58,21,34,-49,-55,-25,-28,85,14,40,-3,21,-45,13,-25,21,14,-13,-21,17,-17,-62,-61,15,35,-43,-28,-96,-65,50,-7,15,-28,-19,27,-25,15,-30,60,-3,-17,-14,-52,61,8,-2,28,-27,-11,-2,-16,-43,4,18,-15,-11,4,17,12,-30,10,-6,7,-23,-73,15,5,25,34,-9,40,13,49,-8,31,35,29,-75,22,-13,-24,-18,38,9,13,-4,-20,52,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.115","t":"Consider this dialogue between Michael and his therapist, in which he expressed the belief that he could no longer pursue activities that used to give him a sense of pleasure and accomplishment because of his brain injury. This conversation occurred in Michael’s third CBT session after he half-heartedly completed an Activity Monitoring Form.","e":[61,52,-153,-30,59,62,48,12,71,-26,-53,12,26,29,-7,-18,-39,-70,-69,41,-68,-16,-42,5,34,32,-10,47,-41,50,99,-17,-5,5,-64,-39,43,78,4,-27,35,-27,-20,-93,45,-31,73,15,3,-28,53,-50,37,-45,130,21,10,-4,27,-59,89,20,-9,56,54,-42,-68,47,-43,-16,60,-26,31,56,-48,38,-26,-6,-14,27,21,7,35,-23,58,7,21,-2,-11,76,-10,0,11,13,-80,-4,-20,5,-12,-3,-73,-29,2,-13,61,53,-5,-41,-9,26,-48,34,-19,-18,-1,23,54,-64,-7,46,-13,-14,-37,50,5,96,-23,19,13,-3,-20,-37,16,9,13,41,18,-23,-15,-8,59,-26,-18,11,3,-33,24,-25,-27,11,3,43,18,19,45,-74,-39,15,44,18,40,1,1,23,-3,-35,21,37,17,-25,-41,-80,3,-26,72,22,-6,-13,-8,-51,8,2,9,30,17,-3,13,8,-50,-32,-4,36,-63,-50,-61,-56,59,3,20,-11,-22,13,-57,9,-54,45,-30,-6,-11,-40,54,-16,-39,3,-67,-5,16,-28,-20,28,-6,-16,-26,-26,23,11,-41,-29,-26,2,-4,-73,67,40,14,55,-4,11,14,59,-3,53,10,-22,-46,12,-2,-19,15,32,5,40,18,13,44,11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.115","t":"Therapist: [examining Activity Monitoring Form with Michael] What does the information on this form tell you, Michael? Michael: I don’t know. Therapist: [trying a different approach] In general, does it look like you are doing things that help you to feel better, or instead, does it look like you are doing things that contribute to your depression? Michael: [exasperated] There’s nothing else I can do. Therapist: What do you mean by that? Michael: Everything is lost. Everything I used to do to make me who I am is gone. And it’s never coming back. Therapist: [gently] So, you’re saying that all of the activities that used to give you a sense of pleasure or accomplishment are no longer available to you? Michael: Pretty much. Look at me. I’m not finishing school. I can’t work in the law firm. Everything that I spent my whole life working toward…it’s gone. Therapist: I understand that going to school, working in the law firm, and doing other things that gave you a sense of accomplishment are not options available to you at the moment. In fact, my hope is that down the line, we’ll be able to examine how you define accomplishment and see if there are other ways for you to attain a sense of accomplishment and mastery. But for now, it might be useful for us to figure out some activities that might give you a sense of pleasure, with the hope that it will improve your mood a bit so that we can work on these larger issues. Does that make sense to you? Michael: [dejected] I guess so. Therapist: What sorts of things did you do for fun in the past…that you did for the sheer enjoyment of them, regardless of whether they helped you with your schoolwork or get into law school? Michael: Nothing, really. School and work were my life. Therapist: [recognizing an all-or-nothing thinking pattern] So, is what you’re saying that other than eating and sleeping, that you spent all of your time with schoolwork or working at the law firm? Michael: [irritable] Well, of course not. I had a girlfriend, you know. Therapist: [brightens] Yes, your girlfriend! And I recall you telling me that your relationship is very strong, despite the fact that there’s been some tension lately. What kinds of things did you and your girlfriend enjoy doing? Michael: We went out to eat a lot, I guess. And we’re both pretty athletic, so we’d do things like playing tennis, going for runs, even shooting baskets. Therapist: Is there anything that would get in the way of you going out to eat, exercising, or shooting baskets with your girlfriend? Michael: No, I guess not.","e":[42,20,-148,-27,14,37,64,-22,58,-49,-63,5,82,36,-34,-21,-13,-77,-80,25,-9,-64,-16,19,23,27,-15,-17,-78,57,61,-33,-21,13,-67,-3,49,121,3,-29,50,7,-28,-93,30,-70,55,-9,11,-18,36,-45,4,31,101,0,11,-1,42,-75,105,27,-31,84,44,-45,-35,6,-50,-35,70,-2,38,44,-37,49,-23,-13,42,-17,24,-8,33,-25,22,3,19,10,0,93,23,46,19,19,-76,-6,13,17,-24,-33,-69,7,1,-7,84,49,8,-63,-11,27,-16,46,-35,-17,-29,1,48,-62,-1,40,-12,13,-8,10,38,45,-16,20,-30,15,-11,-35,-21,46,-5,57,23,-59,-20,-3,64,-25,-50,-15,-22,-9,13,-21,-58,10,16,16,10,31,47,-56,-36,-16,64,36,25,-8,10,21,17,-18,19,55,-1,7,-28,-71,-21,-39,36,9,14,-19,-3,-34,72,-14,44,-22,1,-11,30,-25,-30,-16,21,7,-46,-25,-47,-11,35,-44,4,-17,-35,10,-42,-7,-32,40,1,16,-39,-36,79,-49,4,27,-36,-13,-12,-9,-38,0,5,-12,12,-6,21,37,-49,5,-49,11,-24,-65,42,11,13,37,-23,27,9,109,-11,41,-9,-23,-28,12,4,33,29,23,44,37,31,5,60,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.116","t":"Therapist: If you were to choose a couple of these to do in the next week, which ones would you select? Michael: Going out to eat, I guess. Therapist: Great. Where would you like to go? Michael: My girlfriend’s been wanting to go to a Mexican restaurant that we used to go to all the time before I left. Therapist: That sounds reasonable. When might you go? Michael: I guess I can suggest to her that we go tonight or tomorrow. Therapist: OK. And what about another activity to do between now and the next time I see you? Michael: I don’t know if I’m up for exercising. My coordination’s still a little off. Therapist: Fair enough. Is there something the two of you used to do together that isn’t quite as athletic? Michael: We can probably go for a walk in a park that’s not too far away. She just likes to get out of the house and stay active. Therapist: And when would you do that? Michael: She’s usually over during the day when she doesn’t have to work. I think her next day off is Friday. Therapist: So, eating at the Mexican restaurant tonight or tomorrow night, and going for a walk during the day on Friday? Michael: Yeah. OK. Therapist: Earlier, you expressed the belief that there are no activities that you can do that will give you a sense of pleasure. After this conversation, do you still believe this? Michael: Kind of. But I guess that there are some little things that I can do. Therapist: In my experience, Michael, life is rarely all or nothing, 100% or 0%. I realize that you and I have some work to do to help you redefine your sense of identity and direction in life. But all is not 100% lost. We just need to continue working to find those parts of you that are not lost and make sure they’re working for you, not against you. Michael: Yeah, I see what you mean.","e":[8,47,-172,36,-7,38,12,-26,40,-33,-29,25,30,16,-32,9,1,-76,-45,80,-25,-4,-28,4,-8,22,-5,66,-76,45,28,-43,-5,-5,-31,-23,13,96,17,-88,33,26,-8,-98,59,-117,78,16,-24,-37,5,-42,-6,13,60,7,63,5,32,-59,140,-2,-55,83,34,-19,-73,39,-57,-49,87,8,37,30,-42,25,-5,-17,48,3,-7,7,58,-36,8,30,35,28,14,73,23,24,25,24,-55,-12,-14,14,-22,-56,-41,21,-1,7,42,41,23,-26,-13,35,-11,35,-32,-25,-10,13,45,-104,74,48,-14,21,-28,23,36,34,-59,30,-37,-11,-10,-12,-5,51,-34,67,62,-41,-28,18,81,-10,-16,-37,4,0,7,-35,-13,37,21,32,12,53,60,-62,-27,-15,66,-20,17,-16,14,17,14,-43,16,60,-5,10,-10,-71,-8,-10,31,-3,-4,-15,-12,-37,54,6,27,6,6,-30,8,-21,-37,-33,3,24,-42,-22,-64,-5,55,-60,-6,-14,-28,6,-36,34,-47,61,-11,16,-46,-19,71,-54,6,17,-45,-39,-11,1,-34,34,15,-23,1,-25,4,49,-53,-8,-34,6,-17,-67,41,0,36,11,-11,53,23,57,1,30,10,7,-48,5,29,-2,23,38,29,16,19,10,42,12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.116","t":"In this excerpt, Michael’s therapist accomplished two important clinical goals. First, she helped Michael schedule two activities that were once pleasurable to him. Although this was not as elaborate as Kate’s daily Activity Schedule Form or Claire’s list of activities from which she could choose on a daily basis, it achieved the same aim—to help Michael to attain a sense of pleasure from his life. It is important to keep in mind the spirit of the exercises that are described in this manual and to modify them accordingly so they are tolerable to patients but can still achieve cognitive and behavioral change. Second, after working with Michael to schedule two pleasurable activities, his therapist revisited the belief that Michael had articulated earlier—there were no longer any activities that would bring him a sense of pleasure or accomplishment. The therapist took care to reassess Michael’s belief in that idea after the Activity Scheduling exercise, with the hope that it would model an approach for evaluating rigid thoughts and beliefs that prevent him from doing things that would help him overcome his depression.","e":[13,28,-156,-16,-9,8,47,-19,38,-25,-59,-20,106,46,-25,13,-6,-40,-51,30,-38,-41,-41,-4,23,48,8,-5,-85,29,68,-6,-8,-41,-48,-31,42,81,-34,-52,19,13,-9,-75,40,-71,40,-23,-23,-46,44,-38,23,-27,123,44,33,6,45,-57,126,29,-31,61,30,-27,-30,31,-60,6,41,-27,37,27,-25,38,11,-27,-2,-1,25,-7,56,-41,47,15,38,35,-3,62,2,32,17,55,-86,16,-9,25,-32,14,-77,-7,21,0,39,54,18,6,6,22,-26,29,-33,-16,18,29,65,-67,25,51,4,-15,-12,44,18,37,-48,14,-4,-1,-20,-32,-29,39,-5,34,36,-27,-11,-16,42,13,-54,-9,-41,0,13,-23,-32,17,-4,3,32,27,30,-61,-46,7,43,28,46,-7,11,21,2,-25,35,39,21,22,-39,-74,-19,-26,63,10,29,1,9,-42,28,-31,29,7,-17,-9,34,-24,-85,-55,10,32,-40,-15,-64,-25,42,-14,9,-12,-43,19,-55,13,-51,95,16,-7,-7,-42,56,-29,-18,14,-40,8,-20,-19,-33,13,5,2,-22,-6,-1,35,-35,-3,-15,-5,-18,-58,15,26,21,39,-16,32,17,65,-14,18,40,-11,-79,31,8,-8,-9,54,19,9,7,11,46,-10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.117","t":"As we have stated previously in this manual, it is important to assess patients’ commitment and motivation to follow through with Activity It is important to assess Scheduling, identify obstacles that might interfere with engagement in patients’ commitment and the activities, and problem-solve ways to overcome those obstacles. A motivation to follow through common obstacle that many depressed patients identify is that they with Activity Scheduling, “might not feel like doing anything” on the day an activity is scheduled identify obstacles that might due to fatigue and lack of motivation. One strategy for overcoming this interfere with engagement in obstacle is for patients to write a list of benefits of engaging in the activities, and problem- scheduled activities. Then, they keep the card nearby and consult it in solve ways to overcome those times that they consider not engaging in the activities they had obstacles. scheduled.","e":[14,59,-170,-47,29,11,73,-16,40,-34,-34,12,52,19,13,18,17,-63,-76,48,-4,-3,-29,-19,0,40,25,-53,-52,69,25,-11,47,-93,-38,-31,48,52,29,-7,8,-18,8,-72,26,-51,82,12,33,-51,18,-55,-39,-22,86,40,30,35,8,-20,137,41,-18,49,34,-47,-13,44,-60,8,20,15,47,19,-56,50,3,18,11,5,37,-18,64,-37,77,21,9,5,-29,81,0,12,20,22,-109,33,-25,5,-20,-20,-52,-42,-16,-16,8,1,17,16,27,13,-5,60,-30,-33,40,33,78,-26,-9,19,-7,-15,26,56,9,41,-4,9,46,10,-3,-9,-46,20,-16,3,-29,-37,4,0,36,10,-4,1,-36,-2,-4,-36,-27,9,-5,16,24,7,54,-77,-34,-1,34,25,75,-5,-42,26,1,-27,28,41,11,29,-27,-40,14,-24,76,43,56,-3,28,-76,30,-39,48,-6,-31,-27,37,-46,-67,-26,13,40,-19,-40,-79,-36,47,7,32,-33,-24,8,-42,6,-32,69,-5,-13,-11,-24,54,1,-23,19,-29,-25,3,-9,-30,20,27,-64,3,-23,23,16,-52,9,-32,4,-20,-88,26,21,54,21,-21,39,30,7,-11,6,39,13,-35,26,6,-20,-22,24,4,-18,13,-2,48,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.117","t":"Behavioral Activation Behavioral activation is an approach to treating depression that is based on Lewinsohn’s behavioral model of depression (Lewinsohn et al., 1980). However, even the experts have differing opinions about exactly what it involves. Some therapists, such as Wright et al. (2006), regard behavioral activation as a single procedure in which the therapist encourages patients to identify and implement one or • Behavioral two specific actions that can make a difference in how they feel. Other therapists activation regard behavioral activation as an entire treatment in and of itself that incorporates the strategies described in this section, such as Activity Monitoring, Activity Scheduling, and graded task assignment (Addis & Martell, 2004). In this manual, we refer to behavioral activation as a single procedure.","e":[4,39,-158,-48,43,-41,91,-13,55,-20,-3,29,108,16,-28,-69,-18,-37,-55,-18,-16,2,-26,-23,37,44,2,17,-29,-16,2,6,-1,-12,-60,-14,30,50,-26,-16,2,10,22,-75,7,-30,83,14,25,2,37,-34,6,-59,108,25,7,36,-7,-59,85,101,-50,1,69,-23,-40,39,-36,-46,26,9,38,3,-23,35,-25,-29,24,8,51,-26,82,-64,83,4,-22,9,-30,47,7,53,-4,30,-109,-2,-31,-23,-30,-44,-61,-2,20,-24,-4,29,9,-12,-15,31,-39,61,25,-29,-13,6,62,-32,-3,30,2,-9,-22,-3,-3,36,-37,6,2,-25,-4,-13,-2,-4,-10,14,1,-22,-2,1,35,-6,-39,32,-16,12,11,-6,-14,17,5,17,27,-11,53,-73,-33,12,26,40,78,-9,8,35,-39,-57,2,25,35,4,-46,-54,-27,-16,79,21,60,-42,23,-41,13,-12,29,12,-7,-34,35,-14,-35,-64,13,22,-24,-38,-86,-28,53,-31,58,-25,-6,4,-11,-11,-36,45,17,20,-2,-22,24,-1,64,24,-7,-25,-14,-42,-30,-12,24,11,-7,18,38,4,-37,16,-17,32,-23,-70,11,-42,25,36,-19,18,3,42,9,41,8,31,-60,20,-12,3,-10,23,-22,18,-14,-22,71,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.117","t":"When behavioral activation is regarded as a single procedure, its goal is to produce change in the immediate future, which can build momentum It is often helpful to implement in treatment and instill hope. It is often helpful to implement behavioral behavioral activation early in activation early in treatment so patients can be socialized into the treatment so patients can be process of completing homework assignments and so they can achieve socialized into the process of some change as soon as possible. We recommend that this strategy be completing homework used both in the initial phase of treatment to facilitate tangible assignments and so they can behavioral changes and at later times when patients may be behaviorally achieve some change as soon as “stuck.” Additional specific tips for implementing a successful possible. behavioral activation intervention are offered by Wright et al. (2006, pp. 124–127).","e":[19,34,-149,-19,64,-43,84,35,66,1,-2,38,79,62,-22,-54,9,-45,-58,30,3,-25,-19,-22,22,35,-3,-4,-30,3,29,11,-5,-30,-40,-32,69,10,-14,-48,-4,6,44,-81,39,-25,101,-20,52,-20,28,-45,-21,-11,130,42,19,0,-1,-50,91,73,-54,29,52,14,-34,41,-39,-12,40,2,44,20,-21,12,-14,-27,8,23,54,-33,71,-61,101,20,10,5,-44,50,11,31,-16,14,-130,-21,3,-1,-3,-27,-73,-4,30,6,1,31,24,4,-15,25,-39,57,-5,-35,-14,18,70,-23,25,29,-9,-42,-13,20,11,36,-58,-14,25,-18,-44,-19,-28,-4,4,23,-7,-29,7,2,45,21,-18,55,-29,-13,13,-16,-3,15,-26,12,26,-3,65,-38,-14,12,27,26,86,-37,-46,29,-48,-41,7,14,18,12,-48,-36,9,9,64,17,65,-33,6,-28,8,-54,13,13,5,-6,32,22,-80,-47,19,19,-34,-18,-89,-34,45,-1,31,-36,-32,7,-53,18,-41,52,22,-13,-28,-29,52,-3,-16,1,-39,-3,-23,-34,-30,2,20,-15,-22,11,12,10,-39,-9,-23,34,-45,-40,28,-26,17,10,-2,15,-6,38,-20,22,34,30,-52,17,-8,-27,-34,31,4,4,-16,-3,40,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.117","t":"It is easy to confuse behavioral activation with Activity Scheduling, as the goal of both is to provide a forum for patients to commit to engaging in pleasurable and meaningful activities. Behavioral activation is often simpler and more easily implemented than the other behavioral strategies described in this section. Similar to Wright et al. (2006), we do not recommend suggesting activities or behaviors that are too challenging in order to increase the likelihood that the patient has success. For example, a patient who implements behavioral activation might commit to walking the dog once in between sessions. In contrast, a patient who uses Activity Scheduling might determine precise times of the day to walk the dog on several occasions throughout the time in between sessions. Activities done in the spirit of behavioral activation are usually simple, straightforward, able to be implemented whenever the patient is able to do so, and immediately reinforcing. Other examples include cooking a favorite meal, arranging an album of cherished photos, or going out to a movie. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 99","e":[6,38,-170,-24,46,-46,88,-25,76,-34,-17,30,85,30,-16,-72,-6,-51,-54,9,10,12,-12,-17,20,17,-7,8,-43,18,23,13,28,-29,-21,-46,25,57,-30,-35,5,7,30,-51,43,-62,111,13,0,-39,17,-49,-25,-47,151,9,15,26,-10,-34,124,55,-24,21,70,11,-38,56,-42,-23,29,-25,33,19,-16,26,-24,-14,4,27,34,-44,66,-36,111,8,13,11,-20,69,5,16,17,37,-130,13,1,-11,-1,-28,-70,-29,5,2,-2,17,13,-5,-29,29,-26,64,4,-11,-20,41,71,-30,-4,41,4,-6,-15,10,-22,35,-25,11,26,-24,-15,-9,-5,-2,-8,3,2,-47,0,-8,27,4,-31,22,-48,8,-5,-34,-12,34,-7,12,20,9,58,-64,-19,23,29,44,73,-30,-47,12,-24,-33,6,47,22,-12,-36,-52,-15,-3,74,4,50,-26,20,-49,-5,-26,-5,7,-15,-40,30,-9,-68,-39,-5,23,-31,-28,-107,-34,33,7,23,-28,2,2,-46,15,-31,54,-2,16,-19,-40,59,21,-12,7,-35,-13,-10,-30,-30,-15,46,-25,1,-16,15,8,-31,12,-30,38,-23,-48,31,-9,30,22,-16,26,7,12,10,12,44,25,-53,9,-23,-30,-17,28,-4,13,-7,-24,66,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.118","t":"CASE EXAMPLE: JACK Jack was unwilling to complete an Activity Monitoring Form, stating that he “hates to write things down.” Because she suspected that Jack would benefit from an increase in the frequency with which he engages in pleasurable activities, Jack’s therapist presented him with the behavioral theory of depression and asked whether he viewed himself as being caught in the vicious cycle of depression. Jack agreed that he was bored most of the time, spending most of the day watching television. On the one hand, Jack expressed a reluctance to schedule activities at certain times of the day, stating that he did not want to be controlled and that he wanted to come and go as he pleased. On the other hand, he indicated that he is tired of television and that it might do him some good to participate in a more engaging and meaningful activity. By the end of the discussion, Jack decided to work on a project that he had tabled a few months ago— building a computer from scratch. Playing “devil’s advocate,” Jack’s therapist wondered whether such an undertaking might be a bit much, given the severity of depression. Jack assured her that he truly enjoys working with electronics and that he cares more about having fun with the process than having to finish the task within a certain time period. In other words, he viewed this as a simple, straightforward activity that was already set up for him in his garage and that would provide a great deal of pleasure. Thus, Jack’s behavioral activation exercise was to work on his homemade computer at one time of his choice in between sessions and to notice its effect on his mood.","e":[51,54,-168,-56,1,29,39,-52,58,-39,-53,7,50,78,-41,-37,12,-49,-44,22,-46,-27,-71,-16,12,8,-23,-20,-38,41,22,-38,-41,-49,-64,-39,57,58,0,10,-3,-7,-28,-77,56,-30,49,43,23,-53,52,-61,21,-61,131,46,-7,40,21,-53,72,34,-32,42,60,-20,-8,49,-43,-5,43,-20,10,14,-20,58,-12,-15,21,31,40,-22,57,-47,77,-2,2,7,-21,54,18,24,33,44,-64,9,-31,16,-6,-20,-52,-50,1,4,12,43,-23,-10,-6,12,-23,27,-24,-22,30,13,64,-45,0,27,-49,22,-49,26,10,60,-28,28,8,-6,-7,-12,-21,23,17,48,1,-58,-7,5,88,-39,-29,12,-5,-9,-21,-33,-53,-2,4,4,41,22,40,-53,-40,-2,35,35,48,-12,0,51,-14,-26,2,70,13,46,-42,-80,-33,-19,46,6,74,-31,10,-38,39,-38,30,6,7,-26,39,-19,-38,-54,-17,28,-65,-32,-86,-49,47,3,3,-6,-15,-13,1,11,-77,55,-21,29,-10,-22,46,-1,-28,43,-3,-8,3,-2,-37,-4,20,-22,-9,-10,18,22,-5,-5,-75,22,-56,-94,58,18,4,23,-29,28,39,20,-34,39,13,1,-45,-2,-14,-19,2,41,24,23,15,-15,66,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.118","t":"Graded Task Assignment Graded task assignment is a technique for simplifying behavioral tasks into smaller parts, or what one of us (BK) often refers to in therapy as “baby steps.” It is often used in conjunction with the activity schedule, such that various tasks associated with • Graded task a larger goal can be scheduled throughout the week. Graded task assignment is assignment particularly helpful when patients are faced with complicated tasks, tasks that have multiple or sequential parts, or tasks that have looming deadlines and important implications for patients’ lives. For example, in Part II, you saw that Kate agreed to apply for a job as part of her homework assignment. Her therapist encouraged her to identify the necessary steps to apply for a job. Kate identified three components: (a) completing an online application, (b) requesting her transcripts from nursing school, and (c) notifying references that they may be contacted by the potential employer. In the previous section on Activity Scheduling, you saw that Kate included each of these components in her activity schedule (Exhibit 4.2, page 91).","e":[17,40,-185,-52,-1,-16,67,-16,9,-4,-40,-2,88,49,-55,-27,8,-63,-55,9,17,-15,-3,-15,46,43,5,-31,-41,-10,7,-13,-2,-33,-55,-37,65,0,-12,-38,18,4,5,-84,31,-43,79,6,32,-27,18,-28,1,-1,98,37,43,37,9,4,90,71,-62,63,38,-18,-13,55,-14,-6,17,-19,74,17,-45,2,-26,0,25,35,40,-27,96,14,64,13,5,40,-42,81,-22,41,-7,26,-89,21,4,30,-42,-57,-53,-37,19,-19,-10,15,14,-15,-5,13,-14,47,-25,-21,48,28,49,-61,31,47,25,-47,-36,19,13,105,-62,8,15,-42,4,-29,-30,18,-25,49,-15,-41,19,-12,28,11,-28,24,8,-4,-10,-42,-34,18,-6,6,12,-17,45,-40,-29,10,36,47,53,-16,-32,60,-42,-30,5,36,34,-9,-53,-36,30,-9,29,37,59,-27,26,-18,30,-43,26,12,-39,-20,22,-25,-17,-53,6,33,-44,-15,-75,-44,43,-43,10,-44,-18,-2,-63,15,-16,78,21,12,-15,-25,68,3,2,6,1,-28,-24,-28,-38,8,14,-13,7,-6,42,17,-24,-7,-29,18,-42,-60,26,-10,31,19,-20,35,-8,78,-4,40,30,-21,-65,56,47,-28,-4,47,-10,-6,10,11,45,8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.118","t":"A common obstacle preventing graded task assignment from being Graded task assignment is successful is the presence of negative thoughts or problematic styles of particularly helpful when information processing that interfere with the identification and/or patients are faced with execution of one or more steps that are necessary for completing the complicated tasks, tasks that task. In particular, patients with an all-or-nothing thinking style often have multiple or sequential dismiss the progress they are making toward completing a task and, parts, or tasks that have instead, view partial progress as a failure. We encourage therapists to be looming deadlines and alert to cognitions that interfere with graded task assignment and use important implications for cognitive strategies as necessary to address them. patients’ lives.","e":[31,59,-150,-39,53,45,75,-10,6,7,-14,-6,61,65,-35,20,39,-64,-21,19,-16,-2,-15,-41,33,41,-4,-83,-37,26,20,-7,-9,-51,-63,-11,56,1,14,-17,29,-8,-10,-101,17,-14,67,7,43,-48,45,-40,-4,-23,84,43,12,35,4,-28,51,56,-45,47,13,-35,-37,75,0,9,17,-3,57,-7,-57,32,13,0,18,24,38,-17,83,4,63,16,21,10,-47,111,-15,12,-6,22,-108,50,-27,26,-52,-26,-38,-30,18,-41,1,38,10,25,6,25,-31,90,-21,-49,45,-2,73,-60,-2,16,4,-11,-40,33,-13,71,-22,-30,47,-45,-25,-52,-29,28,-29,41,-18,-33,27,-22,28,4,-23,37,18,-46,16,-37,-35,-16,-9,13,-12,-4,42,-48,-9,29,20,-1,94,10,-32,58,-38,-43,18,25,23,10,-42,-31,60,13,53,47,63,-34,24,-19,2,-42,19,3,-15,-18,30,-7,-39,-20,41,20,-13,-15,-64,-80,43,-38,21,-47,-22,4,-56,11,-51,45,2,7,-22,-11,54,-5,2,6,2,-59,-2,-26,-35,6,-15,-2,-35,8,38,15,-52,-19,-53,19,-34,-67,49,-19,45,31,24,14,19,75,-23,30,22,-2,-74,42,32,-30,-16,44,4,3,-5,15,33,23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.119","t":"Relaxation Training and Controlled Breathing In addition to the other behavioral strategies used in CBT, therapists may also • Relaxation implement relaxation training and controlled breathing. Relaxation and breathing training and strategies may be especially useful for patients who present with agitated depression, controlled anger and impulsivity, and/or anxiety. These strategies work via several mechanisms breathing of action. First, they decrease the physiological arousal that accompanies agitation, anger, and anxiety. Second, they serve as a coping strategy to help patients with these clinical presentations tolerate their distress, rather than immediately engaging in reactive behavior that has the potential to be self-defeating. Third, they provide evidence to patients that they can indeed tolerate distress, which can counteract negative perceptions of their ability to cope.","e":[22,29,-169,-18,48,-6,51,6,64,-37,-39,-22,59,8,9,-38,22,-38,-63,2,-46,-26,-8,-24,21,70,4,23,-24,-9,47,-1,18,-8,-25,-21,76,44,2,18,60,-59,46,-76,-9,-12,75,1,20,-3,72,-99,-39,-76,110,11,19,39,-29,-98,86,6,-56,41,72,-27,-59,50,-2,3,69,-27,43,25,-30,13,-34,-28,-4,19,48,-41,69,-53,95,-2,3,1,-33,64,52,-28,62,51,-45,58,25,-11,-17,-56,-63,-1,12,-13,-6,19,-5,-13,-4,11,-52,37,1,3,2,16,49,-55,13,54,14,0,-20,-36,32,88,-57,-10,40,-6,-6,-34,-40,-3,-33,24,-28,6,8,4,45,-7,-9,16,-20,-22,12,-30,-53,29,-10,17,42,29,57,-40,-39,37,43,38,20,-9,-19,32,-3,-27,-6,35,25,20,-67,-67,-43,11,88,43,101,-34,-20,-75,27,7,36,29,14,11,13,-35,-53,-57,13,35,-59,-27,-79,-53,44,-18,6,-12,-21,-5,1,-22,-38,36,-1,2,0,-38,40,-16,26,31,-26,-2,-10,-30,-39,-10,31,-33,-46,-18,8,-34,-37,-3,7,22,-26,-93,34,25,37,17,-17,8,14,40,18,39,24,24,-55,30,-8,-40,6,1,-8,5,27,-6,35,-1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.119","t":"Below is a script that therapists can use with their patients. It includes the rationale for using relaxation techniques followed by specific instructions on how to get started. One of the things that is often seen together with depression is tension. It is possible that tension contributes to people getting depressed. It is also possible that when people start to get depressed, they become more tense. In either case, the tension adds to the burden of being depressed.","e":[55,38,-162,-51,41,1,25,-27,10,-62,-42,16,42,19,21,-5,18,-37,-10,34,-58,-36,-28,-40,-10,106,7,-1,-52,3,36,-7,-11,-33,-24,-43,53,70,43,26,-4,-22,-12,-70,-16,-82,42,28,1,-16,43,-83,-35,-57,90,29,23,15,40,-48,68,65,-30,70,73,-14,-28,28,14,26,54,0,41,22,-33,8,17,9,18,-24,54,6,39,-72,72,13,-16,-14,-3,62,49,-16,27,47,-91,10,17,30,-30,-81,-35,-18,16,-28,19,28,-6,-33,-7,21,-51,63,-1,-40,40,-23,46,-22,-16,25,-25,26,-6,27,18,27,4,-5,36,-23,-24,-24,-42,13,-4,58,-51,-39,-30,1,47,-12,-30,-12,-27,-29,11,-11,-66,16,-3,-16,6,16,45,-25,-32,-5,69,9,48,-5,-10,28,19,-40,28,74,10,27,-46,-49,-32,-26,79,42,100,-37,49,-77,24,-50,31,-29,-4,-9,16,-59,-69,-44,-22,7,-13,-2,-58,-55,47,0,27,12,-37,3,9,-3,-55,91,-18,7,3,-41,37,-30,18,11,-10,-11,-4,-22,-48,16,14,-8,-13,6,19,8,-57,18,-20,10,-49,-100,40,37,47,24,-19,9,0,48,-6,22,44,23,-32,40,-17,-25,20,11,11,-5,-10,42,51,-33]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.119","t":"Tension usually involves both a subjective feeling of being tense as well as actual muscular tension. When the muscles are tense, they are using up energy. This can lead to feeling very tired at the end of the day. In addition, continual muscular tension can produce physical problems, such as pain, headaches, neck aches, and so on. And, tension in general can cause other problems, such as problems with the digestion, ulcers, and so on.","e":[79,37,-187,-8,40,-19,-12,-9,18,-45,-14,18,-2,-4,37,-21,5,-59,28,29,-75,12,25,-27,-21,121,12,-9,-34,-5,48,-11,43,-78,-53,-41,42,24,30,16,31,-57,-21,-45,0,-33,-20,48,7,-31,-11,-103,-25,-61,98,2,68,-18,44,-12,75,18,-29,55,36,-67,-56,28,53,59,49,-26,32,-10,-48,25,20,2,-25,-18,37,41,57,-29,83,-40,-22,-13,16,99,39,7,40,26,-68,-8,39,59,-33,-52,-20,-19,-24,-3,27,2,-5,-1,-17,11,-49,55,-1,-13,10,-11,59,-42,-34,19,-37,-15,-16,5,-3,13,-20,3,25,-44,-32,-15,-60,-20,8,73,-34,-34,-17,-10,85,-29,-19,-30,-53,-17,32,-39,-8,6,-14,22,-33,-1,63,-38,-41,8,51,11,35,-17,-15,14,22,-55,-6,66,28,14,-54,-39,-12,-6,33,39,82,-61,45,-62,-15,-9,21,-25,-10,-23,-19,-48,-93,-44,0,37,-38,2,-52,-51,35,15,32,-29,-18,-51,0,20,-15,74,-29,9,14,-35,45,-27,2,4,-13,-52,16,-16,-27,21,3,-16,-9,36,-16,-29,-60,-8,-16,-18,-13,-44,103,72,13,28,14,19,7,-11,3,8,35,-22,-59,4,23,-41,29,13,27,0,31,34,34,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.119","t":"By learning to relax, you can stop wasting your energy in useless muscle tension, and this energy can then be used to deal with everyday tasks. Many people who go in for treatment of depression find relaxation training very helpful. I will teach you this technique now and practice it in future classes so that you can use it preventively. Sit in your chair, with feet flat on the floor, and your body in a comfortable position. We • Progressive are going to practice a technique called progressive muscle relaxation. This technique muscle involves tensing and relaxing most of the muscle groups in your body. relaxation","e":[15,55,-171,-19,28,-31,35,5,11,-73,-22,-3,4,0,16,-17,16,-90,-17,43,-42,-20,-27,-11,-4,96,5,3,-10,-3,16,-8,38,-28,-8,-18,57,49,49,10,-3,-44,33,-70,49,-41,65,-8,20,-25,60,-70,-33,-84,84,-12,24,-6,39,-57,138,40,-45,56,45,-50,-57,63,29,26,71,13,34,10,-37,14,13,-20,-18,-19,46,-33,59,-61,58,4,-10,-5,-13,85,38,-6,49,73,-44,5,42,55,-17,-53,-30,-10,37,-17,29,20,-4,-15,6,10,-12,38,-14,-19,-18,-5,68,-12,-1,23,-49,24,10,-16,12,54,-33,-31,28,1,-32,0,-64,11,28,88,-54,-38,12,-17,28,-9,-30,-15,-33,-24,-8,-37,-51,36,-7,-5,35,-15,78,-65,-21,17,99,12,64,6,-7,46,12,-31,8,63,64,10,-63,-55,-23,-37,64,26,76,-60,2,-60,14,-28,12,-3,-3,39,0,-42,-59,-38,-20,22,-46,-31,-45,-20,36,1,8,-13,-42,-33,-2,-6,-20,55,-6,-4,6,-23,59,-4,25,-11,-17,-22,-21,-21,-34,10,0,-6,-26,14,44,-18,-68,7,-11,14,-40,-95,32,55,42,-13,-14,32,-22,23,20,30,49,-3,-37,51,30,-20,17,-11,40,36,6,29,25,-38]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.119","t":"First, see how I tense and relax my left hand. Now you try doing it. Place your hand on your lap, make a fist with it, and tighten up the fist as hard as you can without causing discomfort or pain. Then, hold the tension, hold it, feel what it is like to be tense, and then relax the hand all at once. Pay attention to what it is like to relax. What you want to learn is what it is like to be tense and what it is like to be relaxed, so that later you can just remind yourself to relax and you will be able to do so instantly.","e":[60,34,-146,-2,47,-40,18,14,61,-53,-40,23,-27,54,92,25,36,-85,14,34,-44,-23,-30,15,19,57,-14,30,-45,2,25,-9,-3,-20,3,-84,42,37,-28,28,33,-51,54,-38,74,-55,63,-7,31,23,-9,-63,-46,-82,56,28,52,11,81,-7,101,12,-53,60,-7,6,-47,36,26,21,21,8,77,-13,-73,21,12,-16,15,11,81,-7,75,-58,44,-23,-36,-57,-20,71,50,34,42,57,-15,14,21,127,-11,-75,-63,12,-39,4,-3,59,-9,-13,-13,-36,-23,11,14,-21,34,21,40,-41,23,21,-8,25,-23,-15,44,16,-31,5,44,-11,16,-21,-58,-5,-2,92,-60,15,5,-32,52,-29,-29,-18,-36,-30,4,-36,-20,-2,16,-31,36,5,54,-15,60,22,83,23,34,-52,8,74,37,-36,-16,45,49,31,-77,-48,-35,-45,15,11,35,-64,30,-37,36,-30,13,-3,-23,-20,-28,25,-26,-26,-2,-2,-59,-33,-39,-43,41,-21,-10,7,-38,-47,-1,-10,-62,44,-13,-3,9,-17,68,-4,-14,-24,0,-3,10,-35,-47,15,16,-10,-4,2,24,17,-54,16,-25,5,-31,-53,16,39,21,5,-25,69,-23,18,-16,14,57,30,-72,44,40,-30,42,-4,23,-3,29,-7,26,-50]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.119","t":"Now, I want you to close your eyes so that you can reduce the distractions around you and pay attention only to my instructions for relaxing. You should know that this is not hypnosis. You will be in total control of how much you relax. The purpose of teaching you this is to allow you to develop greater control over yourself, your actions, your CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 101","e":[2,14,-159,-47,48,11,58,-19,48,-36,-8,17,39,25,42,-26,9,-61,-35,-19,-53,-30,-58,-19,13,68,-2,32,-23,33,57,-15,31,-11,1,-39,32,75,-28,40,22,-31,3,-117,29,-38,97,6,21,-38,63,-80,-15,-87,135,-30,2,-6,8,-49,121,46,-20,67,11,-51,-74,44,-5,-2,32,-10,25,26,-68,-9,-16,-14,-19,13,35,-55,49,-44,37,31,-16,-21,-8,73,44,-14,25,57,-40,13,34,31,30,-10,-68,-29,10,-49,46,35,-6,-21,5,-21,-65,40,-28,-24,-7,4,61,-27,35,37,-14,19,4,30,21,63,-34,5,9,-29,-20,17,-21,28,24,51,-39,-46,3,-18,20,4,-30,1,-37,-34,15,-34,-38,-17,-14,16,35,2,35,-69,-17,9,56,15,51,2,-47,43,-5,-18,-11,49,37,4,-78,-49,-44,14,76,39,49,-12,3,-20,48,-46,37,20,-7,15,-1,-56,-78,-18,19,35,-34,-43,-84,-27,33,-18,-2,7,-31,13,-6,8,-62,46,-11,14,-25,-36,56,-23,29,-8,-26,-3,10,-12,-53,17,22,28,-2,-2,-16,-30,-37,-42,36,-13,18,-93,44,29,1,1,3,70,-7,25,57,15,42,-5,-57,27,9,-41,9,6,-14,25,-4,11,45,-44]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.120","t":"It is also helpful to use your breathing to help you relax more deeply, by combining your breathing with the tension-relaxation exercises. First, allow your breathing to become slow and easy, very smooth, very rhythmic. [pause] Pay attention to how that feels. <Pause> Allow yourself to imagine that each time you exhale you go deeper and deeper into a state of complete relaxation. Let your breath take you down farther and farther into a very calm, very relaxed state. Some people like to imagine that each time they breathe out, they are going one more step down a long stairway, and the lower they go, the more relaxed they get. Let your breath relax you as much as you can, and then we will add the tension-relaxation exercise. [pause] OK, now, let’s begin with your right hand.","e":[50,49,-166,-4,25,-20,45,16,31,-64,-33,-1,1,58,22,-3,19,-72,14,-18,-59,-54,-13,-20,23,72,13,10,-63,-10,74,-32,15,33,7,-61,43,48,-5,16,33,-70,38,-30,52,-52,41,-27,9,-12,40,-63,-95,-41,89,1,39,-11,58,-50,62,-3,-9,67,52,-17,-53,43,25,43,42,-30,60,-5,-54,14,-12,16,23,20,40,-45,106,-39,57,9,-19,-33,-20,51,49,-20,41,86,-22,26,50,81,-40,-81,-58,15,41,1,-6,17,7,13,-7,3,-49,14,4,-26,-17,53,69,-22,28,71,-6,26,-17,-39,14,25,-50,-47,19,-49,-20,-7,-44,8,-12,22,-87,-17,-20,-15,42,-8,-6,-12,-63,-41,-12,-57,-69,14,0,-23,32,41,59,-26,-7,29,64,33,28,-8,4,71,-10,-18,5,41,38,30,-31,-57,-39,-2,38,27,97,-66,-10,-67,41,-7,-25,-15,-4,-5,10,-19,-66,-47,21,-2,-8,-40,-56,-19,41,-32,-9,-4,-40,-43,15,-13,-2,54,-11,7,-9,-16,76,-16,16,1,12,-5,-15,-35,-27,25,13,-33,-19,-18,31,-41,-63,-7,-13,4,-13,-91,50,64,56,-6,3,38,-11,45,29,11,59,-14,-64,48,2,-51,10,-5,11,35,19,3,17,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.120","t":"Therapists can apply this procedure to all of the major muscle groups, such as the hands, arms, shoulders, upper back, neck, forehead, jaw, feet, and legs. They continually remind patients to use their breathing between muscle groups. It is sometimes helpful to have them breathe in when they tense up, and breathe out when they relax. At times, patients wonder why their therapist is asking them to tense up if the purpose of the exercise is relaxation. In such instances, therapists can explain that tensing allows people to see clearly the contrasting effect of relaxation when they let go, and that it is more difficult to identify what it feels like to be relaxed without that contrast.","e":[38,65,-192,-27,35,-29,33,15,19,-44,-39,13,24,-1,25,-9,25,-98,9,19,-56,-28,-7,3,-3,93,29,31,-51,-34,65,22,44,-45,-21,-50,68,40,-21,31,45,-62,8,-70,7,-36,51,-3,34,19,32,-85,-70,-75,102,-1,58,25,55,-38,67,9,-65,35,55,-3,-60,43,32,5,57,-7,49,13,-61,19,-30,-11,-19,6,53,-19,65,-39,75,11,-5,-4,-34,96,48,12,49,57,-51,17,54,30,-23,-73,-66,22,2,-1,-6,21,13,4,-6,0,-44,62,-3,10,-21,23,62,-56,12,38,-9,17,-23,-37,-7,41,-53,-18,25,-50,1,-22,-63,-9,14,53,-61,-49,11,-3,32,-3,-8,-28,-1,-26,15,-36,-29,38,0,10,21,29,78,-28,-17,38,66,36,33,-3,-5,43,7,-53,-4,56,41,12,-62,-56,-25,-24,41,52,73,-51,19,-52,13,-18,15,-5,-8,-4,2,-11,-71,-43,11,27,-42,-26,-55,-45,42,-24,23,9,-25,-29,-23,-26,-27,70,-26,12,-1,-42,60,-14,29,10,-17,-40,-4,-31,-30,31,25,-14,-32,-13,17,-19,-47,-12,10,12,-41,-64,45,32,8,-10,1,35,19,27,18,14,14,-9,-58,70,13,-45,11,-5,-18,26,-13,-9,12,-25]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.120","t":"It is important to emphasize to patients that these strategies will not work optimally if used on only one or a few occasions. Much like riding a bicycle, relaxation and breathing strategies are skills that are acquired over time. If patients attempt to use them only in times of distress, then these strategies will probably be of only limited effectiveness because they have not been practiced. Relaxation and breathing strategies often work best when patients first practice them on a regular basis when they are not in distress so that the procedures are readily available in the future when they are in distress.","e":[20,41,-202,-7,39,3,20,-21,52,-34,-25,-38,29,18,-12,-19,4,-59,-39,7,-40,-31,-4,-10,-19,53,-16,11,-41,-8,45,-9,28,-22,-27,-34,41,9,19,-8,35,-36,73,-58,48,-21,55,-1,6,-10,76,-58,-83,-32,127,28,33,26,0,-92,75,-2,-34,47,56,-2,-74,66,23,8,56,-44,42,-5,-50,51,-39,-11,9,46,34,-56,69,-32,111,27,15,-8,-19,81,35,-16,65,54,-90,25,4,-6,-35,-26,-53,-3,19,0,10,16,-10,13,-20,-9,-36,51,-1,-13,-30,51,45,-28,42,50,-19,9,0,-2,27,93,-60,-5,43,4,-18,-17,-50,4,-15,29,-21,11,12,9,50,-29,11,-11,-34,-37,-13,-40,-51,35,-13,8,40,43,59,-22,-37,55,39,25,47,-8,5,40,-8,-32,1,24,25,18,-31,-80,-26,-10,96,19,108,-33,-21,-73,24,-21,-32,3,-11,14,64,-15,-68,-77,20,8,-23,-23,-67,-51,53,-16,21,-2,-15,-14,-7,-1,-47,67,-25,-8,-24,-45,57,-19,12,14,-48,-26,-17,-25,-24,1,29,-7,-64,-4,18,-27,-42,3,-7,37,-34,-94,38,23,26,0,9,-4,24,20,22,20,26,17,-69,45,-33,-52,-3,22,-2,27,23,-18,33,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.120","t":"In addition, it can be useful to incorporate imagery exercises with meditative breathing techniques. In these exercises, therapists verbally present a picture of a calming environment after the patient closes her eyes and begins to block out thoughts and distractions and begins rhythmic breathing. Providing a specific focus on colors, textures, and temperatures can help patients connect with the scenes. It can be helpful to offer options of different scenes (e.g., beach, tropical island, mountainside) to patients before commencing with the exercise to maximize the likelihood that they will be able to visualize the scene and find it to be particularly calming. It is worth noting that therapists should take some caution before engaging in imagery exercises with Veterans with PTSD or military sexual trauma, as certain images or visual cues may trigger trauma-related memories or symptoms.","e":[25,35,-171,-65,24,8,60,-6,34,-25,21,-8,51,51,-32,-21,12,-85,-54,-19,-94,-27,-24,7,4,63,18,43,-56,-7,79,-20,-11,-24,-7,-46,35,49,19,20,45,-35,19,-48,-11,-24,67,-25,7,24,53,-56,-32,-44,92,-11,42,-6,17,-59,90,36,-61,35,54,-45,-94,6,21,29,62,-35,45,35,-65,33,-26,-25,-14,37,38,-34,67,-37,85,51,22,9,-25,58,33,-6,16,64,-50,42,21,36,-34,-18,-56,2,42,-59,3,8,4,0,-7,2,-27,15,-23,-33,-32,-21,65,-49,27,42,-10,19,10,-16,8,51,-59,-73,1,-50,0,-32,-31,-2,-4,43,-16,-28,27,-7,23,7,-5,-29,-23,-25,22,-41,-19,14,-26,17,17,42,80,-43,-32,52,45,5,60,40,23,27,2,-69,22,50,51,-42,-48,-46,-22,-14,48,12,72,-63,-6,-26,6,-24,10,-4,11,-30,2,-20,-77,-36,3,37,-23,-15,-97,-26,32,-7,16,-22,-2,22,-20,21,-37,52,-22,-3,-45,-57,48,-40,13,22,-22,16,11,-6,-49,2,38,16,-40,-43,20,-11,-62,-31,-2,-1,-34,-64,83,14,33,15,5,55,0,27,37,13,41,3,-66,51,-4,-36,0,7,1,8,8,-3,28,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.121","t":"Cognitive Strategies Cognitive strategies help patients to (a) identify unhelpful thoughts, beliefs, and images; (b) distance themselves from unhelpful cognitions before they act upon them; • Cognitive restructuring (c) evaluate the veracity of those cognitions; and (d) if necessary, develop alternative cognitions that more realistically characterize the situation at hand. This process is called cognitive restructuring. At first, patients evaluate these cognitions retrospectively in the therapist’s office and in homework The ultimate goal of assignments. However, the ultimate goal of implementing cognitive implementing cognitive strategies is for patients to be able to engage in the cognitive strategies is for patients to be restructuring process in the moment, as they are faced with situations able to engage in the cognitive that elicit strong affect. Through this process, patients learn how to be restructuring process in the their own therapist by applying the skills they learn to situations that moment, as they are faced with arise in their daily lives. Teaching patients to become their own situations that elicit strong therapists is an important goal of CBT and greatly helps to extend affect. treatment gains and prevent relapses following the termination of regular treatment sessions.","e":[37,24,-142,-57,61,-22,54,22,45,15,-2,-2,75,43,13,-11,-15,-35,-18,26,-47,-28,-16,-14,0,37,-48,20,-24,7,56,0,-1,-40,-50,-39,75,12,-22,-25,26,-5,36,-100,37,12,100,2,31,-9,23,-29,17,-38,117,25,1,40,17,-59,102,49,-41,56,-8,-20,-61,58,-53,0,41,9,22,34,-47,-12,-15,-29,-12,30,54,-60,75,-39,43,36,22,10,-22,84,-6,-2,13,34,-112,38,-19,-35,-31,-32,-74,-8,6,-34,3,59,-14,18,17,26,-73,18,-9,12,2,33,64,-14,48,63,31,-15,9,33,17,97,-76,-30,43,-4,-28,-24,-18,3,-10,41,12,-24,10,33,41,-11,9,9,-9,-59,-1,-29,-45,16,-20,9,27,17,49,-44,-20,22,21,30,68,17,-43,61,-27,-33,32,28,34,33,-56,-38,-18,-3,102,3,77,-3,13,-16,20,4,29,51,18,1,52,13,-39,-30,38,29,-63,3,-90,-52,29,-13,37,-43,-17,7,-34,30,-42,57,10,-28,-57,-20,40,6,15,26,-44,6,5,-14,-37,20,21,-2,-21,20,4,-2,-48,6,16,21,-11,-90,37,-2,42,23,-21,19,29,68,7,44,25,17,-91,-6,17,-45,-2,32,23,46,6,-18,48,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.121","t":"We introduce cognitive strategies after behavioral strategies in this manual because, in our experience, we have found that many Veterans respond best to behavioral strategies at the beginning of treatment, and as they experience an improvement in mood, they are in a better place to acquire cognitive strategies. However, there is no firm rule saying therapists must implement behavioral strategies first. As was seen in Part III, in many instances it is difficult to completely avoid the use of cognitive strategies, as many patients have negative thoughts and beliefs that prevent them from implementing the behavioral strategies, or more generally, from fully engaging in treatment. Furthermore, some patients clearly indicate that they are struggling with negative thinking and that they believe it contributes to their mood disturbance. Such patients already grasp the link between thoughts, emotions, and behaviors and are ready to acquire cognitive mood management strategies.","e":[30,18,-130,-28,66,25,59,-21,38,-6,-28,2,50,67,3,-25,-2,-32,5,29,-71,-29,-37,-46,3,58,-30,12,-22,30,72,1,-15,-52,-55,-48,29,9,-15,-15,47,27,32,-95,3,-14,90,21,30,-8,61,-58,7,-60,98,8,19,23,9,-78,113,39,-55,40,24,-18,-57,80,-45,-6,51,-3,33,-6,-23,23,5,-20,-12,28,29,-46,78,-55,86,37,25,-1,5,99,-6,9,16,44,-97,14,-39,-34,-10,-40,-37,-18,-10,-27,14,53,2,8,-20,33,-80,34,10,-28,-10,34,58,-49,35,60,-16,-12,16,16,18,58,-52,-35,46,-15,-30,-33,-28,-1,-12,28,-3,-21,10,27,39,3,35,32,-28,-49,5,-29,-28,0,-36,19,20,19,50,-59,-9,46,23,9,79,17,-27,39,22,-50,39,10,-3,30,-38,-22,-23,-12,119,39,76,-23,15,-16,3,-18,11,33,10,-20,34,12,-77,-34,23,61,-48,-7,-93,-70,11,-15,40,-17,2,17,-26,26,-48,61,-16,-10,-35,-40,35,8,11,18,-47,-2,6,-7,-39,37,-6,8,-34,23,15,-7,-44,9,2,15,-15,-86,44,-12,43,26,-4,20,26,69,5,45,62,60,-78,25,-26,-43,-20,31,30,30,-15,-32,59,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.121","t":"Before implementing specific cognitive strategies, it is important to educate patients about the cognitive piece of the CBT model. The goal Before implementing specific is for patients to understand that thoughts and beliefs can often have a cognitive strategies, it is significant influence on emotions, behaviors, and physiological important to educate patients responses, and that evaluating these thoughts and beliefs using all about the cognitive piece of the available evidence usually results in the identification of alternative, CBT model. more balanced thoughts and beliefs, which in turn may improve mood and overall functioning.","e":[9,20,-134,-47,83,13,45,14,36,-5,5,17,92,56,24,-18,-20,-45,13,47,-74,-30,-23,-2,-14,47,-41,27,-19,28,61,-22,8,-47,-81,-59,58,33,-13,-2,42,18,9,-106,24,12,91,3,30,-11,17,-40,38,-41,122,39,-6,29,8,-44,120,68,-67,42,3,-33,-62,58,-56,12,60,6,39,30,-48,-17,-24,-22,-11,27,61,-17,54,-16,44,12,8,-21,-24,95,16,-19,33,43,-98,22,-30,-39,3,-2,-80,-25,-10,-16,0,31,-21,9,1,19,-64,4,-19,14,-39,37,63,-28,0,31,15,-23,27,54,12,74,-56,-43,35,-17,-22,-37,-33,-14,13,22,-25,8,12,44,22,10,7,12,2,-48,13,-18,-49,3,1,24,0,7,53,-54,-14,17,43,8,50,35,-41,36,-37,-48,42,18,22,45,-63,-43,-20,5,124,16,62,11,23,-47,0,-9,20,43,-11,1,24,-2,-46,-39,29,47,-57,-22,-77,-40,20,13,37,-14,-28,24,-13,16,-46,53,-6,-29,-31,-44,45,-8,-4,33,-32,8,-1,-12,-42,25,9,-23,-18,1,-6,-21,-30,-26,-14,28,-13,-69,47,3,35,22,-16,-4,26,59,13,41,47,18,-82,6,27,-55,-15,30,-2,35,14,-29,53,-30]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.121","t":"A common way to present this to Veterans is to use basic airborne operations as an example. For some, the notion of standing in the doorway of a C-130 Hercules—the common plane used in modern Airborne Operations and also used at jump school— evokes thoughts such as “I’m going to die” or “My parachute won’t open,” which are, in turn, associated with anxiety and fear. Others, in contrast, have ideas such as “This is going to be an incredible experience,” which, in turn, is associated with exhilaration and excitement. The external stimulus is the same for both, yet the automatic thoughts and associated emotions provoked by the situation are quite different. Not surprisingly, the people who experience automatic thoughts associated","e":[7,22,-193,-25,72,59,23,21,-2,-25,-3,18,47,81,49,-42,0,-72,-12,8,-42,-63,-26,11,19,52,-30,-20,-72,-3,50,-55,-12,-40,-43,-54,3,56,18,-11,54,-55,-14,-54,32,35,73,29,67,-12,24,-45,-15,-35,92,17,66,-16,8,-4,82,44,8,26,60,-2,-73,23,-16,-3,56,-32,-16,46,-55,31,-28,-8,33,34,6,-35,38,-22,75,34,-9,-15,-25,55,41,34,11,17,-115,47,-3,41,-56,-61,-23,-44,-26,-25,-2,2,0,-3,-7,14,-37,63,-55,-44,11,-7,36,-39,21,28,40,19,3,32,36,78,-14,-11,8,-58,-6,-29,-13,31,8,49,-20,-35,8,5,45,2,11,-1,-35,-31,23,-19,-41,-20,-24,38,-22,18,26,-25,-45,-11,28,35,56,13,-3,46,-35,-57,11,19,33,10,-49,-53,29,1,45,-31,76,-42,0,-68,35,-59,36,-6,-1,-22,2,12,-75,-32,10,20,-43,-26,-101,-38,54,9,45,-20,22,17,-33,38,-21,66,13,6,-32,-8,96,-19,-16,1,44,-2,42,-50,-37,37,14,-11,-27,-45,-6,-5,-43,-25,-7,-5,-8,-77,96,-3,-20,-16,38,38,14,26,16,41,25,-11,-78,-7,14,-45,-8,19,-35,1,-24,3,35,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.122","t":"with anxiety and fear are likely to show hesitation before jumping out of the plane, whereas the people who experience automatic thoughts associated with exhilaration and excitement are likely to dive out with no problems. What this is intended to underscore to patients is that it is often our interpretation of events rather than the events themselves that influences how we feel. This section describes several strategies for identifying and modifying problematic cognitions. It is divided into three main sub-sections: (a) working with automatic thoughts, (b) working with core beliefs, and (c) developing problem-solving skills.","e":[61,62,-175,-31,73,36,54,-17,15,-32,-5,1,49,74,21,-21,14,-61,-5,1,-45,-25,-12,-7,15,60,-31,-52,-44,28,62,-26,-15,-70,-66,-69,64,38,-6,0,32,-25,19,-84,-1,2,60,-11,48,-14,40,-48,-15,-24,86,49,17,51,31,-6,82,24,-13,27,54,-13,-81,64,-30,-13,69,-5,13,40,-93,8,15,6,25,52,37,-44,50,-55,59,25,-8,-10,-24,77,35,1,34,40,-100,43,-15,18,-55,-44,-70,-26,5,-24,2,3,0,-18,18,31,-46,55,-23,-11,10,6,54,-20,1,50,-10,30,6,55,40,52,-25,-18,37,-38,-23,-28,-21,16,14,48,5,-6,-14,18,67,24,0,0,-24,-75,14,-18,-54,-8,13,26,-7,25,47,-17,-24,0,70,5,41,13,-22,74,-15,-34,29,47,17,35,-53,-40,11,4,69,-2,82,-56,20,-54,35,-33,12,17,21,-29,11,16,-58,-44,32,4,-56,-41,-95,-63,37,3,43,-17,13,5,-37,-1,-18,88,-10,-7,-43,-38,91,7,-16,27,1,-41,29,-23,7,23,-28,-15,-37,-28,8,11,-25,-25,-9,8,-23,-99,47,-5,21,-8,13,19,31,34,6,55,35,48,-67,-1,25,-50,-23,13,-22,16,-36,-8,24,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.122","t":"Working with Automatic Thoughts As stated previously, automatic thoughts are evaluative thoughts and images that arise very quickly when people experience a shift in their mood. The purpose of working with this level of cognition is to (a) demonstrate to patients the links between cognition, mood, and behavior, and (b) help patients develop a sense of mastery in modifying these cognitions when necessary. This sense of mastery will be used strategically to modify unhelpful core beliefs that are identified as treatment progresses.","e":[21,28,-144,-60,69,-9,61,7,-8,8,27,18,70,74,-1,-1,1,-39,1,26,-5,-25,-18,-20,55,50,-14,-8,-33,5,19,-40,-22,-37,-37,-49,85,24,-10,16,-7,-6,40,-71,20,41,44,-1,36,-8,26,-70,1,-18,135,38,16,65,9,-29,97,65,-18,42,37,-30,-18,16,-23,6,28,-16,11,10,-42,-6,8,2,24,49,47,-88,57,-14,63,20,1,25,-2,90,46,-20,9,34,-124,9,-23,12,-28,-15,-103,-38,1,-21,4,44,-33,22,20,66,-5,34,-16,-26,-4,-1,37,-4,23,78,40,6,-12,73,51,73,-19,-24,25,-19,-3,-40,-5,8,21,77,-4,-48,5,14,45,3,-15,20,-30,-38,20,-39,-44,32,-5,-5,-13,-18,60,-13,-52,24,37,-2,58,14,-63,46,-21,-41,48,24,11,19,-41,-25,-8,-6,75,6,87,-52,41,-46,8,-66,20,-1,-1,-35,-4,-25,-48,-19,46,11,-58,-28,-141,-15,23,-12,45,-42,-12,0,-68,22,-28,74,22,-24,-43,-34,69,28,-18,5,7,8,-12,-34,1,7,26,16,-2,9,-26,-31,-55,-3,-9,14,-6,-73,29,2,15,-5,0,41,7,72,17,45,10,26,-111,4,35,-63,-21,37,8,16,-41,-23,66,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.122","t":"Identifying Automatic Thoughts The first step in working with automatic thoughts is to help patients develop skills in • Identifying identifying instances in which they arise in specific situations. In session, cognitive automatic behavioral therapists ask patients to describe situations associated with a noticeable thoughts shift in mood. As patients provide details about the situation, the therapist uses questioning to identify the cognitions that were activated during that situation—a process called guided discovery. When the therapist notices a shift in When the therapist notices a affect, the most fundamental question a therapist can ask to initiate this shift in affect, the most process is, “What was running through your mind just then?” The fundamental question a following is an excerpt from Claire’s fourth therapy session. This session occurred two days after she had received notification from the therapist can ask to initiate this medical board that they would delay their decision about reinstating her process is, “What was running for another six months and that she was expected to resume work in a through your mind just then?” different capacity in the meantime.","e":[72,3,-154,-61,74,-6,80,8,5,4,-17,36,72,63,-12,-47,8,-66,0,3,-26,-14,-31,-9,27,34,-38,22,-12,10,72,-38,-7,-29,-53,-60,84,2,-22,24,32,-6,19,-100,27,18,56,-6,30,-40,33,-26,-17,-18,102,48,40,64,28,-52,89,54,-35,19,22,-28,-21,41,-27,14,42,-12,38,55,-35,-2,-18,4,9,33,38,-55,73,-41,59,56,-13,36,14,88,27,-9,5,21,-113,13,-36,1,-46,-29,-74,-35,-34,-39,26,33,-26,3,17,53,-23,47,-22,-26,-15,-5,60,-19,46,40,10,8,-41,60,41,63,-52,-6,19,-5,-20,-34,1,13,24,58,16,-29,0,26,56,-7,-6,9,2,-24,26,-33,-48,8,-1,13,-7,-3,78,-39,-49,4,14,9,42,4,-34,47,-23,-29,38,52,34,9,-49,-53,-3,-11,68,48,91,-64,59,-11,29,-69,38,12,6,-30,-8,-23,-33,-40,8,0,-64,-4,-108,-39,44,-40,40,-36,-17,28,-69,19,-39,88,21,-33,-42,-31,83,18,-12,25,-41,13,8,-1,-16,48,33,14,-10,2,-22,1,-44,-24,-15,34,-28,-65,50,9,47,11,-39,16,10,56,2,31,8,25,-98,8,25,-28,-4,20,7,-7,-10,-14,61,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.122","t":"Claire: [visibly agitated] I just can’t believe this! Who do they think they are to put my life on hold like this? And a desk job? Please! Therapist: I’m sorry to hear that you did not receive the news you had hoped for. Claire: [becomes tearful] This is awful! I think there is a real possibility that I won’t be able to fly again. Therapist: Let’s stay with this notion of not flying again for a moment. When you think about not flying again, what’s the first thing that runs through your mind? Claire: [sniffs] That my life will be meaningless. Therapist: And when you have that idea, that your life will be meaningless, how does that make you feel? Claire: Horrible! Sad and depressed. Therapist: On a scale of 0 to 100, with 0 being no depression and 100 being the most depressed you’ve ever been, how intense is the depression?","e":[51,30,-165,-57,33,57,-42,1,15,-47,-76,26,49,36,23,15,-17,-63,-42,14,-59,-78,-57,-2,8,59,-37,12,-112,38,58,-30,-39,-69,-77,-10,-16,107,40,-10,34,-30,13,-87,6,-42,123,35,13,-41,32,-37,-30,23,67,23,20,10,19,-24,69,10,-6,95,39,-30,-67,35,-34,-57,49,-19,12,59,-56,40,-18,-12,31,0,38,-43,53,-9,29,31,31,17,-9,92,14,6,9,14,-63,4,-6,-3,-46,-70,-55,-6,-36,-18,32,7,3,-33,19,-34,-46,54,-32,-25,29,-19,62,-94,11,13,-2,35,19,35,60,56,-13,15,1,-16,-26,-19,-28,47,-12,26,-25,-49,-7,36,59,-47,-24,-17,-32,-62,46,-3,-41,-22,20,4,37,15,45,-39,-27,37,35,17,72,36,-8,35,6,-28,-1,37,24,34,-32,-56,20,-28,63,-19,24,25,-34,-56,51,-9,44,-22,22,-16,3,-5,-45,-50,-18,23,-34,-6,-59,-13,57,-41,5,-13,23,24,-13,-2,-77,27,5,-42,-69,-2,61,-15,0,62,3,-18,3,-41,-26,22,45,-10,33,-4,32,36,-37,-35,11,-4,-7,-96,40,47,-9,26,-48,26,10,59,6,46,4,-3,-49,16,8,-26,15,29,0,0,27,48,33,1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.123","t":"Claire: This is the worst I’ve ever felt. So it’s 100. Therapist: Claire, it strikes me that anyone who has the idea that their life will be meaningless would experience a high level of depression. [draws the situation thought emotion model on a piece of paper] My guess is that this thought—my life will be meaningless—is closely related to the high level of sadness that you’re experiencing. Claire: Yeah, that makes sense. But what can I do about it? This is the way it is right now. Therapist: I understand, so we’ll have to put our heads together and see what we can do about it … [goes on to explain the rationale behind cognitive strategies]","e":[63,27,-144,-65,65,35,-1,7,14,-14,-84,12,60,47,15,4,-33,-35,-26,51,-77,-58,-65,-14,9,68,-22,7,-72,40,44,-22,-38,-58,-85,-29,-14,91,54,-6,23,6,46,-103,-12,-32,110,22,51,-36,33,-58,-9,10,86,55,10,25,7,-42,89,42,-34,91,44,-12,-54,48,-32,-39,67,-14,-4,34,-35,54,-16,7,30,7,23,-52,74,-11,38,48,36,31,-5,118,17,18,23,18,-81,-17,-5,3,-34,-40,-69,-5,-56,-24,23,35,-32,17,-14,-8,-43,31,-46,-34,24,-7,71,-58,26,37,-3,31,19,49,39,46,-7,-2,7,-17,-33,-23,-38,21,-6,60,-31,-26,1,44,47,-43,-7,-15,-43,-55,18,-31,-52,-28,2,10,33,-3,40,-30,-38,30,27,-5,50,49,-13,41,8,-41,10,34,5,44,-28,-59,1,-12,81,-19,33,20,-21,-25,47,-14,67,-16,8,-17,16,-17,-55,-43,-17,19,-33,7,-48,-22,40,-36,17,-26,-3,32,-19,15,-77,37,-4,-34,-55,-31,43,-23,-14,54,-16,4,-26,-20,-27,24,32,-13,35,10,20,39,-44,-10,28,8,10,-91,64,23,4,37,-51,24,0,59,-6,28,9,13,-45,28,6,-20,3,47,11,-11,19,10,55,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.123","t":"Not every patient is as adept as Claire at identifying automatic thoughts. In some cases, patients simply do not know what ran through their minds, focusing exclusively on the resulting painful affect. In these instances, it can be helpful to use imagery techniques for patients to first develop a vivid It can be helpful to use imagery image of the problematic situation, and then to identify the thoughts that techniques for patients to first were running through their minds at that time. Other patients confuse develop a vivid image of the thoughts and emotions, stating “I was sad” or “I was scared,” without problematic situation, and then recognizing the underlying cognition. Still other patients provide an to identify the thoughts that elaborate description of the situation that prompted the shift in affect were running through their but do not touch on the meaning that the situation had for them. Below minds at that time. we list a variety of questions therapists can ask to assist clients in identifying key automatic thoughts (J. S. Beck, 1995).","e":[60,17,-142,-81,56,-15,35,15,6,15,2,14,80,59,-8,-10,-5,-48,-19,12,-57,-14,-42,8,22,31,-34,21,-66,52,69,-14,-16,-82,-37,-48,47,46,24,38,45,4,36,-71,-14,14,62,-28,27,-21,35,-52,-4,-18,138,39,26,33,46,-39,75,68,-15,24,31,-15,-61,11,3,8,49,-22,29,51,-58,-2,-21,-26,22,39,68,-72,62,-33,68,50,31,36,32,83,14,1,18,70,-85,15,-18,42,-56,-16,-84,-19,-29,-58,13,26,-8,12,25,28,-13,20,-20,-19,2,-9,32,-51,24,33,17,21,-4,53,58,49,-29,-45,32,-17,-32,-27,3,25,26,69,16,-24,22,44,47,25,-17,-40,-23,-42,7,-16,-47,14,0,14,2,15,56,-30,-35,38,17,9,52,18,-28,33,5,-61,42,36,41,0,-24,-23,-7,-18,90,7,61,-38,40,-13,27,-60,28,-1,4,-29,-6,1,-35,-54,15,23,-48,4,-87,-21,29,-5,26,-26,-10,33,-43,29,-52,67,0,-56,-42,-49,54,13,-32,42,-36,5,-10,-19,-31,25,19,8,-1,-14,-16,2,-18,-1,-9,-1,-11,-79,71,-2,42,-6,-27,38,-27,43,-14,15,14,21,-70,19,33,-35,-18,25,-3,11,-5,-21,52,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.123","t":"Questions to Elicit Patients’ Automatic Thoughts What do you guess was running through your mind at that time? Might you have been thinking _______ or _______? Were you imagining something that might happen or remembering something that did? What did this situation mean to you (or about you)? Might you have been thinking _______? [Therapist chooses thought that is opposite of the expected thought] Consider this dialogue with Jack, who had difficulty understanding the rationale and procedure for identifying automatic thoughts.","e":[66,-1,-112,-62,58,26,35,-2,27,-26,-12,45,68,58,-23,-30,35,-57,10,5,-37,-8,-57,3,50,1,-39,3,-65,23,44,-56,0,-38,-92,-47,62,15,-16,-16,42,17,-13,-71,34,26,39,6,28,-22,20,-54,19,-22,123,39,74,48,35,-18,78,5,-2,29,22,-17,-32,47,3,-8,76,7,26,24,-37,6,-32,12,35,23,46,-52,57,-37,58,43,-9,32,31,89,8,-24,36,48,-94,-23,-25,6,-69,-45,-82,3,0,-37,31,46,-15,21,2,20,-4,35,-31,-47,13,-8,45,-13,64,55,14,20,-50,52,28,59,-36,-19,31,-26,25,-58,-14,41,-26,36,17,-41,46,4,97,0,-9,-6,-15,-34,32,-47,-65,45,11,22,-4,6,29,-47,-37,35,28,14,48,10,-34,39,-27,-53,41,61,0,24,-24,-51,4,-26,60,60,64,-52,25,-10,21,-40,35,-5,-15,-63,-4,13,-26,-19,2,32,-29,-46,-88,-37,42,-11,36,-8,18,36,-68,46,-57,68,-10,-26,-7,-33,78,3,-29,22,-18,25,9,-22,-28,45,5,-5,-36,-11,-16,-1,-17,0,-31,38,-40,-90,50,12,36,15,-35,16,4,65,29,28,22,-3,-100,14,18,-25,14,45,1,16,12,12,47,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.123","t":"Jack: And just like always, my son Christian calls, doesn’t even ask how I’m doing, and just asks to speak with his mother. Therapist: When that happened, what ran through your mind? Jack: Ran through my mind? Nothing, I just handed the phone to my wife without saying anything else. Therapist: OK, that’s what you did. How did you feel in that situation? [deciding first to identify the affect, then to link the affect to the thoughts] Jack: Oh, you know, it’s just the same ol’, same ol’. Therapist: Actually, I’m not sure what you mean by “same ol’, same ol’.” Did this bother you? Jack: Yeah, I guess it does bother me.","e":[62,-17,-137,-88,24,39,9,-58,47,-12,-80,11,45,60,-38,-22,24,-69,-7,58,-77,-2,-54,-32,55,-5,-43,11,-80,46,92,-39,-22,-36,-119,-24,9,30,10,0,44,-6,-23,-98,73,-81,0,66,62,-72,-14,-63,-18,-31,100,22,28,56,19,16,60,39,-27,68,50,-28,-5,61,-43,-6,74,-39,30,15,-31,27,-2,-13,40,20,16,-20,47,0,-2,27,26,61,-33,95,8,-11,-10,36,-72,-7,-20,9,-11,-66,-52,1,-26,-53,51,63,25,19,9,-20,-48,-3,6,-47,12,-45,89,-48,41,5,-20,19,-37,21,22,48,-6,34,-5,-47,-8,-48,4,-3,-6,12,9,-46,1,0,40,20,2,-14,2,-28,28,-48,-45,-4,55,16,5,33,27,-58,-22,6,41,55,32,-14,30,27,-21,-27,-19,62,19,11,-19,-60,-3,-25,37,19,26,-65,-8,-6,18,-36,60,-6,-18,-19,3,-54,-11,-44,-10,22,-69,-24,-54,-38,10,6,10,-6,-4,17,-5,5,-55,41,6,4,5,-6,66,-20,-35,41,-42,-9,11,-3,-82,31,-3,26,1,-17,9,-14,-16,4,-30,37,-42,-88,67,25,9,36,-28,34,-1,55,2,43,40,18,-60,11,21,-37,35,14,-2,17,-16,-11,63,-49]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.124","t":"Therapist: So when your son calls, you answer the phone, and he immediately asks for your wife. How does that make you feel? What emotion do you experience? Jack: Hurt, I guess. Therapist: You felt hurt in that situation. [pause] Can you tell me how you felt hurt? Jack: [describing the situation instead of identifying the automatic thought and also becoming more agitated] He does this a lot. No “Hi Dad, how are you”—no nothing! Therapist: [gently] It certainly seems like this prompts a lot of emotion in you, Jack. So as you talk about it, what is going through your mind right now? Jack: It’s all of that. He has no respect for me! He doesn’t appreciate anything I’ve done for him! I’m going to die an old man, all alone, because my son’s off doing whatever kids these days do! Therapist: [reflects for a moment] These are powerful thoughts, Jack. No wonder you were feeling hurt that day when Christian called. Jack: Yeah, I guess I didn’t realize that all of this was in my head. Therapist: So, the first step in helping you to improve your mood is to identify the thoughts you are having. Jack: I guess so. I mean, it’s pretty depressing to think about it all. So I just try to block it all out…just go about my business. Therapist: And does that help your life to be more satisfying? Jack: Not really. My life is not satisfying at all. [Therapist went on to link the situation with his thoughts, emotions, and subsequent behaviors (e.g., numbing) to illustrate the links among these construct]","e":[62,11,-139,-102,13,29,-5,-30,58,-34,-73,1,26,33,-23,0,19,-32,-44,52,-61,-27,-51,-4,30,32,-41,24,-89,72,62,-30,-53,-11,-129,-14,39,68,30,-22,51,-34,-5,-90,35,-107,26,23,62,-35,-4,-110,-13,-20,101,7,25,45,24,-38,71,38,0,61,58,-21,-17,30,-35,-21,42,-24,33,7,-28,60,-12,3,38,21,33,-21,49,-45,3,11,-11,43,-3,93,25,5,-11,34,-67,9,-20,19,-3,-62,-56,10,-34,-43,33,44,-7,18,16,-23,-42,9,-17,-52,3,-12,77,-68,28,42,-11,68,-36,34,60,73,-37,27,-30,-12,5,-58,0,12,17,28,18,-27,-12,13,63,9,4,-10,-18,-19,8,-46,-48,-3,33,-6,7,31,43,-53,-8,10,59,50,13,7,7,41,35,-33,6,35,28,24,-16,-88,10,-41,44,11,42,-45,-6,-11,50,-35,89,-29,-15,-10,20,-38,-16,-43,2,18,-82,-14,-50,-40,24,-17,2,-15,8,12,-9,6,-47,54,3,13,1,-18,40,-33,-29,29,-55,33,11,5,-45,13,14,17,0,-10,6,20,-20,9,-45,31,-58,-103,67,33,16,46,-32,7,12,71,6,40,36,22,-86,26,-16,-30,11,-16,37,27,15,-21,73,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.124","t":"Notice, in this case, that once Jack’s therapist supplied examples of possible automatic thoughts Jack might have experienced, he then responded with a barrage of his own examples. This is not uncommon with some patients, particularly when they initially have difficulty identifying automatic thoughts. This process is much different than many people are used to, so it takes time and creativity for it to resonate with some patients. Once patients supply their own examples, however, it is important to use their words, rather than the hypothetical automatic thoughts that you supplied.","e":[60,33,-138,-65,23,11,4,1,34,5,-33,4,39,73,-47,-22,26,-80,0,33,-41,-37,-47,-2,13,26,-35,-2,-63,11,49,-27,-42,-54,-73,-32,64,6,5,13,30,10,-5,-69,59,-2,54,19,39,-8,41,-51,-4,-22,139,60,39,62,53,-44,65,48,-30,28,45,5,-37,61,-26,27,46,-20,9,11,-29,15,-9,-3,15,67,37,-47,75,-56,73,21,-7,34,6,85,39,-12,19,72,-89,16,-52,11,-37,-38,-87,-17,-6,-35,19,30,-11,11,6,26,-10,30,-27,-16,0,-4,52,-51,36,43,-5,19,-54,37,13,75,-20,-5,39,-35,2,-32,-10,31,16,29,23,-53,25,1,48,-1,-11,-2,3,-49,-8,-50,-79,51,29,-6,10,43,30,-20,-47,16,28,19,45,-18,-17,29,-9,-39,27,52,22,17,-26,-72,-11,8,66,19,75,-40,19,-30,49,-62,20,-5,27,5,3,11,-27,-41,22,28,-49,-32,-69,-20,39,-15,25,-9,22,18,-27,14,-74,84,-18,11,-39,-52,66,1,-47,47,-30,13,-7,2,-48,23,3,9,-2,-44,-9,-23,-42,-4,-28,43,-19,-112,64,-24,19,-15,-17,23,4,51,-19,13,32,41,-71,-6,25,-46,21,21,-2,22,-13,-30,51,-27]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.124","t":"The Thought Record is a tool for patients to systematically record descriptions of situations associated with a shift in affect, their emotions, and their automatic thoughts. It is a means for patients to collect “data” on their automatic thoughts and further examine the notion of the interrelatedness between thoughts and emotions. Therapists can suggest to their patients that the Thought Record is a “test” to see if • Thought Record their thoughts and emotions are truly linked. Some patients like to think of themselves as “detectives” or “scientists” as they work to identify their thoughts and examine their associated emotions. The most basic Thought Record consists of three columns: (a) situation, (b) emotion, and (c) thought. A Thought Record can be completed using a whiteboard, blackboard, pad of paper on an easel, or a sheet of paper. Figure 4.1 displays a Three-Column Thought Record.","e":[36,39,-165,-107,57,-32,31,20,-23,-37,-9,17,30,31,4,-51,-4,-54,4,19,-9,-23,-88,18,16,71,-27,-27,-59,71,28,2,-4,18,-63,-93,26,-32,14,4,31,-11,4,-82,47,50,9,-12,48,4,11,-32,30,-8,122,68,34,50,1,-16,70,17,-61,42,53,-33,-25,44,3,10,50,-9,43,23,-33,23,-26,26,41,14,84,-77,38,-6,48,8,-17,-2,-21,82,-18,-18,-1,20,-78,11,-17,-2,-12,26,-90,-65,10,-37,34,28,-56,27,9,20,-17,27,-24,-9,-1,-7,57,-16,50,20,13,42,31,64,3,17,17,0,17,-9,-41,-50,-48,23,25,58,0,-25,17,31,77,3,-41,-3,2,-38,20,-71,-62,32,14,-17,-2,17,6,-24,-30,49,76,25,37,40,-53,66,-17,-52,27,22,7,-11,-5,-61,33,27,69,7,61,-12,57,-45,0,-28,35,-41,-13,-57,39,-39,-28,-28,21,23,-50,-7,-49,-26,6,-32,45,-38,10,22,-69,21,-42,71,8,0,-43,-16,85,2,19,38,-25,-7,5,-27,5,18,45,20,13,-31,21,-10,-63,-13,-20,13,-67,-89,16,-6,37,-14,-31,32,7,45,3,20,-9,8,-75,3,-5,-42,11,46,3,-8,12,-25,65,-52]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.125","t":"Figure 4.1. Three-Column Thought Record Date Situation Emotion Thought • Three-Column What event led to a shift What emotion(s) did you What thoughts or images Thought Record in emotion? experience? ran through your mind? (Rate on a 0–100 scale) What did the situation mean to you? Entries on the Thought Record can be completed in session, and if the patient agrees that the identification of automatic thoughts is valuable, the Thought Record can be assigned as homework. Completion of the Thought Record as a homework assignment allows patients to begin to understand the effects of automatic thoughts on their mood in their daily lives.","e":[52,8,-176,-88,61,10,39,-18,-17,-21,-34,13,48,44,-1,-18,21,-49,-27,43,9,-24,-94,-7,35,59,-40,-39,-66,43,35,-2,0,-25,-68,-88,52,-11,1,-1,54,1,10,-55,44,19,14,-11,73,8,11,-27,11,5,106,72,45,26,26,-3,81,10,-26,35,42,-9,-38,71,-12,-21,52,20,39,17,-41,26,-37,0,20,36,68,-30,61,-16,78,21,20,11,-15,89,-30,-5,10,-7,-78,39,-19,43,-28,1,-101,-78,0,-34,28,23,-32,29,4,19,-33,53,-20,-5,14,-9,54,-8,41,53,11,15,13,87,3,22,-15,-3,20,-37,-24,-51,-34,37,4,33,-14,-30,9,21,82,12,-30,-2,-31,-32,9,-62,-50,14,6,-8,5,13,28,-27,-51,19,37,27,30,-3,-62,37,-1,-37,39,24,6,14,-45,-58,26,-15,49,23,50,-22,43,-33,0,-51,21,-28,4,-61,11,-3,-61,-15,-6,38,-27,-22,-86,-45,15,-17,11,-8,32,21,-68,29,-44,81,25,-3,-23,-45,59,8,-36,29,-20,6,20,-5,14,19,10,3,20,-29,12,-1,-39,0,-10,3,-45,-86,32,-10,40,14,-33,31,8,56,-3,32,7,-6,-79,18,25,-42,3,54,12,-6,12,-14,44,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.125","t":"Therapist: Can you tell me in your own words how emotions are related to thoughts and behaviors? Jack: What you’re saying is that when I think something bad, it ends up making me feel bad. And then I act on it without thinking about it. Therapist: Yes, that’s what I’m saying. Do you buy that? Jack: Yeah, I guess I do. I never really thought of it before. Therapist: We have a real simple tool for being able to figure out what you’re thinking in these situations, with the idea that once we identify what’s running through your mind in these situations, we can eventually begin to evaluate those and see if there are times when you’re making yourself feel worse than you need to. Would you be up for learning more about that tool? Jack: OK, shoot. Therapist: [shows Jack a Three-Column Thought Record] We call this a Thought Record. It is a way for you to jot down situations that are tough for you, in which you experience a shift in your emotion, and the subsequent thoughts that run through your mind. Maybe we can do an entry together so that you can see how it works? Jack: OK. Therapist: [Therapist moves the chair so she is sitting next to Jack] We’ve already identified how you were feeling and what you were thinking when Christian called and immediately asked for his mother. Let’s turn our attention to another situation that occurred in the last week. Were there any other times when you experienced an increase in negative emotion, whether it was anger, frustration, or even depression? Jack: I got down once when I couldn’t have a slice of pizza when the guys from poker night ordered it. Man, I wanted that.","e":[72,29,-139,-84,32,10,19,-3,23,-36,-46,32,32,54,-21,-3,30,-34,-17,55,-45,-34,-51,-14,-2,43,-79,25,-90,54,52,-51,-57,-37,-82,-24,26,34,15,-9,47,14,11,-127,51,-66,65,22,36,-24,28,-82,9,-21,114,39,51,29,42,-48,55,31,-43,43,50,7,-42,44,-43,-22,65,-4,30,6,-27,35,-8,0,35,5,44,-25,46,-60,48,12,-3,61,10,105,7,4,18,27,-70,18,-27,3,-25,-46,-77,-23,-38,-40,45,51,-25,4,10,16,-34,26,-19,-42,8,-1,66,-47,20,41,1,74,-22,38,30,38,-2,9,-36,-24,-39,-58,-6,21,-7,49,16,-50,-14,30,96,11,-20,-2,-2,-31,-14,-53,-72,14,18,-1,-14,32,61,-30,-21,24,74,23,43,26,4,32,28,-41,27,67,26,29,-23,-74,-1,-25,28,27,58,-29,25,-13,37,-26,62,-37,14,-30,15,-31,-6,-72,17,22,-54,-10,-50,-63,16,-61,27,-19,8,15,-18,18,-48,57,0,-5,-21,-31,68,-12,-9,31,-21,16,13,-3,-22,12,10,13,-7,-22,-14,20,-12,-15,-37,-6,-72,-76,60,9,34,21,-47,22,12,101,-5,49,9,54,-77,6,29,-37,24,11,25,20,15,-32,50,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.126","t":"Therapist: [gently] Does the strict diet that you’re on prevent you from having pizza? Jack: [glumly] Yeah, cheese and grease make my pancreatitis act up. I can’t eat anything that’s worth tasting. Everything is bland. I don’t even care if I eat anymore. Therapist: You’ve identified a good situation to consider in the Thought Record. [gives Jack the Thought Record and a pen] So, it sounds like the situation that caused the upset was not being able to eat pizza at poker night, right? Jack: Yeah. Therapist: OK, go ahead and put that in the situation column.","e":[65,85,-181,-11,-11,29,-34,2,32,-39,-38,48,18,32,-12,6,-9,-41,-27,59,-23,-41,-33,-7,36,22,-53,64,-68,19,21,-46,-16,-37,-35,-15,51,70,-4,-27,25,71,13,-121,51,-49,47,47,-11,-33,22,-101,-33,-32,60,7,47,-10,66,-37,46,-10,-55,42,26,15,-48,42,-22,-1,76,-11,63,-3,-28,-3,-30,-6,18,29,14,7,42,-16,5,7,34,5,14,109,11,9,26,68,-52,22,-32,19,-30,-23,-66,-4,-15,-31,62,65,26,25,50,10,18,40,-13,-40,49,14,56,-70,11,8,-25,45,9,52,-12,77,-41,48,38,-30,8,-11,11,28,-3,43,14,-56,-13,-17,78,14,-3,-10,42,-36,-2,1,-48,-6,29,27,-11,18,66,-50,4,10,59,15,71,-7,0,24,22,-36,18,71,4,66,-35,-63,0,-36,-12,8,10,-15,17,-31,33,-23,48,22,36,-16,-2,-14,-41,-35,16,27,-51,-43,-22,-21,62,-32,10,-1,-63,6,-37,-17,-56,47,-71,0,-38,-21,45,-19,-25,18,-32,-3,4,7,-51,28,21,-28,-30,-21,-17,0,-19,-20,-38,-3,-49,-118,80,3,12,30,-13,43,14,15,-37,23,20,11,-60,22,41,-51,0,12,2,20,15,-4,64,7]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.126","t":"Therapist: Great, you’ve got the first step down. Now let’s turn to the second column. How did that make you feel? Jack: I felt like I never get to eat anything that’s good. Therapist: [differentiating between emotions and thoughts] It sounds like that’s something that actually ran through your mind, that you thought. What I’m wondering is how you felt. What emotion did you experience? Jack: Unfair. It’s just not fair. Therapist: [continuing to help Jack differentiate between emotions and thoughts in a sensitive manner] OK. You viewed this as unfair. And how did you feel inside? Angry? Frustrated? Self-Pity? Jack: Mostly down. Therapist: You were feeling down. Go ahead and jot that in the second column under emotion. [Jack writes “down”] On a scale of 0 to 100, with 0 being not down at all, and 100 the most down you’ve ever felt, how down did you feel? Jack: Oh, I’d say about a 75. Therapist: A 75. Go ahead and write that in parentheses after “down.”","e":[81,28,-162,-90,8,42,32,-4,31,-46,-54,25,54,33,-12,-17,54,-50,-15,25,-56,-3,-64,-10,5,46,-49,-4,-96,58,13,-30,-47,-19,-71,-11,40,48,2,-13,61,4,8,-98,32,-69,47,48,30,-21,23,-81,-4,-12,94,18,15,22,51,-11,48,-5,-59,44,68,5,-47,40,-70,-25,65,-27,42,-7,-68,18,-25,-24,60,16,16,16,77,-25,22,0,2,67,-10,108,-5,24,2,28,-79,-9,-29,-17,-20,-78,-57,13,-30,-54,57,43,26,9,2,-20,-47,22,-27,-56,12,0,90,-62,-23,32,1,72,-16,54,34,57,-14,26,-36,-30,8,-43,-18,18,-13,47,2,-60,-15,7,69,-10,-15,-10,1,-46,13,-43,-53,3,47,-5,36,23,27,-68,13,27,39,54,32,41,7,39,38,-13,4,76,15,34,-21,-61,6,-48,31,19,56,-7,18,-14,58,22,46,-8,30,-47,16,-37,-25,-41,15,27,-59,-36,-62,-47,49,-32,9,-3,22,22,-25,5,-59,89,-30,16,-13,-47,51,-19,-15,20,-9,0,14,-9,-36,8,11,1,18,-22,19,24,-29,-21,-36,1,-48,-102,50,-24,30,24,-31,19,25,51,2,18,24,30,-88,14,19,-25,21,23,12,32,24,7,37,10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.126","t":"Exhibit 4.5. Jack’s Three-Column Thought Record: Step #2 Date Situation Emotion Thought What event led to a shift What emotion(s) did you What thoughts or images in emotion? experience? ran through your mind? (Rate on a 0–100 scale) What did the situation mean to you? 8/18 Guys ordered pizza. Down (75) Couldn’t have any. Therapist: You’re doing a great job, Jack. Now let’s turn to the final column, the one in which we identify your thoughts. When the pizza was delivered CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 108","e":[27,38,-199,-67,40,23,15,-11,1,-42,-48,30,40,39,-5,-42,39,-25,-26,66,5,-25,-87,-41,34,39,-50,24,-87,12,38,-23,-37,-16,-53,-49,34,15,15,-22,34,12,-18,-109,49,-32,24,49,38,-9,15,-41,11,-21,113,38,56,15,24,-10,63,10,-40,34,47,-20,-46,58,-44,-32,77,-12,44,20,-57,4,-47,-17,-7,2,62,-3,59,-33,30,17,37,29,-13,94,-32,-1,2,40,-73,20,-46,15,4,-33,-88,-56,-20,-39,39,41,-18,29,15,10,-38,37,-19,-23,26,1,61,-26,14,33,18,36,11,62,-16,20,-22,23,-5,-27,-13,-37,-13,44,-22,27,-22,-33,1,22,109,10,-27,-7,1,-26,-12,-53,-53,-19,17,6,-1,26,35,-49,-23,21,34,34,50,3,-22,23,33,-54,22,45,25,66,-58,-76,11,-33,15,4,39,-7,35,-22,26,-37,49,5,3,-56,8,-7,-39,-37,6,41,-38,-31,-49,-66,38,-19,4,-1,17,22,-45,32,-58,90,-20,16,-27,-41,55,-25,-27,9,-7,17,30,-1,-12,20,-12,4,-4,-22,10,20,5,-33,-31,-9,-57,-68,51,-15,27,17,-21,49,43,37,-24,25,24,13,-76,19,22,-53,24,34,10,-6,-8,-4,50,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.127","t":"and you realized that you could not have any, what ran through your mind? Jack: Shit, I can’t have any. Therapist: [realizing that this was a description of the situation, rather than an automatic thought that facilitated his negative emotion reaction] OK, so you can’t have any pizza. What does that mean? Jack: I can’t eat, I can’t even have a beer anymore. There’s no enjoyment in life anymore. Therapist: [repeating the key automatic thought] There’s no enjoyment in life anymore. It makes sense that you would feel down. Go ahead and jot down that statement in the “thought” column.","e":[58,50,-157,-19,32,55,-24,16,9,-45,-50,38,27,62,-15,-11,-14,-37,-22,50,6,-31,-42,-24,49,35,-17,51,-112,36,35,-63,-33,-9,-43,-22,41,49,28,-26,11,16,6,-104,42,-41,64,37,14,-21,50,-112,-9,-18,82,33,51,-42,25,-12,40,-6,-43,83,69,-12,-40,31,-3,-19,72,-25,14,-6,-37,42,-32,5,26,20,28,-8,70,-18,37,2,31,2,25,101,-15,10,6,43,-62,-22,-31,17,8,-46,-75,-23,-49,-38,92,45,-11,16,19,41,-24,39,-27,-36,15,-11,69,-86,37,2,-21,66,15,62,16,65,-33,33,-6,-9,-5,-35,-6,34,-3,16,-14,-60,-14,-2,95,-11,-5,-8,-3,-39,-1,-62,-67,9,23,22,5,7,55,-62,-2,19,29,-8,56,47,-21,35,19,-48,2,23,-7,67,-32,-61,-6,-32,28,6,30,-28,-24,-34,27,-19,58,25,33,1,-2,3,-21,-55,15,17,-21,-51,-36,-28,64,-28,27,-8,-7,5,-41,1,-60,69,-60,16,-20,-12,69,-23,-43,4,0,-8,24,-28,-22,24,18,-9,-38,-24,18,11,-2,-19,-35,-2,-45,-102,71,-14,17,24,3,37,-1,58,-36,3,10,32,-54,12,29,-42,4,33,20,35,-2,8,60,8]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.127","t":"Exhibit 4.6. Jack’s Three-Column Thought Record: Step #3 Date Situation Emotion Thought What event led to a shift What emotion(s) did you What thoughts or images in emotion? experience? ran through your mind? (Rate on a 0–100 scale) What did the situation mean to you? 8/18 Guys ordered Down (75) There’s no pizza. Couldn’t enjoyment in life have any. anymore.","e":[32,39,-201,-48,37,56,18,-13,0,-49,-47,41,36,69,-5,-26,31,-24,-25,69,15,-29,-87,-35,24,31,-33,-12,-76,26,32,-12,-28,-23,-52,-50,29,3,32,-34,31,16,-12,-82,64,-36,7,46,60,-5,15,-25,10,-12,110,64,56,14,26,9,41,-2,-23,25,53,-17,-41,53,-30,-44,72,-6,13,10,-50,9,-34,-19,6,13,53,-2,70,-26,31,7,34,26,-6,88,-32,17,11,17,-77,28,-42,32,15,-26,-92,-58,-22,-40,50,24,-25,45,18,16,-39,50,-15,-25,31,-12,65,-19,12,24,8,36,11,83,-9,9,-17,23,-3,-36,-14,-36,-24,40,-18,22,-17,-36,6,26,131,12,-23,-25,-13,-34,-5,-67,-45,-13,22,9,6,27,25,-48,-33,18,28,16,50,-1,-16,25,22,-54,22,36,12,59,-51,-67,18,-35,1,9,47,-5,20,-37,24,-38,46,-5,14,-63,7,-1,-50,-34,-5,32,-39,-41,-39,-66,30,-2,1,13,27,-1,-42,28,-51,87,-10,13,-21,-48,57,-19,-48,-9,-3,2,41,-5,3,24,-24,-2,-18,-21,30,13,19,-24,-25,-9,-63,-73,50,-5,30,23,-19,40,40,31,-36,27,-2,0,-54,3,25,-42,17,38,4,-8,13,-14,47,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.127","t":"Notice on the Thought Record that, in the Emotions column, Jack was instructed to rate the intensity of his emotion on a scale of 0 to 100 (0 = no [emotion]; 100 = most [emotion] I have ever experienced). This rating accomplishes two purposes. First, it demonstrates to patients that there is variability in the intensity of negative affect that they experience. Patients often realize that the degree of emotional intensity is associated with the nature of automatic thoughts they identify, such that more intense • Alternative emotional experiences are often associated with more negative, or maladaptive, response automatic thoughts. Second, as will be described in the next sub-section (i.e., Evaluating Automatic Thoughts), the goal of cognitive restructuring is to help patients develop different, more balanced cognitions to counteract negative or maladaptive automatic thoughts. Cognitive behavioral therapists often have patients provide another rating of the intensity of the emotion after developing an alternative response, which provides evidence to support the notion that cognitive restructuring helps to reduce negative affect.","e":[64,37,-159,-76,47,-2,45,39,28,-20,5,37,68,40,23,4,-7,-24,0,49,-35,-56,-31,-20,22,90,-20,-22,-38,27,50,-3,-25,-33,-81,-19,37,57,-1,18,4,-23,53,-75,33,22,73,13,66,-12,16,-55,17,-33,140,48,-20,52,36,-40,46,22,-28,64,36,3,-33,34,-44,9,12,-18,-38,39,-54,-10,-14,-18,21,36,58,-44,89,-40,67,0,19,28,5,96,30,22,20,6,-93,33,-9,10,-16,-27,-88,-3,-4,-16,21,49,-19,34,20,24,-47,31,-19,-39,18,-7,66,-23,-8,68,30,4,4,52,15,43,-20,9,32,-34,-24,-34,-20,-19,16,41,-20,-58,-9,70,64,16,5,14,-35,-42,13,-30,-33,25,-10,-26,34,-31,10,-51,-21,22,28,50,67,36,-34,52,-9,-51,30,35,16,32,-63,-51,28,-24,52,20,71,-34,29,-21,6,-20,61,10,21,-34,22,12,-40,-3,39,20,-82,-7,-94,-27,28,-6,22,-38,17,24,-21,-5,-75,57,12,6,-44,-11,44,15,-13,5,-17,2,5,-22,-7,17,15,8,9,-14,8,-13,-14,-16,-8,21,10,-83,47,19,10,29,-9,20,18,63,20,28,23,26,-89,-8,14,-35,-18,23,-21,26,-11,-13,65,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.127","t":"We find that many patients respond favorably to Thought Records after some time has been spent with them in session because they provide a concrete means for evaluating thoughts and ideas that have been unhelpful to them. Such re-evaluation, in turn, often instills in patients a sense that they are Thought Records provide the making meaningful changes in treatment. Moreover, Thought Records opportunity for patients to slow provide the opportunity for patients to slow down their thought down their thought processes processes and identify the link between their thoughts and emotions and identify the link between more systematically than they might have otherwise. In fact, many their thoughts and emotions depressed and anxious patients report that one thought prompts another more systematically than they thought, which prompts another thought, which prompts yet another might have otherwise. thought, etc., with each thought being more negative and distorted than the previous one. We call this phenomenon the runaway train effect. Use of the Thought Record will stop the “runaway train” by interrupting the cascade of thoughts. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 109","e":[26,36,-187,-98,82,-1,59,48,9,-34,-25,31,37,19,-1,-47,20,-49,-32,4,-6,-11,-63,-6,2,78,-36,-15,-51,68,70,-42,-2,-8,-68,-51,33,-18,19,12,57,-16,25,-92,56,2,71,9,56,-37,44,-41,-1,-24,105,15,17,37,-6,-56,63,31,-44,24,70,-23,-32,41,12,-8,46,14,1,24,-34,52,-27,13,-23,3,42,-68,19,-8,49,11,34,26,-35,82,-1,-53,20,43,-88,40,3,-22,-31,11,-87,-47,8,-59,20,36,-46,22,13,1,-37,9,-16,-20,13,-1,54,-33,6,18,4,25,-10,54,24,47,14,-17,42,-25,-38,-24,-35,6,16,29,-7,-31,12,-1,68,-8,-24,-3,-11,-35,21,-40,-75,2,-9,3,9,23,27,-40,-25,53,44,17,43,12,-56,66,-17,-36,27,28,23,-14,-26,-54,14,14,61,15,96,-36,10,-52,6,-47,33,-15,12,-38,23,-22,-56,-72,33,23,-60,3,-83,-36,17,-8,33,-37,2,29,-52,-14,-44,44,-23,8,-34,-47,64,2,22,32,-34,-30,33,-30,-9,40,50,15,-1,-48,16,-41,-56,-46,-29,8,-43,-83,28,-17,41,-4,-5,12,1,39,20,32,-7,16,-83,9,-2,-43,-3,17,4,24,-11,-7,73,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.128","t":"Not all patients may necessarily respond favorably to completing Thought Records. For example, some patients have limited educational, language, or English-speaking skills and find the completion of Thought Records to be a burdensome task. In these instances, therapists can take the lead in completing the Thought Record for them in session, such that they sit with their patients in a side-by-side position; list the situation, emotions, and thoughts; and visually demonstrate the link between them. Sometimes, using the letters ABC to represent the cognitive model can be helpful with this type of patient. Figure 4.2. The Link Between Situations, Emotions, and Thoughts","e":[10,31,-161,-109,66,-1,31,-2,30,-11,-30,-15,24,48,13,-28,6,-83,-24,22,-49,-9,-53,17,10,62,-28,-1,-72,38,33,-2,-6,-32,-62,-64,39,-6,-3,11,69,-18,-16,-100,44,-8,35,9,62,-7,19,-30,6,-2,120,69,38,60,18,-31,98,31,-69,40,65,-3,-29,77,-8,-7,36,0,66,27,-45,17,-30,10,31,28,65,-38,52,-37,53,26,-17,17,-28,102,-3,-20,16,36,-90,27,-30,-1,-21,-5,-84,-35,19,-57,27,20,-21,15,-7,16,-44,22,-24,-10,8,-24,56,-32,35,33,-2,13,0,56,12,53,-8,-19,32,-13,-39,-43,-35,44,14,53,-12,-34,38,14,58,12,-10,-16,-7,-47,0,-44,-53,16,1,1,5,42,33,-43,-26,15,41,16,48,24,-56,59,12,-46,46,21,7,-7,-34,-65,27,16,73,12,51,-2,46,-46,16,-52,46,-29,-9,-37,1,-23,-42,-39,31,43,-41,-11,-76,-61,27,-26,35,-19,-3,17,-55,23,-51,62,-20,-3,-36,-36,59,-2,-18,55,-42,-4,-1,-21,-41,44,42,0,11,-55,26,-11,-61,-4,-30,15,-30,-78,40,-7,55,-12,-10,54,6,72,0,28,22,15,-77,30,7,-26,-18,44,1,-1,14,-25,52,-24]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.128","t":"In Figure 4.2, the letter “A” stands for activating event, “B” for beliefs or automatic thoughts, and “C” for emotional and behavioral consequences. Drawing a diagram using these letters can help the patient visualize the flow of how activating events give rise to automatic thoughts, which in turn give rise to unpleasant Drawing a diagram using these emotions and self-defeating behaviors. For other patients, Thought Records invoke painful memories of school struggles and remind them letters can help the patient of a school assignment. Cognitive behavioral therapists are creative in visualize the flow of how working with patients to develop exercises and assignments that fit their activating events give rise to patients’ individual personalities that at the same time achieve CBT’s automatic thoughts, which in basic goals. For example, therapists might create straightforward turn give rise to unpleasant checklists of patients’ automatic thoughts identified in each session and emotions and self-defeating ask patients to make a check mark each time they catch themselves behaviors. thinking the automatic thought in the time between sessions.","e":[33,5,-165,-97,86,-27,79,14,31,-21,-26,42,102,51,25,-33,-11,-68,-14,26,-41,-3,-32,15,44,46,-14,16,-70,-8,30,9,-6,-67,-46,-26,55,40,-3,-1,36,12,-2,-64,29,-19,59,8,37,-4,19,-80,27,-21,122,47,24,43,-4,-16,73,89,-23,53,61,5,-45,29,-55,-13,35,-31,55,52,-45,16,-57,-17,16,55,38,-33,74,-39,98,25,0,8,-46,80,-15,1,-12,12,-95,9,-8,3,-22,-14,-88,-34,-13,-15,5,27,-15,-24,-6,15,-56,50,-40,-11,8,-4,50,-52,14,36,22,21,-2,51,5,66,-22,-15,33,-51,-13,-33,-2,-3,26,44,1,-31,-12,27,41,-3,-1,20,-29,-32,-3,-13,-43,39,-17,26,-10,3,47,-41,-18,27,21,9,57,20,-64,34,-50,-55,27,36,10,21,-50,-44,16,-19,31,5,41,-12,23,-66,17,-35,50,20,20,-25,-17,1,-44,-23,36,29,-71,4,-92,-66,7,1,18,-20,8,24,-59,16,-28,79,-29,14,-39,-23,53,15,-14,25,-34,-11,11,-33,-54,11,42,-6,-2,-15,-12,20,-26,-6,-31,18,-44,-78,37,9,18,-1,-27,26,23,38,21,42,24,28,-78,17,18,-48,-30,48,1,26,-30,-12,57,14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.128","t":"Evaluating Automatic Thoughts There are a number of strategies that can be easily implemented when automatic thoughts are identified so that more balanced, adaptive interpretations can be constructed. The strategies are, for the most part, relatively simple; yet, they require consistent practice. We often remind patients that they have had a substantial amount • Evaluating of time to practice responding to the world in a way that elicits automatic thoughts. automatic Therefore, it stands to reason that it will take a commitment along with some work thoughts and practice to develop a new way of responding to the world, which will then become a habit. In other words, patients’ previous cognitive style has been over- learned, and most of the time they do not put a great deal of effort into addressing the logic of their thoughts—they just trust them to be sound and reliable. With practice, they will learn a new way of evaluating information from their environment, and eventually it will become as automatic as the automatic thoughts. For military personnel, this can be likened to learning to march at Basic Training. At first, the CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 110","e":[39,13,-160,-58,83,17,71,-14,20,11,-5,-2,47,58,15,-45,5,-68,9,21,-10,-28,-48,-36,27,30,-46,13,-54,16,32,-42,-11,-51,-40,-40,56,21,0,9,36,-13,35,-62,48,12,74,15,37,-21,28,-61,4,-29,125,43,-5,44,-2,-55,115,33,-52,22,32,-24,-45,53,-25,-7,46,-19,1,18,-59,16,-29,-1,2,43,39,-53,64,-53,77,4,8,13,-8,113,27,-12,26,46,-108,26,-36,8,-52,-40,-75,-41,-19,-21,22,31,-32,21,-13,25,-40,42,-13,-15,-20,-2,60,-32,9,78,36,7,-22,34,21,67,-35,-18,41,-11,-8,-19,-7,-1,7,49,-5,-61,-6,5,38,-17,-4,29,-23,-20,-7,-37,-55,26,5,22,-6,9,54,-39,-35,38,30,20,36,16,-48,47,-14,-22,12,56,27,1,-46,-39,13,-14,102,-6,87,-50,13,-32,-4,-46,18,16,-1,-26,12,-1,-43,-53,51,43,-60,-21,-96,-26,52,-26,52,-30,8,28,-50,29,-55,89,-3,-16,-44,-58,77,35,-28,36,-3,19,7,-4,-28,15,25,-7,-17,2,-10,-29,-58,7,22,22,12,-87,53,-4,11,13,-14,28,29,55,25,33,38,26,-99,-25,22,-39,-4,13,8,30,-26,-16,45,-30]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.129","t":"commands sounded foreign, and they had to think about how and where they stepped. However, after practicing it enough times, they knew exactly what to do when they heard, “Column Left, March!” In fact, they eventually did it instinctively.","e":[22,-3,-199,-26,99,32,54,-9,19,-26,-80,26,71,60,26,-55,45,-64,-17,71,-10,-5,-33,-36,38,-4,-37,-26,-21,9,37,25,15,-44,-45,-93,-8,-23,-15,-15,59,2,-46,-53,83,-40,31,18,61,-27,-16,-74,-39,-10,57,28,54,-37,61,11,74,10,-46,16,9,-8,-41,78,-35,-1,66,-39,48,0,-66,38,-25,-13,3,28,22,-17,71,-9,46,47,28,-10,-18,93,-37,-26,-10,32,-90,12,-17,34,13,-43,-25,-30,-22,-26,36,36,50,-21,-20,-42,-4,45,-1,-8,-8,12,93,-19,25,51,-6,-12,-32,8,37,62,-29,-18,-1,-42,-5,3,-25,-8,-7,84,-13,-16,38,-16,57,31,1,1,2,-41,31,-54,-20,19,0,-16,-6,58,21,-34,-15,23,18,-13,26,-38,-52,40,19,-68,-7,40,8,-10,-66,-11,9,-9,36,18,33,-55,8,-49,8,-30,-11,20,-34,-48,-8,7,-34,-65,-19,46,-51,-8,-46,-64,15,-3,1,16,1,-21,-30,-5,-47,55,0,31,8,9,98,1,-33,-16,-29,-19,16,-23,-27,14,-33,-6,3,-24,36,2,-44,30,-34,11,0,-104,57,4,39,-28,0,29,44,10,2,-7,52,-25,-57,35,34,-10,10,35,2,19,8,6,38,1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.129","t":"As previously stated, a common method to help patients evaluate their automatic thoughts is to ask questions that stimulate critical thinking and accurate examination of these cognitions—a process called Socratic questioning. We encourage therapists • Socratic to refrain from directly challenging the accuracy of their patients’ automatic thoughts. questioning In fact, there is often a “grain of truth” in these thoughts, and it would damage the therapeutic relationship to overlook that. The goal of Socratic questioning is for the patient and therapist to work collaboratively to evaluate the automatic thought’s validity or usefulness and to develop an alternative, balanced response that follows logically from the evaluation. Below we list common questions that you can ask your patients after they identify problematic automatic thoughts.","e":[90,28,-128,-64,59,-5,63,-4,26,53,47,4,64,36,-46,-50,27,-86,-17,34,-53,-39,-34,12,60,26,-22,10,-41,20,36,-10,5,-4,-33,-49,107,18,-36,2,19,-43,33,-107,66,-10,52,-42,31,-63,17,-82,-11,-9,71,66,26,75,-1,-17,64,18,-16,19,47,-3,-18,42,-43,28,47,-6,62,29,-65,6,-3,10,19,26,45,-73,62,-42,28,55,-23,10,8,83,32,-26,45,41,-101,53,-23,-2,-24,-21,-80,-1,-15,-19,4,25,-6,28,32,13,-21,31,-30,-19,19,11,74,-20,36,14,7,41,-12,61,19,75,-44,-1,6,-10,-3,-59,-22,-18,-14,60,9,-45,15,-21,42,-5,-10,18,4,-37,-2,-25,-69,27,-8,-5,-14,-3,51,-37,-29,15,36,30,30,-4,-45,47,-8,-1,23,24,20,11,-48,-74,22,2,76,21,59,-80,46,-16,31,-38,41,-3,-4,-12,25,-10,-4,-40,33,14,-45,-24,-100,-19,53,-23,37,-34,-11,20,-57,15,-52,68,-12,-28,-35,-45,79,2,-5,32,-38,5,34,-23,-9,29,17,-25,-26,6,-15,-2,-81,-5,-4,30,-41,-105,41,-4,25,13,-9,44,25,45,17,24,20,32,-95,-8,14,-52,9,-11,-6,52,-35,-20,43,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.129","t":"Questioning Automatic Thoughts What evidence supports that thought? What evidence does not support that thought? Could there be any other explanations? What is the worst that could happen? The best? The most realistic? If the worst thing were to happen, how bad would that be? How would you cope with it? Do you know for certain that _______ will happen? Are you 100% sure about this? Does _______ have to lead to or equal _______? Is ______ really so important or consequential? Does _______’s opinion really reflect that of everyone else? What is the effect of believing my automatic thought? What is the effect of taking a different perspective on this situation? How useful is it for you to be focusing on this thought? What should you do about this? What would you tell a friend if he or she were in the same situation? If you must be in this situation, how can you survive it? What wisdom can you gain from this situation to deal with similar circumstances in the future? Note: Many of these questions can be found in J. S. Beck (1995) and Heimberg and Becker (2002).","e":[76,20,-97,-17,87,56,43,9,30,18,-3,-17,35,86,0,-22,14,-51,12,33,-24,-49,-75,-4,28,17,-78,-24,-61,-12,25,-9,-12,-90,-89,-32,60,28,5,-13,33,27,34,-98,59,-26,69,18,77,-37,50,-24,5,-40,85,43,38,31,33,-53,82,30,-48,15,38,-22,-46,75,-24,-13,21,2,-13,9,-72,39,13,-1,38,56,45,-59,78,-44,-16,24,11,2,1,91,57,-11,33,24,-61,26,-60,5,-62,-16,-50,-30,-3,12,31,1,13,29,9,8,-57,-16,-25,-11,-13,15,90,-34,39,60,17,67,-19,67,6,51,-47,-7,4,-38,-7,-30,-8,16,0,62,-9,-17,7,4,95,11,-14,12,-49,-50,3,-21,-60,9,1,1,-9,11,34,-32,-59,41,34,5,33,6,-25,27,-44,-3,38,28,29,31,-58,-65,19,1,86,-24,55,-66,-11,-30,15,-41,20,-30,28,-31,36,21,-22,-23,34,-28,-39,-44,-73,-50,69,-5,39,-24,-10,6,-66,42,-36,71,0,-17,-8,-65,84,9,5,49,-24,21,20,11,-11,59,-15,10,-8,5,-8,-4,-46,-17,-17,28,-24,-112,47,4,35,2,-21,32,31,60,11,16,19,23,-65,-14,42,-52,17,63,21,71,-19,13,47,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.129","t":"When therapists first introduce the process of Socratic questioning, they usually take the lead in asking these questions to facilitate patients in viewing their thoughts from a different perspective. Cognitive behavioral therapists take care not to argue with patients or pressure them to change their thoughts; rather, they approach this process with a collaborative, inquisitive, and curious spirit. The ultimate goal is for patients to be able to engage in this process, particularly in the moment when they notice automatic thoughts that have the potential to lower their mood or prompt an effective behavioral response. The following dialogue illustrates the manner in which Michael’s therapist helped him evaluate the idea that his life was not worth living, which was associated with substantial depressive affect and often prompted subsequent suicidal thoughts.","e":[64,20,-130,-41,80,20,59,-4,29,26,-6,-12,60,52,-27,-59,19,-77,-12,55,-84,-33,-24,8,33,41,-28,31,-23,7,66,29,-30,-11,-44,-45,90,40,-30,6,23,-37,23,-151,24,-56,69,-31,28,-37,32,-68,-6,-24,67,32,28,70,-11,-55,70,15,-21,26,34,-1,-26,49,-63,25,55,-2,56,40,-29,33,-6,-9,9,4,55,-49,46,-60,34,59,-6,20,-12,66,10,-31,17,27,-90,35,-36,-30,-14,-34,-59,-6,-11,-10,1,32,15,13,7,14,-70,39,-39,-18,21,24,64,-42,44,28,-16,22,0,35,7,93,-44,-4,15,-18,-14,-53,-17,-22,-17,66,-8,-27,16,3,62,20,6,16,0,-37,16,-19,-38,-9,-24,26,11,29,35,-44,-25,12,29,19,28,-4,-43,41,1,-31,40,-2,19,4,-45,-77,-4,3,92,25,54,-55,25,-34,16,-33,44,-4,18,-13,24,-16,-28,-46,2,18,-49,7,-91,-56,60,-26,22,-24,-28,11,-58,32,-63,68,-21,-25,-51,-42,54,-27,0,22,-69,10,19,-9,-26,49,16,-22,-17,12,-3,9,-75,-11,12,29,-35,-81,58,17,26,29,-23,22,32,59,20,37,41,24,-73,7,8,-29,-8,4,7,37,-20,2,41,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.130","t":"Therapist: Should we turn to the first item on the agenda? Review of your Thought Record? Michael: Sure. Therapist: [scanning assignment] It looks like a number of the automatic thoughts you experienced in the past week revolved around a certain theme— that life is not worth living now that you’ve suffered an injury that may prevent you from attaining the academic and professional success you had hoped. Michael: [looks dejected] Yeah. Therapist: I know this has been a concern of yours since we started treatment. I’m curious, Michael—you did some things early on to improve your relationships and to generally become more active. When you were doing these things, how was your view that life isn’t worth living affected? [attempting to identify evidence that contradicts the idea that life is not worth living] Michael: I guess it took my mind off of being suicidal, if that’s what you mean. Therapist: So, one outcome of engaging in those behaviors was to distract you from potentially harmful thoughts. That’s great. I’m also wondering if they provided a different perspective on life for you, perhaps, that life is worth living. Michael: I don’t know. I guess doing those things gave me some short-term gain. But, what kind of life is worth living if the only time I get enjoyment is from occasionally going out to eat or watching a movie with my girlfriend or my mother? Therapist: You’re right, we still have some work to do to reach one of your treatment goals—to develop reasons for living. I’m wondering, though, if you still believe that life is 100% not worth living. Or, are there times, even if they are fleeting, when you can see some purpose? Michael: I don’t know. Maybe there’s some purpose. My girlfriend told me that she’s staying by me no matter what. I was kind of surprised about that. But, in other ways, it all just seems so pointless. My ambitions, my career plans…all down the toilet! Therapist: [gently] Does not going to law school and not pursuing a career in politics have to equal a life worth living? Michael: It seems like it for me. Therapist: Do you know of other people who have not gone to law school or had a career in politics who have lives worth living? Michael: [pause] I see what you mean. My mom, I guess. She doesn’t have anything other than a high school degree, but people really look up to her. She really tries to make a difference. And she really makes a difference for me. Therapist: So, might it be helpful for us to work together to redefine, specifically for you, what it means to make a difference and to have a life worth living, given your new life circumstances? Michael: Yeah, I think so. Therapist: So, we started with your idea that life is not worth living. After this discussion, what might be an alternative way of looking at your life?","e":[43,22,-119,-50,54,67,5,5,60,3,-46,-9,65,16,-49,-24,-16,-54,-33,41,-49,-58,-30,28,11,39,-24,23,-105,51,89,-39,-27,-6,-74,-7,69,106,48,-52,16,-19,4,-103,27,-54,71,-9,34,-23,47,-32,5,68,104,5,10,28,-14,-79,96,42,-46,61,60,-30,-31,8,-32,-32,56,1,2,34,-6,111,2,18,10,16,4,-31,27,-44,-4,38,22,9,-4,90,6,35,-1,-1,-83,10,-12,-18,-31,5,-68,-2,-15,-17,61,33,-5,-37,-26,3,-18,13,-41,-33,-3,0,87,-84,26,53,1,40,21,23,37,76,-26,-12,-9,23,-12,-43,-22,38,-12,85,32,-49,-25,13,91,-12,-15,3,-7,-19,12,-22,-29,26,3,31,3,48,33,-56,-12,-5,49,4,8,5,-6,26,28,-11,33,11,1,16,-5,-92,33,-36,89,-32,29,2,-36,-50,44,-5,36,-27,19,9,21,3,-27,-38,-7,23,-55,-7,-28,-28,56,-29,24,-21,-25,7,-63,10,-51,52,-12,-3,-36,-37,71,-30,-3,39,-59,-15,-5,16,-38,48,25,10,18,-12,22,20,-73,-37,-36,-6,-27,-80,45,21,-6,12,-9,23,41,91,-11,48,6,0,-21,3,27,-20,2,13,30,31,37,27,42,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.131","t":"Michael: I guess that life doesn’t have to be meaningless just because I can’t do what I expected to do. That it’s up to me to find different kinds of opportunities to make a difference. Therapist: Well put, Michael. Now, I’d like to explore what effect this different perspective has on your mood. In looking at your Thought Record, it seems that when you had the idea that life was not worth living, your depression was at a very high level, 95 to 100. Now that you have an alternative way of viewing things, how would you rate your depression? Michael: I guess lower, like a 60 or so. This is all still really overwhelming for me. Therapist: In my experience, it’s a lot easier for people to work on their problems when their depression is at a 60, rather than when it is at a 95 or 100. Would you say this is the case for you? Michael: Yeah, definitely.","e":[43,39,-150,-63,30,70,21,14,24,-33,-47,-1,60,31,-20,-5,-25,-85,0,66,-81,-60,-59,-10,12,46,-1,-7,-71,56,44,-15,-18,-6,-97,6,37,122,80,-46,9,-32,21,-65,26,-40,61,47,37,-38,40,-39,17,8,91,28,-35,15,29,-30,85,33,-22,70,45,2,-50,47,-65,-52,51,-22,-14,28,-36,80,-23,-4,43,11,29,-13,57,-15,40,5,35,17,0,105,11,17,10,37,-68,-8,-21,13,6,-20,-56,-4,-20,-15,44,51,8,-21,-24,-10,-28,24,-57,-53,21,7,85,-71,0,51,6,48,29,39,36,33,22,29,12,-19,-15,-42,-33,28,-10,73,16,-42,-30,12,64,-10,-7,-10,-25,-36,15,-24,-52,3,2,11,42,24,7,-65,-31,18,45,1,30,24,-3,44,43,-31,2,38,-19,21,-29,-76,17,-39,82,-27,25,20,-18,-25,68,-3,38,-23,-7,-20,44,-28,-58,-15,-7,13,-39,-9,-42,-10,61,-24,20,-20,-26,29,-17,-5,-88,67,-3,6,-38,-50,32,-37,-7,26,-31,11,-45,1,-35,29,18,-4,42,7,58,11,-81,-3,-8,24,14,-95,48,36,-15,43,-32,5,33,67,-3,44,7,20,-30,30,9,-33,19,47,-7,5,17,39,44,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.131","t":"A useful tool for helping patients evaluate their automatic thoughts is an expansion of the Three-Column Thought Record described previously—the Five-Column Thought • Five-Column Record. The first three columns of this Thought Record are the same as the Thought Thought Record Record described previously—patients record the situation or event that elicited a shift in affect, the intensity of the associated emotion, and the automatic thought. However, the Five-Column Thought Record requires that patients supply two additional pieces of information. In the fourth column, patients record alternative responses to the automatic thoughts listed in the third It is critical for patients to column. They arrive upon the alternative response through the process complete the outcome column of Socratic questioning, illustrated in the previous dialogue. In the fifth in order to provide evidence column, they record the outcome associated with the alternative that the cognitive restructuring response. The outcome might be a reduction in the negative affect listed process is facilitating positive in the second column (e.g., depression decreases from a level of 100 to changes in their lives. a level of 60). However, the outcome could be an entirely different emotion (e.g., “content” instead of “depressed”). The outcome could also be an adaptive behavioral response that the patient initiates as a result of the more balanced alternative response. It is critical for patients to complete the outcome column in order to provide evidence that the cognitive restructuring process is facilitating positive changes in their lives. Figure 4.3 is an example of a Five-Column Thought Record.","e":[50,28,-165,-105,69,-32,48,-9,-10,11,-11,-8,51,28,12,-46,11,-68,-7,48,-27,-24,-82,4,37,76,-46,-7,-76,56,52,-5,-11,-8,-86,-65,79,8,2,11,25,-1,46,-50,43,19,65,-19,41,-14,0,-23,7,-6,104,61,11,40,17,-5,58,18,-35,41,64,1,-22,73,-38,-3,48,2,41,13,-38,42,-41,11,22,31,77,-52,79,-27,58,7,21,10,-32,53,-11,3,9,23,-93,44,-29,-11,-38,-2,-84,-61,12,-30,25,40,-35,21,17,10,-32,29,-29,-30,-6,-27,65,3,30,36,8,34,19,68,10,26,-12,11,52,-25,-20,-48,-36,21,30,75,3,-43,12,17,52,-4,-28,23,7,-52,11,-36,-59,41,8,-33,-3,29,13,-40,-37,15,34,32,31,-4,-82,71,-21,-19,37,39,1,12,-21,-81,17,-13,74,-1,80,-49,33,-32,22,-28,22,-6,12,-31,14,0,-25,-31,31,18,-66,-32,-76,-39,15,-17,41,-33,15,33,-51,14,-44,74,3,-3,-18,-34,85,16,10,29,-19,17,21,-6,14,20,34,13,-5,-15,13,-22,-46,-12,-22,6,-43,-94,31,-25,24,-23,-24,32,14,49,-2,41,-10,24,-73,-6,2,-51,12,47,8,43,4,-4,60,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.132","t":"Figure 4.3. Five-Column Thought Record Date Situation Emotion Thought Alternative Outcome Response What event led What What thoughts Re-rate the to a shift in emotion(s) did or images ran Use the intensity of the emotion? you through your questions to emotion you experience? mind? evaluate the listed in (Rate on a automatic Column 2 or 0–100 scale) What did the thought and list a new situation mean construct a emotion you to you? more balanced are thought. experiencing. Describe what you will do differently as a result of the alternative response.","e":[26,5,-178,-89,94,16,54,-26,12,-52,-39,19,79,63,9,-22,27,-57,-24,65,-22,-50,-55,-1,9,56,-57,-20,-84,20,13,-8,18,-27,-82,-50,35,18,30,-13,30,-7,17,-36,56,-22,30,-1,66,-20,10,-10,8,-12,121,62,28,34,17,-23,79,18,-17,32,70,-15,-47,69,-40,-37,47,-8,-11,24,-50,12,-33,-16,-3,30,79,-24,86,-21,81,-1,25,14,-34,77,-7,13,22,-5,-90,21,-43,13,-22,-22,-72,-56,-3,-39,30,25,-40,45,-4,9,-56,34,-26,-15,8,-35,67,-6,-1,60,15,42,15,62,11,7,-2,-18,0,-39,7,-53,-20,23,-8,25,-7,-50,5,18,95,13,-23,-12,-28,-20,5,-48,-21,15,28,29,6,37,12,-44,-32,35,19,9,64,2,-33,25,-17,-31,27,34,19,17,-53,-62,14,-25,59,24,74,-24,13,-26,-2,-45,40,-14,16,-86,30,7,-45,-31,-18,48,-60,-30,-56,-76,3,-11,13,-6,52,37,-61,33,-39,66,-22,2,8,-55,85,-6,-6,20,-25,23,36,8,1,30,2,-9,-12,7,20,-1,-33,-16,3,8,-24,-88,50,7,22,22,-27,39,35,29,29,28,3,-2,-56,20,54,-12,4,34,6,3,25,-11,38,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.132","t":"The following transcript illustrates the manner in which Kate’s therapist introduced her to the Five-Column Thought Record. This dialogue occurred in the sixth session of CBT; the third and fourth sessions had been devoted to behavioral strategies such as Activity Monitoring and Activity Scheduling, and Kate’s therapist introduced the Three-Column Thought Record in the fifth session. Exhibits 4.7 and 4.8 show the manner in which Kate filled in her Five-Column Thought Record.","e":[14,33,-178,-84,54,-13,37,-27,17,-10,-94,-21,80,34,-13,-56,1,-48,-24,33,-21,-23,-56,-19,24,71,-49,19,-43,29,83,-23,-3,-2,-57,-91,70,-7,-40,-36,72,15,-6,-71,24,-35,63,29,-6,31,-2,-7,7,-29,99,69,1,17,-4,-26,81,0,-67,49,47,-4,-48,123,-65,-1,47,-24,65,15,-7,21,-39,1,-3,43,67,-25,68,-24,63,15,15,27,-30,50,-9,-7,1,26,-68,10,-31,-29,-26,-4,-92,-40,17,-21,27,42,-30,-7,5,0,-52,33,-30,5,-26,-6,47,-46,31,20,-10,-15,6,41,-12,51,-33,3,23,-36,-37,-43,-38,24,15,63,-2,-34,4,19,36,10,-30,0,20,-26,29,-62,-43,13,22,-2,-9,36,12,-44,-17,20,47,29,31,-8,-40,31,-30,-12,22,42,28,7,-42,-85,-1,-17,45,19,48,-34,23,-24,20,-21,3,22,-8,-35,-12,-28,-26,-41,7,39,-62,-23,-55,-67,48,-20,13,-24,1,34,-79,34,-39,74,-31,9,3,-45,74,19,-16,35,-39,7,11,-20,-17,32,18,15,-11,-17,20,-7,-36,-6,-17,-2,-72,-70,10,-4,24,32,-30,29,-11,46,3,33,11,16,-61,12,5,-35,2,71,-4,10,40,-12,54,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.132","t":"Therapist: [reviewing the Three-Column Thought Record Kate completed for homework] It looks like you’ve identified several thoughts associated with sadness, such as I’ll never see my children again, as well as several thoughts associated with anxiety, such as I’m going to be evicted. Kate: Yes. I really had a lot of negative thoughts in the past week. Therapist: Did you find this exercise helpful? Kate: A little. I guess it helps to know what I am thinking. But I’m still the same—still depressed and anxious. Therapist: I’m glad you brought that up. The purpose of the Three-Column Thought Record is twofold—one, to give you practice in identifying automatic thoughts that come up during the week, and two, to provide evidence for the link between emotions and thoughts. Now that you’ve spent some time recording situations, emotions, and thoughts, do you believe that there is a link between your thoughts and emotions? Kate: Yes, it makes sense. If I constantly focus on the loss of my children, then it’s no wonder that I am so down. Therapist: You’re right. And I also want to acknowledge the comment that you made a minute ago—that your depression and anxiety did not change as a result of doing this exercise. That also makes sense because there is more to this process. You’ve identified the thoughts, but you have not yet evaluated them to see whether or not they’re accurate. Kate: How do I do that? CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 114","e":[47,-1,-147,-109,56,26,42,3,7,-21,-55,-3,75,21,-37,-19,10,-27,-31,48,-23,-31,-75,-9,36,83,-61,12,-73,67,69,-36,-28,-24,-71,-53,73,48,-24,-14,87,-9,-2,-104,3,-46,81,8,21,-20,26,-69,17,-15,100,23,21,10,-4,-38,100,10,-61,61,59,-21,-53,49,-37,-13,60,12,40,32,-46,33,-31,4,6,31,49,-28,37,-34,58,7,25,21,-5,77,-18,3,18,46,-64,38,-7,-8,-36,-19,-91,-28,-21,-49,20,30,-35,-6,15,-10,-57,27,-21,-21,-7,-13,42,-60,21,45,15,18,4,36,13,43,-28,12,10,-24,-33,-32,-32,34,10,42,-36,-30,-17,19,45,21,-46,-4,-1,-11,13,-57,-65,0,-12,-25,-2,4,51,-45,-30,34,58,46,45,21,-27,58,7,-22,20,43,30,3,-29,-87,3,-34,51,18,47,-29,23,-23,30,-11,56,-13,9,-11,4,-25,-42,-47,31,39,-50,7,-88,-36,34,-39,21,-13,13,36,-46,20,-35,48,14,-9,-18,-47,62,-15,4,44,-15,-1,9,-18,-28,13,11,12,-7,-19,5,11,-60,-35,-18,-22,-52,-96,49,-11,28,26,-28,20,-7,94,29,35,28,19,-71,25,-1,-40,12,32,1,21,16,-17,65,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.133","t":"Therapist: Let me show you a tool that is similar to the Three-Column Thought Record. [pulls out a sheet of paper] This is called the Five-Column Thought Record. You’ll notice that the first three columns are the same as they were before—situation, emotion, and thought. But there are two additional columns. One is for you to write down an alternative response. I will work with you today to develop ways to evaluate your automatic thoughts to come up with more balanced, adaptive thoughts. And the other column is for you to write down what happens once you have constructed an alternative response. For example, are you less depressed? Are you feeling something entirely different? Or will you do something differently as a result of viewing the situation with the alternative response, rather than the original automatic thought? Kate: So the goal is for me to come up with an alternative way to look at the situation? Therapist: You got it. Why don’t you choose the entry from the Three-Column Thought Record you completed for homework that was most distressing for you? Kate: Definitely the time when I tried to reach my children on the telephone for three days in a row, and they did not return my calls. Therapist: [handing Kate the Five-Column Thought Record] OK, we’ll focus on that situation. Can you record on this new sheet the same information you had on your Three-Column Thought Record—the situation, emotion, and thought? Kate: OK. [records information] Therapist: Your thought was I’ll never see my children again. It’s not surprising that that was associated with a very high level of despair—95 to 100. Now that you have some distance from the situation, do you still believe that you’ll never see your children again? Kate: [sighs] No, I guess not. I finally was able to talk to them. My husband is still being difficult, but he reluctantly agreed to meet me halfway so that I can pick them up in a couple of weekends. Therapist: I’m glad to hear that, Kate. I know this issue has been weighing on you. So, in the moment you had the idea that you were never going to see them again. What would have been a more balanced way of viewing the situation at that time? Kate: Gee, I don’t know. I was completely consumed with emotion. Therapist: If you were to think about it in as systematic a way as possible, what evidence did you have to support the idea that you were never going to see your children again? Kate: They hadn’t returned my calls in three days. I didn’t know what to do. Therapist: [Here, the therapist decided not to discuss Kate’s assumption that not talking to her children for three days was equivalent to not ever seeing them again] And what evidence refutes the idea that you would never see them again? Kate: Well … it’s not like my parental rights are terminated. Legally, I have to at least be able to visit them.","e":[67,25,-147,-121,37,15,10,5,8,-21,-69,-37,57,14,-29,-8,33,-47,-55,44,-23,-30,-56,13,8,78,-59,11,-85,89,83,-16,-9,-13,-115,-44,72,32,-17,-36,82,10,-17,-87,22,-73,79,-3,26,-19,23,-52,-10,17,80,25,26,2,2,-17,87,16,-61,67,54,-4,-65,61,-32,-63,39,9,29,12,-17,49,-36,4,27,44,56,-32,31,-41,16,13,38,25,-24,68,-42,3,-5,-2,-54,27,-8,-17,-34,-18,-81,-46,-21,-45,29,10,-28,-15,18,-14,-51,14,-26,-37,-6,-23,40,-63,50,16,4,33,0,38,49,45,-30,21,5,-22,-18,-34,-34,46,16,54,7,-35,7,17,58,-7,-26,3,13,-17,12,-54,-43,16,11,-15,-12,34,33,-58,-16,44,57,28,40,18,-39,56,10,11,24,44,13,-9,-23,-91,31,-31,34,15,53,-38,0,-37,44,-1,54,-26,22,-2,-3,-11,-5,-30,43,28,-70,-1,-58,-64,15,-41,25,-24,23,38,-54,20,-51,51,-3,7,-18,-34,66,-8,-2,61,-46,-2,23,-18,-14,33,20,16,29,0,12,10,-60,-21,-17,-2,-67,-104,42,21,17,19,-51,26,-11,57,17,40,-15,24,-65,10,15,-35,25,42,13,30,44,-17,67,-3]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.134","t":"Therapist: That’s one piece of evidence that goes against the idea that you’ll never see your children again. Is there any other evidence against that idea? Kate: My mother’s really angry at Kevin as well for all of this. She’s also been in contact with him and is trying to figure out a visitation schedule. Therapist: Good. So when you keep all of those things in mind, what might be an alternative way of viewing the situation? Kate: [pauses] That it’s unrealistic to think that I’ll never see them again? Therapist: Yes, that works. How would you formulate that into an alternative response? Kate: Um … how about “This is just short term. I have to be able to see them again, even if it will take going to court to arrange visitations.” Therapist: That sounds great. Go ahead and jot that down in the fourth column.","e":[61,38,-138,-67,-10,46,-37,9,22,-19,-50,19,59,30,-83,-10,27,-43,-32,53,-57,-3,-51,-2,9,15,3,35,-80,49,129,-24,5,-97,-87,-32,50,43,-26,-87,80,40,-10,-75,15,-74,65,51,-21,-49,11,-58,0,16,52,40,47,5,12,-38,109,26,-54,72,52,-12,-93,52,-29,-72,24,10,1,-16,8,38,-12,-5,7,44,63,3,31,-44,30,35,40,14,-25,58,-20,11,9,15,-54,13,-16,5,-57,-54,-85,-14,-29,-35,33,0,5,-2,25,-19,-69,3,-33,-10,6,-26,53,-86,55,31,-19,15,-19,41,44,65,-60,9,-20,-35,-4,-10,-15,20,5,32,40,-5,0,22,58,0,8,-7,2,-12,44,-20,-21,35,15,23,-31,19,32,-68,-19,23,56,27,68,31,21,28,-32,4,5,51,-11,5,-51,-77,15,-44,16,-5,9,-45,-39,-56,34,-15,58,0,25,-10,-6,-7,-8,-59,29,21,-65,-17,-26,-57,37,-14,23,-33,-8,6,-39,42,-50,23,-6,-22,-24,-23,57,-13,-6,62,-29,-18,23,-24,-59,37,4,36,29,1,24,18,-45,-10,-24,19,-53,-102,25,39,30,54,-7,4,-6,47,-7,15,6,-21,-31,-9,30,-50,24,32,16,51,36,-5,57,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.134","t":"Exhibit 4.7. Kate’s Five-Column Thought Record: Step #4 Date Situation Emotion Thought Alternative Outcome Response What event led What What thoughts Re-rate the to a shift in emotion(s) did or images ran Use the intensity of the emotion? you through your questions to emotion you experience? mind? evaluate the listed in (Rate on a 0- automatic Column 2 or 100 scale) What did the thought and list a new situation mean construct a emotion you to you? more balanced are thought. experiencing. Describe what you will do differently as a result of the alternative response.","e":[13,11,-176,-76,75,28,38,-16,22,-42,-44,13,89,85,-5,-22,26,-50,-31,73,-14,-50,-49,6,20,62,-48,-8,-86,27,14,-25,15,-27,-80,-50,40,1,18,-30,44,-5,20,-38,48,-41,35,14,57,-6,5,-9,16,-11,115,69,34,33,12,-20,69,5,-29,38,61,-15,-53,80,-48,-35,50,-6,4,21,-46,8,-31,-15,5,35,76,-27,90,-18,75,-10,25,28,-26,72,-6,5,22,-5,-82,24,-40,12,-24,-15,-87,-51,-7,-34,34,29,-45,41,-1,2,-47,29,-29,-18,10,-35,54,-12,-7,38,25,30,14,64,10,16,-18,-17,7,-34,-6,-56,-24,33,-10,23,-6,-38,9,8,86,20,-29,-18,-17,-18,18,-48,-25,10,24,8,-5,38,9,-48,-23,36,25,14,77,2,-25,35,-6,-25,23,39,21,10,-51,-77,19,-21,49,17,66,-18,14,-31,19,-45,45,-9,7,-79,15,13,-45,-27,-7,43,-65,-26,-56,-75,9,-6,11,-5,48,47,-76,35,-27,73,-16,1,9,-64,95,-2,-19,18,-24,19,42,1,-4,29,0,0,-24,5,23,-1,-24,-15,-4,3,-41,-86,43,7,23,26,-33,45,19,22,12,29,-1,9,-63,22,52,-7,7,41,3,4,37,-24,49,-24]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.134","t":"9/12 Kids did Despair I’ll never This is just not return (95–100) see my kids short term. phone calls again. I have to be 3 days in a able to see row. them again, even if it will take going to court to arrange visitations. Therapist: When you had the idea that you would never see your children again, you experienced a lot of despair, at a level of 95 to 100. When you have the idea that this is just short term, that you’ll see them again even if you have to go to court, do you still feel despair? Kate: No, not despair. Scared, though. And maybe frustrated that Kevin is putting me through this process. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 116","e":[60,14,-191,-67,22,57,-7,-15,27,-49,-55,30,49,4,-19,-14,2,-29,-54,37,-48,-23,-77,-25,17,58,-55,37,-47,41,89,-12,14,-75,-69,-29,69,49,32,-42,74,8,4,-85,-6,-36,65,38,31,-75,32,-79,-3,-24,40,25,-19,-5,-1,-18,110,8,-35,52,57,-9,-70,35,-49,-55,46,7,-3,28,-40,44,-42,-21,-6,57,73,0,26,-20,36,26,32,57,9,78,-22,5,4,60,-71,2,-4,24,-33,-59,-49,-24,-31,-55,8,19,1,-11,56,-42,-100,17,-28,-1,17,26,35,-63,15,21,17,-10,29,20,36,63,-32,25,26,-24,-21,0,-33,23,3,32,-8,3,-30,39,60,-17,2,2,5,-27,39,-25,-48,1,8,-13,16,24,30,-68,-26,53,38,39,55,38,-22,45,-3,-28,3,45,8,22,-44,-95,30,-24,21,-20,5,-23,-33,-55,34,-29,58,4,37,0,28,-48,-3,-46,19,29,-69,-9,-65,-29,46,-15,13,-22,34,31,-24,23,-54,62,1,1,-15,-42,68,-46,-17,23,-29,-16,20,-30,-55,38,26,16,-2,14,40,26,-42,-17,-7,16,-17,-101,22,17,-18,33,-15,-1,18,16,29,7,36,15,-56,17,-32,-25,15,38,5,4,13,13,68,16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.135","t":"Therapist: On a scale of 0 to 100, how scared and how frustrated? Kate: Um … scared maybe a 50. And frustrated at a 60. Therapist: Are you better able to handle problems when your despair is at a 95 or 100, or when your fear is at 50 and your frustration is at 60? Kate: Definitely when my fear and frustration are in the middle of the scale. I was so upset about my kids not calling back that I didn’t eat for a day and a half, I quit trying to call them, and I missed an appointment with my psychiatrist. Therapist: So, what might you do differently if you had the idea that you would be able to see your children, even if it involved going to court? Kate: I probably would have looked into getting a lawyer. Therapist: Ah, so it sounds like two things would have happened had you had the alternative response handy at the time you experienced despair. One, you would have been feeling something different. Although fear and frustration aren’t pleasant, they would have been at a manageable level. And two, you would have taken the beginning steps to arrange for visitations with your children. Kate: Yeah, I guess that’s right. Therapist: Go ahead and jot down those outcomes, both the new emotions and the action you might take as a result of the alternative response.","e":[55,54,-171,-54,37,54,-11,12,32,-27,-53,1,55,31,-11,23,41,-65,-47,37,-61,-53,-32,-4,-23,45,-37,21,-54,72,67,-4,18,-54,-123,-9,67,57,17,-68,121,-18,5,-88,-15,-71,42,31,33,-22,26,-75,2,4,76,59,-13,2,23,-27,76,6,-54,48,45,28,-61,53,-19,-61,42,-23,18,3,-53,11,-26,-27,19,56,46,-19,43,-34,23,-12,25,52,13,75,-43,29,-3,13,-67,8,6,16,-38,-36,-57,-5,-40,-34,6,-2,30,-24,1,-27,-57,10,-31,-32,19,6,61,-70,-4,18,40,22,7,17,63,63,-49,30,11,-8,-1,-24,-33,9,-4,67,22,15,-14,38,71,2,22,-2,13,-28,21,4,-29,4,18,-1,8,43,32,-47,3,57,36,12,57,22,-11,53,20,-4,11,57,-20,15,-26,-60,18,-21,28,16,55,-33,2,-49,99,-15,63,-9,26,-7,29,-42,-11,-40,44,14,-100,12,-50,-34,55,-9,27,-27,-1,36,-25,-9,-59,77,-14,-5,-4,-40,39,-40,-10,45,-46,-20,17,-16,-47,32,14,-12,8,4,29,27,-57,3,-13,15,-35,-101,40,32,3,56,-25,-6,2,37,1,26,17,49,-71,29,4,-25,8,60,-3,11,46,-10,63,23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.135","t":"Exhibit 4.8. Kate’s Five-Column Thought Record: Step #5 Date Situation Emotion Thought Alternative Outcome Response What event led What What thoughts Re-rate the to a shift in emotion(s) did or images ran Use the intensity of the emotion? you through your questions to emotion you experience? mind? evaluate the listed in (Rate on a 0- automatic Column 2 or 100 scale) What did the thought and list a new situation mean construct a emotion you to you? more balanced are thought. experiencing. Describe what you will do differently as a result of the alternative response.","e":[14,11,-175,-77,76,29,40,-17,24,-44,-45,14,90,85,-5,-24,25,-50,-32,74,-12,-50,-48,7,18,60,-48,-7,-89,30,17,-24,15,-27,-80,-49,39,1,21,-28,44,-4,23,-41,48,-42,35,14,58,-6,3,-9,14,-10,116,66,35,32,14,-21,68,7,-28,37,61,-14,-54,80,-50,-34,51,-8,4,21,-45,8,-31,-17,6,36,79,-29,91,-18,73,-11,24,30,-27,73,-5,4,25,-5,-80,22,-41,10,-23,-14,-83,-50,-6,-34,36,30,-48,41,-1,0,-47,30,-31,-21,12,-38,55,-10,-8,39,24,29,14,62,10,16,-14,-19,7,-35,-3,-57,-25,35,-9,22,-5,-38,10,8,85,20,-29,-16,-16,-17,17,-47,-24,10,25,8,-5,37,9,-49,-25,37,27,12,76,2,-27,35,-7,-25,24,37,23,9,-51,-77,18,-21,51,17,67,-17,15,-31,18,-45,46,-11,7,-80,14,14,-46,-27,-4,41,-65,-27,-56,-73,9,-5,11,-5,47,48,-77,33,-29,72,-15,-2,8,-64,94,-1,-20,16,-24,21,40,0,-4,28,1,-1,-23,6,24,-1,-24,-16,-5,4,-40,-86,45,8,24,25,-30,45,19,22,12,31,-1,11,-63,22,53,-6,6,40,4,3,38,-25,50,-23]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.135","t":"9/12 Kids did Despair I’ll never This is just No more not return (95–100) see my kids short term. despair. phone calls again. I have to be Scared (50) 3 days in a able to see Frustrated row. them (60) again, even Call if it will lawyer. take going to court to arrange visitations. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 117","e":[50,11,-207,-54,44,28,-11,-28,24,-55,-49,37,29,8,9,-24,6,-26,-54,31,-29,-32,-82,-34,5,50,-47,33,-15,63,75,-8,14,-62,-62,-29,58,34,39,-17,72,-4,-6,-82,-12,-43,76,42,52,-60,30,-74,6,-40,33,28,-30,-19,-6,7,123,10,-47,46,51,-11,-49,33,-42,-45,61,-8,16,23,-53,29,-52,-17,-23,63,74,-7,12,-35,38,15,30,58,5,75,-26,6,-3,58,-71,2,0,26,-44,-74,-24,-35,-22,-67,2,20,9,-5,35,-28,-101,38,-13,-3,28,31,38,-49,1,20,11,-14,29,17,33,48,-3,31,39,-28,-29,-3,-31,14,2,23,-23,15,-22,35,64,-32,10,6,1,-19,46,-18,-63,-7,12,-15,25,9,38,-69,-23,52,43,35,30,27,-44,59,-12,-43,-5,51,14,27,-29,-88,15,-13,30,-5,8,-26,-13,-52,34,-41,65,34,23,-6,29,-56,-12,-44,8,41,-56,-9,-57,-35,44,-9,8,-22,30,28,-4,24,-55,62,8,-7,-22,-24,63,-44,-23,10,-35,-23,29,-38,-41,43,19,10,-9,15,48,22,-26,-4,9,29,-17,-92,34,4,-32,21,-11,7,11,23,30,16,45,34,-57,23,-40,-19,15,37,-1,11,-7,34,54,11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.136","t":"As patients begin to identify their unhelpful thoughts, they may begin to notice specific patterns in both the types of thoughts and the situations that are difficult for them. Patients may even begin to notice that they have a particular style of interpreting events and situations. These styles are referred to as types of cognitive distortions. For example, in the transcript presented previously, Michael was • Cognitive distortions demonstrating overgeneralization, one type of cognitive distortion, when he was equating the inability to pursue his expected academic and career path with a lack of meaning in his life in general. In Kate’s case, the idea that she would never be able to see her children again was an example of all-or-nothing thinking, another type of cognitive distortion, because she failed to recognize the “shades of gray” indicating that, in the long term, some sort of arrangement would be made so she could have scheduled visits with them.","e":[62,33,-157,-74,55,41,15,13,51,-3,19,-1,59,96,3,-22,-23,-25,9,56,-63,9,-39,-13,3,39,-30,-19,-57,18,54,5,-11,-63,-79,-55,71,17,30,34,28,7,26,-80,7,-2,52,31,21,-35,21,-28,38,-24,115,14,16,23,31,-37,54,48,-24,43,-27,-6,-96,44,-21,-55,64,-13,5,5,-13,21,0,4,22,25,59,-30,48,-16,56,37,23,15,-4,66,-17,-43,-14,32,-112,19,-29,20,-36,-35,-85,-16,8,-42,14,55,-49,16,18,-8,-54,55,-32,-16,9,-19,18,-2,29,54,13,-26,-15,97,9,80,-32,6,53,-26,-8,-25,13,26,9,71,25,-9,-3,41,60,-18,1,-27,27,-55,26,-20,-35,18,-19,16,24,26,22,-38,-36,26,34,-1,57,16,-39,34,-32,-56,31,45,6,2,-42,-32,19,-26,91,12,82,-61,18,0,-15,-29,5,26,31,-16,33,8,-37,-16,28,8,-51,-20,-64,-59,37,-2,19,-54,0,-6,-47,45,-46,73,-4,3,-45,-8,58,-17,9,-17,-27,5,-3,-23,-42,33,47,-1,0,3,34,-8,-29,-10,9,-4,-22,-100,72,19,23,-5,-12,17,9,28,-14,67,2,-16,-82,-8,8,-57,-2,33,-15,31,7,7,67,18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.136","t":"It can sometimes be helpful to introduce patients to a list of cognitive distortions so they have labels with which to identify their cognitive patterns. However, we do not believe that this is needed with all patients. In some instances, patients become overwhelmed when they attempt to evaluate numerous automatic thoughts they have identified. On the other hand, some patients can find Once patients recognize specific it helpful to see that they are prone to making a small subset of the cognitive distortions, they may cognitive distortions. Once patients recognize specific cognitive begin to conceive of ways to distortions, they may begin to conceive of ways to correct certain correct certain cognitive cognitive patterns rather than having to address numerous negative patterns rather than having to thoughts. We encourage you to become familiar with the definitions of address numerous negative these cognitive distortions, as it will help you ask your patients relevant thoughts. questions to stimulate critical thinking as they evaluate their automatic thoughts. You can find such a list on pages 11–12 of the Wright et al. (2006) book or on page 119 of the J. S. Beck (1995) book.","e":[45,29,-128,-68,69,18,43,28,44,14,12,22,75,84,-3,-32,2,-45,23,41,-43,-17,-66,-15,1,63,-30,-20,-54,26,71,-25,-30,-75,-63,-54,72,12,14,47,36,25,20,-95,17,52,68,-6,47,-35,31,-46,4,-11,96,40,18,38,57,-63,80,49,-23,15,0,-2,-61,61,-8,14,45,4,34,20,-45,32,10,-14,5,31,48,-42,98,-34,69,34,31,18,5,66,17,-18,20,88,-88,28,-37,1,-71,-33,-94,24,2,-33,-2,45,-3,17,37,18,-43,2,-14,-10,-5,-5,43,-65,19,49,11,-28,1,64,28,43,-30,-30,66,-43,-19,-37,-2,-1,15,35,20,-17,5,32,40,16,10,-16,-3,-64,-5,-33,-47,34,8,21,-1,-4,51,-46,-23,19,11,18,49,8,-53,75,-37,-37,41,31,18,13,-46,-29,22,-43,81,13,71,-55,37,-6,6,-38,6,26,24,-8,6,13,-30,-28,59,14,-36,-17,-89,-55,33,-9,46,-44,-16,5,-49,18,-49,80,-7,-28,-47,-27,68,-18,1,21,-47,9,-20,-18,-26,43,32,12,-5,-26,33,-23,-43,-8,0,10,-15,-97,55,-16,35,-5,-40,27,-5,41,-13,36,32,16,-107,-3,-5,-41,-30,31,-5,40,-10,25,81,6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.136","t":"Even the most seasoned cognitive behavioral therapists occasionally find instances in which patients complete the cognitive restructuring process and construct viable alternative responses, but they do not experience the expected decrease in negative affect. Usually this occurs when the automatic thought that was “restructured” was not the key thought precipitating the negative emotional response, or when the patient did not fully “buy into” the cognitive restructuring process or the alternative thought. Below we list additional possible explanations (J. S. Beck, 1995).","e":[62,35,-124,-47,63,36,60,36,58,-26,-23,46,66,18,11,-19,3,-36,-26,68,-59,-35,-32,-6,-8,75,-29,28,-49,6,100,1,-25,-47,-84,-26,62,33,-16,-7,29,19,32,-89,31,-17,95,15,38,-28,52,-58,-20,-49,106,-5,19,60,8,-74,48,36,-27,73,24,-11,-27,55,-27,-21,17,8,-7,33,-20,-3,-18,-43,-9,14,44,-33,71,1,74,27,36,26,-3,105,4,-19,20,11,-91,15,-30,8,-72,-48,-53,5,-20,-29,4,59,-4,-24,17,30,-77,22,-31,-31,29,-17,51,-40,27,38,1,-14,-22,5,-7,76,-35,8,43,-31,-20,-22,-13,13,-3,20,5,-22,2,36,57,22,15,4,-26,-37,49,-24,-29,31,-19,-5,11,-1,40,-35,-23,13,35,16,73,-9,-23,43,-12,-59,26,27,8,1,-42,-51,-12,-8,79,48,71,-37,7,-27,-18,3,28,13,75,-25,16,45,-63,-44,13,28,-71,-23,-92,-58,7,-3,47,-5,22,23,-7,-9,-43,27,11,-10,-39,-23,53,17,-1,12,-36,-7,13,-8,-27,38,-5,3,-23,-26,44,-7,-29,-2,-16,4,-11,-72,54,5,42,15,-18,16,27,20,3,39,43,51,-49,8,17,-36,-14,36,19,30,-3,-16,55,12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.136","t":"Explanations for Unsuccessful Cognitive Restructuring There are more important or central automatic thoughts that were not identified or evaluated. The evaluation was implausible, superficial, or inadequate. The patient did not fully articulate the evidence that supported the automatic thought. The patient understood at an intellectual level that the thought was distorted but did not believe it at an emotional level. The patient discounted the evaluation.","e":[72,39,-136,-79,59,51,50,35,42,3,-9,8,70,44,20,-36,35,-31,-14,45,-36,-29,-36,17,36,41,-48,-16,-35,18,83,4,15,-58,-68,-28,79,43,6,-11,-4,8,31,-71,33,47,56,18,35,-30,49,-29,22,-13,103,38,1,56,47,-32,51,29,-10,53,16,-19,-18,71,-16,-44,27,2,-3,18,-64,-6,-25,-10,-9,19,53,-34,80,-4,58,30,19,29,3,87,-24,6,18,17,-115,-1,-51,1,-68,-10,-79,-29,-19,-21,48,45,-6,3,2,28,-40,40,-10,-36,31,-45,70,7,39,44,3,21,-16,43,16,65,-39,-4,65,-36,-11,-16,-21,-4,30,37,-5,-52,-21,21,48,-12,12,-19,-8,-53,32,-19,-66,40,18,14,33,-27,26,-53,1,5,18,16,53,20,-57,53,-29,-19,31,40,19,22,-32,-31,35,12,58,39,81,-43,8,-27,13,10,7,18,47,-30,27,39,-66,-26,38,4,-55,-41,-85,-46,43,2,33,-12,-12,14,-16,1,-83,52,-29,-18,-50,-17,45,9,-3,27,-11,-7,8,-26,-20,18,6,-35,5,-11,34,-8,-28,13,-17,22,-12,-102,35,16,25,18,-8,-9,35,29,-40,50,9,-14,-78,-5,15,-54,21,9,-14,74,2,-4,37,25]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.136","t":"Claire, for example, went through the cognitive restructuring process to evaluate her belief that her life will be meaningless if she is not able to resume her position as a pilot. In collaboration with her therapist, she constructed the alternative response, Although I will be disappointed if I cannot pursue a career as a pilot, I am an CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 118","e":[40,1,-160,-57,61,19,-4,-17,50,-17,-46,-10,70,56,24,-26,-26,-39,-15,0,-48,-73,-44,19,39,48,-50,15,-61,7,80,4,-7,-66,-36,-32,16,67,-1,-5,11,-14,24,-105,13,-2,124,1,27,-33,28,-33,-16,-10,109,17,22,45,3,-48,79,54,-33,96,20,-40,-51,64,-39,-55,38,-15,25,86,-55,-5,-37,-9,-13,2,62,-52,54,-5,37,42,40,15,-7,69,14,27,-1,21,-70,-19,2,-19,-52,-23,-73,-17,-17,-16,14,40,4,-14,28,-6,-53,15,-27,4,18,-19,54,-34,31,40,20,-32,2,32,9,73,-58,-5,41,-15,-16,-3,-11,31,5,21,-37,-49,-9,54,38,-41,-4,8,8,-54,24,-8,-51,-9,-3,13,37,-5,46,-39,-23,26,34,19,67,27,-29,57,-29,-29,-13,31,30,44,-48,-58,2,-13,95,5,36,5,-9,-44,29,-9,32,28,22,-11,27,6,-67,-61,-4,15,-52,0,-94,-62,24,-20,15,-26,4,24,-5,22,-61,39,-8,-34,-52,-9,67,-3,17,32,-28,-5,-4,-28,-30,26,25,-16,-8,-22,16,8,-15,-29,26,-6,15,-88,30,14,36,18,-20,59,17,49,4,60,38,13,-45,24,10,-22,-2,34,-16,7,12,16,19,-1]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.137","t":"intelligent and successful person and can use those qualities to pursue a related career that has worth and prestige. When she first identified the automatic thought, Life will be meaningless, she assigned a rating of 100 to the associated emotions of sadness and depression. After cognitive restructuring, she rated her level of sadness and depression at an 85. In the following transcript, Claire’s therapist works with her to identify the reason why cognitive restructuring did not result in a significant reduction in negative affect.","e":[46,27,-158,-44,41,26,16,15,25,-5,-50,21,72,36,25,18,-16,-26,10,36,-74,-65,-61,-11,59,106,-36,-11,-45,10,53,10,-39,-48,-79,1,44,78,63,1,3,20,56,-66,20,7,94,-11,78,-27,13,-37,-10,3,106,58,-14,45,17,-34,40,37,-36,73,36,-20,-16,45,-44,-18,11,-16,3,62,-54,30,-11,8,22,26,39,-49,84,-5,44,13,30,20,0,105,13,36,5,30,-59,3,-14,5,-27,-14,-47,-17,-20,-16,23,48,4,-9,-10,20,-41,24,-18,-30,21,-39,70,-23,18,55,16,3,27,59,22,60,-35,13,33,-23,-35,-26,-33,29,-2,69,-14,-35,-22,46,57,-1,15,-16,-48,-68,19,-14,-60,0,-23,-20,32,-8,2,-54,-36,33,25,5,42,31,-25,58,-4,-42,-2,13,3,55,-25,-52,7,-17,83,-32,39,-7,-10,-49,43,-32,54,15,9,-46,27,-13,-64,-21,36,15,-59,-8,-73,-39,41,7,17,-44,-3,30,-1,8,-79,43,20,-25,-62,-11,50,-1,-21,17,-18,-20,-24,-38,-14,24,1,-6,18,-12,15,13,-25,-7,15,-2,5,-86,49,34,20,29,-25,23,9,54,-14,46,12,24,-44,31,2,-19,-5,35,-2,15,2,31,41,15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.137","t":"Therapist: You constructed a very balanced alternative response, accounting for the fact that you’d be disappointed if you couldn’t pursue a career as a pilot, but that you have faith in your abilities to be successful at a related career. Yet, you’re still very sad and depressed. Why do you think that is? Claire: [sniffs] It’s just that I’ve spent my whole life preparing for this. I know I could do something else that is meaningful if I really had to, but it’s going to take so much work. [speaks softly] I just don’t know if I have it in me to invest the same amount of energy and commitment into another career. Therapist: Ah, so the issue is that there are some other automatic thoughts at work here—the idea that another career will require the same amount of work as you had put into being a pilot, and the idea that you won’t be able to put in that same amount of work. Claire: Yes, that’s it. Therapist: Well, let’s take a look at these ideas systematically, in the same way as we did with the idea that life will be meaningless if you cannot be a pilot. Claire: OK. Therapist: Let’s start with the idea that pursuing another career will require the same amount of work. I’d like to get a sense of exactly how much work you put into being a pilot. Claire: I’ve been focused on it my entire life. When I was a little girl, I would read about planes. I worked non-stop in high school to get into a top university. I did ROTC in college, and as soon as I graduated six years ago I began intensive training in the Air Force. I’ve been doing that ever since. Therapist: Let me make sure I understand. Did every course and every activity in which you participated in high school and college focus exclusively on flying planes? Claire: Well, no, I had to take the typical classes, too. You know, math, science, English, etc. Therapist: And did you major in aviation at your university? Claire: No, my university didn’t offer that major. Therapist: What did you study? Claire: Mechanical engineering. Therapist: Did you enjoy that? Claire: Yeah, actually I did. I think it gave me a good sense of the mechanics of the machines I’d be working with. Therapist: So, if the worst case scenario were to happen—that the medical board rules that you cannot fly in the Air Force—does your mechanical","e":[4,20,-154,-30,25,38,-9,-35,45,-46,-59,-24,58,67,24,1,-3,-77,-17,-6,-35,-96,-23,15,17,13,-83,-12,-120,17,63,-50,-15,-56,-43,-29,-39,108,19,-17,39,-33,3,-118,6,-46,111,-12,15,-36,31,-49,-33,39,80,-3,26,23,12,-75,83,49,-56,112,24,-37,-36,15,-28,-36,39,-43,44,66,-66,37,-25,-7,44,1,46,-25,36,-9,35,15,33,-4,-8,100,35,60,-2,14,-41,-31,8,8,-55,-46,-38,-9,-34,-3,42,13,4,-40,15,-11,-36,19,-51,-18,-17,-11,46,-67,9,35,-3,-2,-16,19,34,57,-47,2,-3,28,5,-13,-24,60,-21,39,-31,-66,-15,19,48,-28,-23,-17,-13,-45,4,0,-39,-17,8,23,8,22,47,-42,-13,12,57,47,66,21,-8,26,-5,0,-26,47,32,58,-23,-34,32,-25,92,-13,52,2,-32,-35,69,-33,30,-18,13,-7,10,-12,-67,-54,-12,26,-58,-8,-78,-19,51,-61,1,10,-2,41,-26,23,-46,47,6,-20,-39,-6,68,-11,-16,73,2,-35,4,-32,-61,36,48,-18,9,-5,-3,17,-21,-30,8,-2,12,-77,54,-6,20,4,-19,56,3,66,11,46,25,-18,-56,-3,34,-1,-8,45,32,12,28,31,-5,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.138","t":"engineering background prepare you are an alternative career? Or the other general classes you took in college? Claire: [looks stunned] That’s true. I’ve been consumed with flying and spending a lot of my mental energy and spare time on preparing to be a pilot. And, of course, all of my training after college centered on flying. But you’re right, my actual major was something different. Therapist: Would a career as a mechanical engineer be fulfilling to you? Claire: I won’t lie to you, it would be disappointing relative to being a pilot. But I guess I have some background in that area. Therapist: Could you even focus a career in mechanical engineering on designing parts of airplanes? Claire: [brightens] Yeah, I guess I could. When you think about it, I might even be pretty good at it, since I have the practical experience of flying. Therapist: Let’s revise our alternative response. Before we had come up with, “Although I will be disappointed if I cannot pursue a career as a pilot, I am an intelligent and successful person and can use those qualities to pursue a related career that has worth and prestige.” Can we make that more specific to incorporate mechanical engineering? Claire: Um … how about, “Although I will be disappointed if I cannot pursue a career as a pilot, I have a bachelor’s in mechanical engineering, and I can look for a job in which I can design parts for airplanes.” Therapist: Great! Now what level of sadness and depression are you experiencing? Claire: [smiles weakly] It’s lower. Maybe a 40 or 50.","e":[-16,28,-163,-21,4,54,-23,-27,51,-54,-35,-9,84,54,7,25,5,-82,-10,-8,-52,-78,-16,16,34,11,-72,-38,-109,9,37,-60,-6,-66,-75,-32,-33,93,37,-28,59,-40,-6,-106,25,-12,105,-12,38,-33,31,-43,-11,27,80,-15,36,38,60,-66,58,82,-53,99,7,-2,-31,28,0,-25,36,-31,34,72,-61,19,-14,-25,41,5,34,2,47,15,34,18,-3,-1,0,84,28,71,-17,10,-53,-16,8,-8,-42,-34,-15,-2,-21,10,44,26,-7,-66,15,5,-31,16,-43,-16,-18,-4,29,-60,1,46,-26,8,2,10,44,75,-49,-6,20,-6,10,-17,-25,29,-8,54,-39,-38,10,49,45,-3,-30,-43,-23,-48,7,19,-59,-4,-4,15,24,22,52,-36,-22,-13,58,29,66,3,-9,44,1,-6,-50,39,42,42,-21,-27,40,-26,63,-48,51,-36,-3,-43,62,-50,27,4,-13,-27,13,8,-77,-39,-16,34,-91,-25,-66,-48,35,-17,-6,2,12,48,-51,15,-27,58,13,-8,-32,-26,64,-13,1,42,-2,-38,-1,-40,-52,47,39,-25,-8,-3,28,19,-8,-35,-3,8,11,-77,62,-20,20,20,-12,41,-5,52,16,56,22,-12,-58,-20,33,-13,25,46,42,13,30,35,-25,-30]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.138","t":"In this example, Claire’s therapist suspected that she was discounting the more general training that she had completed, such as her college education, which did not focus specifically on flying. Moreover, he realized that there might be a way for Claire to continue to pursue her interest in airplanes even if she were unable to be a pilot. Nevertheless, it would have been counterproductive for Claire’s therapist to point this out directly, as it would have invalidated Claire’s strongly held belief that being a pilot was the sole source of meaning in her life.","e":[45,25,-154,-24,47,79,-20,-13,49,-37,-64,-13,94,75,6,-11,-20,-69,10,-26,-52,-55,-41,4,28,-9,-58,-32,-96,15,39,-32,-8,-77,-43,-41,-23,83,14,-7,15,-5,-23,-70,11,-15,86,9,20,-18,38,-35,-38,12,94,38,21,19,48,-60,75,55,-48,77,5,-23,-60,23,-12,-28,54,-43,20,63,-46,21,-4,-17,7,-7,57,-35,38,-9,51,71,19,3,5,83,27,45,18,26,-70,-6,5,6,-42,-25,-55,-4,-1,13,54,15,15,-7,10,0,-41,23,-65,0,5,-1,55,-80,29,29,-32,10,-16,69,15,58,-45,-22,0,-3,3,-36,-17,42,11,21,-22,-33,11,39,58,-5,-6,-40,-13,-56,1,-1,-28,-14,12,47,15,20,37,-24,-18,12,48,9,66,25,11,24,-30,-16,-25,32,21,57,-50,-15,24,-34,107,-10,69,-9,-14,-44,34,-49,2,12,28,-13,10,12,-81,-66,-23,33,-62,-9,-82,-63,51,-5,3,-2,-22,9,-7,28,-64,45,-21,-46,-35,-34,33,-30,-21,46,-18,-20,-11,-17,-56,46,33,-18,-27,-18,-3,30,-18,-29,7,5,4,-97,49,2,15,0,-21,54,11,51,-24,24,31,-22,-54,1,19,-19,-20,25,-5,38,21,32,-2,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.138","t":"Coping Cards A coping card is a valuable tool to use once patients have been introduced to, and • Coping cards have exhibited some proficiency in, earlier methods for evaluating and modifying automatic thoughts, or for those who may have difficulty learning or using other ways of working with their thoughts, such as a Five-Column Thought Record. Coping cards can help patients quickly recognize re-occurring automatic thoughts and then “over- learn” adaptive responses to these thoughts. Over-learning is useful because it increases the likelihood that the adaptive responses will be Coping cards can help patients recalled during stressful situations. In addition, coping cards have the quickly recognize re-occurring potential to be used more frequently than longer or larger documents automatic thoughts and then because the patient may be more likely to place the card in a more “over-learn” adaptive responses easily accessible location. To construct a coping card, the automatic to these thoughts. thought (or core belief) is usually placed at the top of the card, and the","e":[24,50,-193,-94,56,-45,30,-3,-1,-24,-28,1,54,29,22,-2,6,-40,4,21,-43,-54,-26,18,12,54,-7,27,-70,33,43,-38,-13,-40,-16,-23,65,-6,10,12,4,-6,66,-73,45,27,57,6,30,-10,23,-78,-5,2,106,29,24,48,7,-21,68,43,-55,37,57,-13,-22,58,-19,5,88,-2,33,36,-35,32,-37,8,17,65,77,-48,58,-33,91,6,23,25,-32,56,-2,23,4,38,-67,56,-21,-27,-63,-14,-72,-28,58,-2,-2,57,-34,14,-4,20,-33,16,-6,-34,7,9,52,-21,41,23,-1,20,-1,57,28,71,-29,-22,48,-9,-2,-56,-63,11,46,57,-20,-22,21,28,41,3,4,-24,-11,-53,13,-66,-60,-7,4,8,-14,57,50,-12,-27,25,62,33,52,-5,-58,69,-12,-49,26,22,22,36,-34,-71,21,-29,72,-4,115,-25,4,-51,7,-57,45,31,-13,-23,32,14,-35,-49,25,30,-57,-8,-94,-57,29,22,21,-15,-3,7,-35,-3,-53,69,-14,-11,-18,-12,71,37,-14,32,1,24,-6,-18,-27,12,46,-25,-1,-33,11,-20,-33,2,-14,10,-32,-103,39,-6,24,0,-30,50,3,52,26,47,16,1,-57,41,-11,-59,-7,43,-16,12,-1,-31,59,-37]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.139","t":"There are several benefits to using coping cards. First, coping cards are simple to create during or following the therapy session as homework. Second, they are highly transportable because of their size. Third, we have found that coping cards are particularly useful for Veterans who benefit from visual cues and who prefer to use simple approaches. Finally, patients may be more likely to remember to follow simple instructions or recall helpful coping statements if such information is readily available in an easy-to-use format.","e":[12,62,-165,-86,55,-35,31,-1,30,-15,-38,-11,53,31,1,6,-3,-45,-10,6,-45,-48,-34,4,-1,38,-5,32,-73,13,77,-17,-13,-54,-9,-3,56,17,7,0,-5,-8,49,-60,20,-4,57,8,40,-1,35,-113,-36,41,114,-32,12,-4,27,-20,51,49,-65,47,63,-12,-19,47,-23,30,73,-10,37,29,-48,24,-28,6,10,61,50,-55,8,-44,100,-1,26,22,-30,74,-26,53,22,50,-60,45,-6,-13,-35,-13,-33,1,61,14,9,27,-6,-6,-16,0,-46,23,-2,-28,35,21,47,-33,53,39,-22,18,-12,9,15,51,-29,-12,42,-8,1,-26,-90,19,32,46,-41,-10,21,4,56,-4,-22,-22,-39,-50,14,-49,-36,-22,-16,5,15,47,58,-20,-11,13,51,42,66,-19,-53,53,1,-50,30,10,13,47,-28,-53,8,-28,58,-31,98,-1,-1,-50,-3,-49,45,9,3,-26,41,29,-75,-32,21,17,-44,-7,-97,-81,26,31,4,7,-29,23,-34,-6,-44,67,-23,-16,-12,-35,42,13,-19,36,0,12,-27,-14,-43,11,53,-38,14,-39,12,15,-19,5,-11,10,-40,-88,48,5,31,-5,-8,63,15,59,28,22,49,1,-59,60,-14,-67,-12,47,-22,-4,4,-30,32,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.139","t":"To illustrate the manner in which one might use coping cards, consider how these strategies were applied with Claire. Over the course of their work together, her therapist recognized that Claire experiences interpersonal difficulties due to the assumptions she makes about others. The therapist attempted to use coping cards to preemptively deal with future problems that may arise in this area.","e":[55,12,-161,-63,64,2,-4,-11,5,4,-71,-9,56,56,4,15,-13,-36,-9,7,-84,-51,-40,41,8,54,-4,29,-77,-3,51,-15,-9,-85,-44,-20,23,38,26,9,-1,26,44,-84,-17,-28,57,9,29,-2,38,-78,-24,16,104,32,8,35,47,-51,70,34,-35,49,51,-26,-35,43,-28,-4,81,-20,52,44,-30,10,-3,0,15,46,51,-48,40,-31,65,33,49,30,-33,72,5,58,35,32,-73,26,-7,-23,-70,-29,-71,3,42,3,6,47,-1,8,-12,3,-64,31,-6,-25,37,6,23,-67,62,35,-5,-2,-23,39,2,45,-62,-23,31,3,-15,-29,-42,16,9,35,-8,-12,30,27,51,1,-18,-43,-27,-51,16,-45,-39,-28,7,42,20,67,58,-3,-51,17,43,6,64,-6,-23,55,-32,-47,45,30,33,61,-38,-53,-29,-26,88,-3,92,-8,-21,-40,23,-49,41,9,7,-35,35,4,-50,-77,-1,34,-17,-2,-54,-67,21,-2,5,-19,-31,22,-24,28,-65,66,-36,-48,-19,-32,29,-4,-28,46,-34,17,-17,-23,-51,18,8,-20,-13,-18,-4,8,-45,20,9,-5,-23,-89,40,12,14,28,-42,49,-10,39,-13,40,18,32,-37,57,-10,-31,-34,63,-3,-3,20,-11,20,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.139","t":"Therapist: Claire, in the last few weeks, we have talked a great deal about the automatic thoughts you have regarding what people might be thinking about your injury. I would like you to take out your homework (last week’s Thought Record) so that we can go over one of the automatic thoughts you have been having. Claire: I seem to continually assume that whenever someone is being nice to me regarding my injury, that they automatically assume that I am incapable of performing my job or even daily life. Therapist: How has that made you feel? Claire: Well, it makes me feel badly about myself, but it also makes me feel angry. Therapist: Does this automatic thought link up with an underlying belief that you may have about your situation? Is that why you get angry? Claire: Yeah, we discussed that last week. It makes me think I am never going to be able to do the things I did before, like flying. I believe the doctors on the medical board are going to assume the same thing that everyone else does—that I am incapable. Therapist: So, whenever you experience someone trying to help you, you instinctively think that they assume certain things about you, like you are not capable. Claire: Yeah, that’s it. Therapist: What I would like to do today is to develop some strategies to help you be prepared to combat these automatic thoughts when they happen in the future. Claire: OK. Therapist: Let’s take a moment and think of a situation in which you might experience the automatic thoughts that we just discussed. Claire: When I walk into restaurants, people always rush to hold the door for me. They may just be nice people, but I assume they pity me. That triggers all of the thoughts Therapist: Good. What do you imagine that would make you feel like?","e":[67,2,-146,-58,60,40,28,12,25,-9,-41,8,13,28,40,4,-16,-53,-26,24,-67,-57,-37,19,34,63,-67,44,-82,26,42,-32,-37,-65,-76,-15,32,66,9,9,44,-5,34,-98,-19,-34,104,-19,19,-2,13,-107,-11,12,125,26,54,41,17,-52,76,23,-29,37,26,-1,-52,38,-17,-29,41,2,24,36,-55,46,-36,28,38,29,36,-24,39,-61,39,29,30,51,-15,111,27,4,5,20,-80,-6,-17,-14,-83,-47,-81,-11,-37,-16,22,32,-9,1,10,20,-9,42,-10,-37,-23,-14,58,-72,22,36,13,30,-31,43,63,74,-61,-3,-1,3,-3,-39,-10,44,1,83,34,-37,-1,22,56,18,-23,-39,-16,-44,13,-17,-61,16,3,35,-24,10,72,-4,-37,26,40,10,37,13,-37,37,0,-6,35,57,55,41,-4,-60,11,-21,52,-12,4,-36,-21,-34,41,-31,55,-21,6,-26,-10,18,-36,-72,16,34,-46,-8,-64,-18,56,-48,19,-22,-6,26,-48,8,-39,73,20,-37,-48,-26,54,9,-21,50,-17,-10,-5,-33,-20,29,44,-9,8,-5,-41,9,-27,5,7,-33,-22,-92,56,11,35,28,-57,30,-3,79,26,49,8,21,-86,18,14,-29,14,26,18,23,-15,-2,35,-25]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.140","t":"Claire: Angry, sad, and bitter. Therapist: How would you know if the person was pitying you or being nice? Claire: Well, I wouldn’t necessarily know that. Therapist: So, it would be somewhat inaccurate to always think that you are being pitied when, in fact, some people are genuine. Do you know of or have you experienced any situations in which someone is genuinely nice and not pitying you? Claire: My friend Aaron always used to hold the door for me when we would eat out, and he still does, so I just assume he is doing what he would do naturally. Therapist: Is there a way that you can use this evidence in the future to help you deal with new situations? How might you do that? Claire: I could remind myself that most people are genuinely nice and that I know many situations in which people do not pity me but are being genuine and chivalrous. Therapist: What else? Claire: Well, I could also say to myself that just because I assume people are thinking a certain way does not really mean they are. I mean, I really don’t know what they are thinking. I am just mind reading and assuming the worst. Therapist: How would that relate to what you assume about the medical board in these situations? What might you tell yourself to avoid spiraling into a negative thought process about your being allowed to fly again? Claire: Well, the people at the restaurant are not the doctors, so it would be illogical for me to infer what the doctors might think from how a person at the restaurant behaves. Therapist: Great. What I would like to do now is put all of that information on a card so that when you are in a situation like this, you can simply take out the card and remind yourself of the strategies that we have developed. Here is the format for the card.","e":[80,20,-160,-95,73,17,-6,-6,28,3,-57,7,22,46,20,-4,18,-53,8,39,-99,-51,-45,13,23,23,-72,55,-94,9,-13,-13,-6,-44,-64,3,17,80,20,15,59,41,18,-79,-14,-51,83,8,31,-22,16,-83,-15,30,98,24,54,57,30,-62,58,5,-27,56,48,10,-63,23,-31,-55,58,-3,42,61,-27,29,-53,15,37,1,58,-47,40,-31,44,12,38,34,-21,95,14,-9,52,30,-50,36,-18,-18,-92,-26,-41,5,-6,-13,17,33,25,24,9,-51,-19,19,-37,-8,18,6,54,-61,41,69,13,44,-28,50,53,43,-46,-5,-9,2,-11,-37,-8,21,-29,70,42,-36,20,21,53,17,-39,-37,-18,-69,0,-11,-18,11,7,43,22,33,20,-41,-44,9,49,56,61,8,-23,23,0,-12,12,65,43,24,-21,-27,13,-16,54,-26,27,7,-35,-34,35,-43,67,-14,24,-32,29,-7,-27,-79,-5,29,-46,30,-40,-23,25,-35,1,-15,-23,6,-7,46,-80,48,12,-34,-30,-16,26,-21,-19,33,-32,21,-36,-5,-51,38,40,-24,-3,11,-28,41,-13,19,-23,-44,-48,-106,49,23,19,45,-63,27,8,49,0,26,1,28,-47,43,12,-44,19,32,6,36,50,-32,34,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.140","t":"The therapist then goes on to explain to Claire the manner in which the completion of the coping card is similar to the completion of a Thought Record. For Claire, she listed the automatic thoughts at the top of the coping card (see Exhibit 4.9). On the bottom of the card, she listed specific coping strategies that included some alternative responses to this thought. Exhibit 4.9. Claire’s Coping Card Thought: When people do nice things for me, they think that I’m not able to do things for myself. I hate when people pity me.","e":[67,11,-166,-82,64,2,20,-7,-8,-2,-83,-13,52,63,28,2,-10,-56,9,22,-66,-60,-71,33,41,67,-21,15,-94,8,20,-25,-32,-61,-29,-5,42,3,14,16,28,14,43,-90,6,-38,58,10,40,-5,43,-50,-21,1,95,40,34,37,36,-23,63,36,-25,70,65,-30,-31,57,-38,13,67,-2,29,19,-45,23,-24,3,24,37,50,-62,42,-21,73,26,29,40,-30,94,-14,14,15,29,-69,33,-7,1,-80,-8,-79,-21,28,-10,21,39,-8,5,-7,12,-22,25,-16,-18,16,1,70,-51,75,49,16,22,-28,40,8,57,-35,-9,27,2,-24,-41,-30,45,26,62,-3,-26,23,27,28,-7,-13,-17,-29,-72,27,-48,-60,-40,19,12,13,53,39,-21,-36,37,50,25,49,-11,-41,56,-13,-38,24,27,42,32,-33,-64,-3,1,77,-16,70,5,-17,-56,34,-61,43,1,26,-50,30,35,-29,-67,33,46,-39,9,-75,-51,11,-8,19,-25,6,14,-30,10,-71,88,-19,-18,-16,-6,43,11,-32,39,-14,26,-26,-31,-30,37,33,-19,-4,-26,3,18,-31,12,7,-23,-24,-103,21,5,11,14,-38,65,-10,66,-7,33,16,15,-49,80,5,-32,-27,56,13,25,22,-22,59,-36]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.140","t":"Coping Strategies: Remind myself that people are genuinely nice and that I have experienced many situations in which people do not pity me but are being genuine and chivalrous. Remember, just because I assume people are thinking a certain way does not really mean they are. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 122","e":[31,5,-182,-84,96,25,38,-48,30,1,-52,11,27,27,33,-17,-15,-33,6,34,-70,-31,-45,-8,35,68,-45,74,-29,-5,2,4,-7,-24,-22,0,32,50,21,3,45,-18,23,-86,2,-19,79,22,29,-11,53,-75,13,-42,113,-29,16,23,-16,-52,112,35,-45,40,59,-37,-74,65,-58,-17,64,-6,21,51,-56,4,-60,15,-13,11,56,-29,31,-43,74,8,8,6,-18,62,-5,-2,31,62,-75,33,-23,-15,-41,-51,-32,-11,-12,-28,13,39,16,27,7,-33,-62,31,-9,0,-9,25,61,-48,30,72,17,6,18,32,9,52,-45,-11,32,-20,-5,-34,-22,12,-6,41,-23,-21,14,21,39,-12,-22,14,-10,-66,-24,-34,-57,-31,14,38,20,22,25,-69,-34,33,53,16,55,-14,-29,35,2,-11,-11,35,42,36,-52,-57,-15,-16,88,-24,27,-5,-7,-47,11,-34,60,41,-22,-35,26,1,-36,-41,10,49,-21,-15,-79,-33,39,-11,12,-30,-12,35,-19,32,-68,61,-14,6,-5,-50,42,-19,-1,6,-19,27,-20,-11,-43,9,13,-8,-18,0,13,15,-26,-6,0,-6,-7,-112,47,-7,6,25,-21,42,20,45,33,43,57,37,-73,58,-20,-63,20,36,6,15,-12,-28,37,-39]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.141","t":"Although the most common usage of coping cards is to summarize the automatic thought and either the alternative response or ways to cope with the automatic thought, it is important to note that coping cards serve many uses and can be used creatively by therapists to remind patients of any of the cognitive behavioral strategies described in this manual. For example, a patient could have had success with a number of activities intended to promote behavioral activation, and he could list those activities on a coping card so that, in times of especially pronounced depression, he can consult the card and be reminded of the activities that have helped him to break out of the “vicious cycle” in the past. If a patient found a particular relaxation or controlled breathing protocol especially helpful, she could summarize the main components of that protocol on a coping card to consult in times of distress when she might not remember the specific steps of these strategies. Later in the manual, we discuss the cognitive behavioral approach to problem-solving; coping cards can be used in conjunction with this intervention, such that a patient records the sequential steps that he will take in order to address the problem that is discussed in session.","e":[12,52,-166,-77,44,-58,37,-4,20,-14,-38,-20,80,49,15,-24,-9,-31,-16,17,-41,-49,-23,37,-7,56,6,25,-67,-2,54,-17,-5,-51,-38,-18,58,2,18,15,-18,2,51,-62,17,9,48,4,22,-11,51,-107,-11,-9,119,0,24,21,27,-42,75,31,-20,25,69,-17,-36,59,-42,26,101,-18,46,27,-37,12,-18,2,26,66,53,-75,43,-32,86,12,30,9,-31,58,-5,32,21,56,-64,33,-13,-31,-44,-12,-74,4,50,4,-6,45,-17,-4,-3,3,-26,32,-8,-38,14,36,30,-22,51,51,-19,27,-14,14,26,73,-27,-27,60,-10,-3,-33,-54,14,32,30,-26,-27,15,16,42,-32,-1,-2,-21,-35,24,-62,-54,-4,-8,26,7,39,86,4,-39,22,48,35,72,-11,-59,50,-25,-45,29,11,24,40,-43,-61,-23,-16,90,2,113,-6,-20,-71,23,-53,48,5,-1,-15,40,15,-45,-27,25,34,-40,9,-111,-41,10,25,18,-1,-9,24,-32,-7,-58,65,-25,-3,-19,-22,54,30,-9,38,-24,30,-9,-27,-43,8,35,-27,-4,-29,14,12,-25,23,7,10,-38,-101,35,-1,30,0,-16,54,10,45,19,20,32,40,-59,67,-22,-47,-22,43,-12,6,-4,-21,72,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.141","t":"In all, the fundamental idea underlying coping cards is that they are a quick, easy- access method for patients to remember and apply the strategies developed in session into their daily lives. Coping cards are easy to make in session so that patients have something tangible to take home with them. Therapists Patients are more likely to use who use coping cards are encouraged to spend time with patients these cards if they are made of identifying where the cards will be kept and the specific circumstances colored paper or laminated. under which they will be consulted. Moreover, we have found that patients are more likely to use these cards if they are made of colored paper and/or laminated. Additional information on coping cards can be found in Wright et al. (2006, pp. 118–119).","e":[25,78,-171,-102,49,-32,4,-11,20,-18,-34,-23,55,27,-4,15,-11,-46,-11,30,-52,-44,-26,7,-22,27,6,29,-69,-4,60,-17,-1,-61,-3,-23,59,14,28,3,-15,2,41,-70,8,4,53,6,19,-1,29,-103,-21,15,94,0,12,36,26,-28,55,57,-46,60,68,-5,-18,65,-4,19,76,-4,43,49,-17,20,-24,10,11,56,66,-45,30,-38,75,-5,19,11,-20,75,-29,17,34,42,-83,38,-20,-30,-48,-25,-61,-7,49,5,-4,38,-25,11,-11,9,-33,36,-21,-22,42,24,42,-22,73,41,-3,23,-5,27,26,59,-29,-22,42,1,-13,-32,-71,-11,25,39,-8,-7,25,6,47,-9,-12,-35,-28,-47,36,-63,-28,-3,24,14,6,61,73,-9,-6,27,40,41,63,-20,-66,39,-14,-46,35,8,23,33,-26,-55,-24,-5,68,-16,115,-3,-9,-68,18,-57,20,-4,13,-14,44,4,-31,-46,27,33,-33,4,-80,-54,17,21,13,-1,-8,19,-15,9,-53,78,-31,-16,-9,-17,40,9,-41,34,-2,13,-22,-13,-63,0,58,-28,6,-21,13,8,-32,24,-25,17,-32,-88,37,8,14,7,-26,65,30,34,11,15,29,26,-53,41,-15,-77,-21,57,-23,-11,9,-37,47,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.141","t":"The 3Cs Approach: Catch It, Check It, Change It A simple mnemonic acronym that has been developed to help patients understand and use cognitive restructuring is the 3Cs Approach: Catch It, Check It, Change It • 3Cs Approach (McQuaid et al., 2000). This three-step approach (shown in Figure 4.4) is useful for helping patients manage their mood. We have found this approach to be particularly useful with Veterans who have difficulty organizing and structuring more complex information. Figure 4.4. Catch It, Check It, Change It. Catch It Check It Change It","e":[43,10,-185,-73,56,-21,51,2,35,22,4,21,77,8,15,-34,-14,-72,-30,25,-24,-50,-28,-6,47,20,-9,22,-66,23,70,20,13,-40,-61,-44,25,8,-25,1,8,60,11,-43,30,-25,79,-15,57,-20,0,-55,21,8,86,13,34,12,25,-44,79,48,-14,45,28,-12,-48,85,-14,-40,56,13,19,31,-44,-9,-50,-50,11,19,47,-42,75,-18,46,31,40,-11,-39,47,-40,21,4,34,-101,14,21,11,-33,-27,-61,-28,-21,-50,-27,68,-7,4,28,-7,-38,20,31,9,12,32,59,-11,34,31,2,-31,-2,70,16,19,-56,-6,23,-31,-25,15,-24,-11,-1,59,3,-14,12,24,11,3,33,9,18,-10,7,-55,-20,-18,3,20,8,-19,38,-51,-7,24,23,37,42,-17,-57,79,-49,-54,32,46,-5,3,-79,-22,-1,-35,25,25,39,-44,-18,-39,21,-41,51,74,-9,26,24,22,-33,-29,-3,26,-19,-25,-52,-18,0,-30,30,-17,3,6,-20,21,-52,37,21,11,-40,26,56,-2,-20,-21,-20,33,21,-25,-40,27,4,-1,9,-49,22,-10,-33,-21,16,21,-4,-81,36,-8,30,4,-13,36,14,41,14,56,33,4,-86,43,23,-51,-7,36,5,16,-17,-42,50,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.141","t":"(1) Catch It. This first step involves catching the automatic thought associated with a change in mood. Sometimes it is easier to identify a shift in mood first and then to ask yourself what was going through your mind just then. For example, patients may be coached to think about a time in the recent past when they noticed a negative shift in their mood. For some patients, it may be helpful to imagine or describe the situation CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 123","e":[31,-19,-177,-48,66,37,48,-21,21,-9,-4,72,74,43,13,-52,10,-61,9,18,-18,-14,-42,-23,-12,58,-33,38,-33,27,49,-29,-5,-36,-52,-32,42,8,25,19,29,9,7,-78,32,-11,88,18,32,-37,33,-48,0,-76,103,23,27,18,41,-52,91,45,-42,38,34,-23,-53,41,-32,-22,45,16,7,35,-46,0,-30,-37,5,7,53,-59,63,-35,98,19,14,20,-16,77,23,-20,19,50,-114,-2,-31,34,-12,-55,-62,-50,-42,-50,-5,53,-37,-27,12,6,-52,36,-8,-22,-9,30,53,-36,9,54,11,22,7,75,28,30,-44,-3,33,-27,-9,-27,-5,24,23,28,10,-35,5,6,55,-3,3,-8,-16,-3,17,-42,-63,7,3,-5,26,0,74,-83,-16,32,43,-4,51,5,-58,33,-5,-51,30,61,16,10,-62,-46,-13,-36,69,44,37,-33,2,-25,17,-60,37,42,9,-43,-3,-25,-40,-48,1,9,-38,-23,-82,-32,29,-27,26,-14,9,38,-47,33,-67,62,16,-17,-37,-51,53,1,-26,-19,-51,49,-4,6,-25,18,24,28,-17,-23,1,10,-16,-13,7,31,-20,-68,43,4,29,13,-34,28,14,51,8,41,27,50,-114,28,10,-52,-9,30,11,-3,-28,-10,48,-35]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.142","t":"(2) Check It. In the next step, patients are instructed to check or evaluate whether the thought is true, complete, or balanced. Patients may ask themselves, “What is the evidence indicating that the thought is true?” Similarly, patients may be instructed to ask themselves whether the thought is complete or balanced. A complete thought is based on all of the important and relevant information related to the situation that was associated with the initial automatic thought. A balanced thought includes information that is not extreme and is more fair and reasonable than the initial automatic thought.","e":[70,13,-155,-56,98,6,31,6,39,-1,17,0,29,47,-20,-20,12,-77,5,38,-30,-10,-67,-1,20,39,-48,10,-70,3,-5,-1,49,-18,-73,-46,60,16,11,-27,9,7,-10,-81,28,-2,18,5,59,-36,-9,-32,-8,8,95,76,18,42,6,-59,62,40,-56,48,55,-37,-52,64,-14,-16,24,-37,46,-3,-38,21,-1,16,-7,14,80,-74,94,-6,42,-4,-20,-27,-10,101,30,-25,46,29,-74,10,-35,18,-8,-32,-63,-23,-14,-37,29,45,-11,20,-16,-7,-21,-8,-33,7,20,-2,119,15,22,48,8,20,21,52,31,31,-17,-16,15,-23,16,-29,-47,1,19,46,29,-11,6,-16,26,6,-20,12,16,-45,40,-20,-23,44,11,40,20,-17,7,-85,-19,30,57,9,68,33,-63,47,-14,-28,8,40,6,-11,-55,-39,37,3,88,3,59,-44,30,-23,9,-36,49,27,18,-49,20,-24,-43,-33,17,49,-58,-17,-59,-23,47,-15,49,-23,6,22,-60,38,-74,95,-8,-2,-38,-12,55,2,6,37,-20,17,-4,-3,-30,25,41,-6,12,-45,10,-8,-66,-11,-22,29,-3,-110,31,-4,63,-5,-16,35,29,54,-12,32,12,24,-82,27,30,-76,4,36,6,12,8,7,25,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.142","t":"(3) Change It. The third step involves changing the automatic thought into a more accurate thought. In this step, patients are instructed to think of a replacement thought that is true, complete, or more balanced than the initial automatic thought. The 3Cs Approach aims to help patients learn ways to talk back to their thoughts and replace an automatic thought with an alternative, more balanced or helpful thought.","e":[41,16,-155,-75,78,23,28,3,1,37,-2,21,67,19,-14,-5,16,-75,-5,59,-21,-33,-37,-31,15,18,-6,28,-57,24,59,9,28,-16,-67,-49,79,40,-21,-12,12,48,39,-70,30,-34,59,-30,69,-6,1,-54,-8,24,82,59,11,52,11,-45,46,35,-9,20,27,-25,-45,77,-26,-40,51,-3,50,0,-51,-36,-16,-33,32,36,34,-55,104,-23,33,38,15,-6,-17,73,-39,6,29,29,-117,-4,1,31,-20,-33,-84,-38,-7,-40,-31,58,10,2,29,21,-28,11,7,-43,18,-11,65,-8,58,42,21,-2,-7,66,44,28,-65,-21,51,-25,2,-9,-38,0,21,57,23,-34,-2,39,20,18,11,16,0,-17,24,-47,-24,-4,35,31,31,-27,25,-39,-17,39,32,16,52,-34,-69,58,-23,-30,20,41,6,0,-51,-36,6,3,61,2,27,-64,-14,-41,4,-29,35,42,17,15,0,14,-32,-22,5,45,-25,-25,-80,3,39,-6,40,-12,22,10,-34,5,-39,75,21,-3,-28,15,74,45,-15,-17,-6,25,23,-10,-31,15,3,-13,2,-50,16,-41,-39,-18,4,31,4,-83,37,-12,30,-15,-2,24,22,50,31,59,26,18,-93,19,62,-51,-28,37,16,35,-23,-41,26,-6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.142","t":"Working with Core Beliefs You will recall that core beliefs represent the most central, fundamental beliefs about ourselves, others, and our world. Our experience is that therapists do not usually focus on core belief modification early in treatment. Rather, working with core beliefs is done after the therapist has developed the case conceptualization and established a strong alliance with the patient. Usually, these beliefs often develop early in childhood and remain dormant until they are triggered by periods of acute stress. In some Veterans, core beliefs develop in young adulthood after particularly difficult or traumatic experiences in the military.","e":[22,14,-169,-74,42,34,18,12,34,-28,-19,8,21,10,-4,8,-31,-5,-2,67,-65,-49,9,-46,-7,40,-10,28,-18,22,76,-8,32,-50,-9,-109,24,40,47,-60,6,16,11,-87,7,-44,55,-29,27,13,38,-79,16,-29,105,23,-1,58,-3,-71,112,50,-83,67,16,-6,-60,42,-25,-29,32,-20,0,46,-30,7,-23,-3,16,38,78,-38,58,-36,34,38,-16,33,-3,107,50,3,-37,-1,-95,-22,-13,1,-25,9,-54,-52,8,-28,2,40,-3,-6,-15,24,-67,46,-33,-12,-18,5,76,-31,10,12,-14,-12,1,109,29,52,-36,-39,24,12,-7,-32,-51,-8,4,63,-5,-6,0,73,37,11,21,-7,3,-59,18,-52,-16,42,1,54,-9,41,7,-31,-43,16,54,-23,40,17,1,22,35,-10,-3,51,30,41,-29,-36,-15,-8,95,31,78,-42,21,-12,-24,-25,0,31,-2,-4,36,-29,-43,-35,-30,22,-41,17,-73,-84,7,-4,40,-64,9,10,-38,50,-30,72,-3,-6,-33,-8,60,-13,-50,40,-31,6,-15,27,-36,39,19,-5,7,18,10,-10,-37,11,30,17,-16,-81,62,45,42,5,-29,45,56,37,5,15,31,12,-62,42,3,-30,-33,43,2,38,-31,-1,40,-43]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.142","t":"Core Belief Identification In a similar manner as working with automatic thoughts, the first step in working with core beliefs is to identify and clearly articulate them. Most often, core beliefs are identified by the therapist using guided discovery, which is often applied when the patient describes crises that emerge during treatment or recalls critical negative experiences from her past. As the patient describes these negative experiences, the therapist develops hypotheses about specific core beliefs by speculating about particular beliefs that might lead the patient to react in a specific way. Once the therapist begins to formulate hypotheses about the patient's beliefs, she looks for opportunities to share them with the patient in order to obtain feedback. The best • Core belief opportunities to solicit feedback occur either when an emotional topic is being identification discussed or when an emotional reaction occurs during the session. At this time, the patient may actually articulate a belief as an automatic thought. For example, the patient may express the belief on a Thought Record or articulate the belief when the therapist asks what was running through her mind in a particular situation. The therapist recognizes the patient’s response as a core belief when (a) it is associated with significant affect, (b) it summarizes a theme that has been evident across the patient’s previous Thought Records or other cognitive restructuring work done in session, and/or (c) it is consistent with typical core beliefs observed by cognitive","e":[42,33,-156,-86,48,4,48,22,27,-9,-6,10,52,39,-12,-10,-12,-44,15,56,-75,-29,-20,-22,11,36,-37,13,-14,23,52,-13,36,-41,-36,-103,51,20,18,-15,14,8,10,-86,6,-4,45,-3,47,15,28,-51,36,-40,101,65,-3,65,22,-83,103,52,-59,38,35,-8,-55,60,-15,-15,34,-15,17,29,-46,-2,-13,-4,20,56,85,-53,59,-21,67,51,-29,38,6,81,35,-16,-19,8,-96,12,-24,2,-32,-3,-75,-55,-11,-39,16,49,-21,6,5,32,-34,45,-48,-25,-18,-22,105,-39,14,27,-22,33,-27,108,26,53,-34,-49,28,9,-7,-52,-29,-6,35,59,11,-15,-10,45,7,19,11,0,18,-53,20,-50,-41,45,18,46,-4,24,14,-46,-42,-7,49,-6,49,20,-18,46,13,-33,20,35,56,8,-13,-38,-1,0,93,39,65,-41,29,-15,-2,-37,27,53,16,-11,48,-21,-25,-44,-21,11,-57,20,-71,-73,11,-23,24,-40,3,18,-48,30,-41,54,10,-20,-34,-13,55,3,-28,58,-16,34,-22,23,-21,14,34,-21,9,9,-11,5,-53,6,0,9,-16,-101,66,11,56,2,-23,20,20,51,-14,18,16,10,-81,12,21,-25,-17,43,-9,58,-28,-16,66,-33]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.143","t":"behavioral scientist-practitioners, such as J. S. Beck (1995; see Chapter 11 on core beliefs). CBT Strategies for Identifying Beliefs 1. Looking for the expression of a belief as an automatic thought 2. Recognizing a common theme across automatic thoughts or situations 3. Directly asking the patient what he thinks the belief is 4. Reviewing a belief questionnaire 5. Using the downward arrow technique (Burns, 1980) 6. Completing a Cognitive Conceptualization Diagram","e":[20,1,-144,-47,76,-25,68,-32,20,0,20,18,69,62,4,-45,-37,-54,44,45,-28,-10,4,-23,-4,31,-60,56,-22,11,31,-5,19,-49,-49,-86,47,5,-4,12,36,-1,21,-89,40,16,83,8,34,-5,12,-66,63,-55,96,39,-30,69,13,-69,119,56,-61,12,26,-42,-70,55,-40,-4,60,-17,37,48,-52,-25,-48,-11,24,61,71,-47,69,2,67,37,-22,20,-10,61,3,-24,11,51,-76,29,-31,-28,-14,-30,-87,-23,-37,-17,4,54,-10,-16,-18,12,-70,18,-29,5,-45,29,81,-25,14,42,16,33,-4,61,11,66,-74,-49,18,-7,-4,-35,6,-11,5,37,-9,5,7,57,31,11,-1,21,12,-54,-20,-59,-31,22,46,31,19,8,53,-42,-27,26,38,12,33,-13,-37,44,-16,-34,29,48,55,44,-40,-41,-17,4,94,19,40,-25,18,-10,9,8,34,75,8,-25,44,-12,-12,-43,23,-2,-68,-2,-102,-56,13,4,27,-56,-12,24,-36,49,-31,40,0,-5,-33,-25,53,17,-42,45,-48,47,-13,-2,-35,23,11,-25,-10,-4,-8,29,-28,16,16,11,-5,-85,40,-15,58,19,7,32,38,38,-13,22,24,14,-68,14,13,-39,-8,53,25,60,-22,-6,60,-29]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.143","t":"One specific strategy for identifying core beliefs is the downward arrow technique • Downward arrow (Burns, 1980), in which the therapist asks the patient a series of questions such as technique “What does this mean to you?” or “What does this mean about other people?” The idea is to identify the meaning or the fundamental idea that underlies the cognitions that patients express. The downward arrow technique begins with the identification of a key automatic thought. The therapist hypothesizes that the content of the automatic thought is not consistent with the severity of the emotional reaction experienced by the patient and wonders if the patient has a core belief that has not been previously expressed. The therapist then asks the patient, “What does that mean to you when you thought…?” The therapist may use an “If–Then” question to identify the belief; for example, “If your thought was true, then what does that say about how you view yourself?” While carefully listening to and summarizing the patient’s responses to the questions, the therapist may continue to ask the patient about what any given response means to her until the core belief is expressed.","e":[39,12,-156,-57,55,4,94,-27,25,4,-9,26,85,24,5,-4,-1,-70,10,58,-65,-9,-36,-8,40,9,-9,18,-50,36,30,-27,13,-11,-69,-101,49,18,16,-9,20,3,16,-95,29,-19,60,-9,40,-3,9,-96,27,-53,64,25,20,42,47,-46,61,65,-40,32,30,-50,-76,32,-8,-14,60,-42,18,14,-28,25,-22,-17,54,1,65,-72,37,-25,48,39,-4,50,17,62,16,2,10,34,-87,-8,-15,-18,-40,-32,-62,-14,-3,-41,3,62,-13,-18,-23,15,-45,28,-48,-8,11,-29,75,-46,17,-8,10,11,-26,67,28,82,-78,-27,-21,-1,-20,-32,-30,16,17,38,-19,-18,16,47,34,13,-21,-9,31,-24,-2,-44,-17,-1,19,21,22,-6,57,-42,-41,-12,62,5,55,10,23,70,-27,-55,35,42,59,18,-22,-17,20,-42,81,21,45,-44,21,-20,-1,0,60,37,-5,0,32,-23,-5,-67,-14,13,-58,5,-68,-60,29,-11,30,-27,-18,15,-39,31,-55,40,-9,5,-14,-2,76,-18,-4,27,-20,17,20,-7,-45,32,25,-20,-2,-2,-5,15,-48,6,-15,-23,-33,-116,29,-24,78,16,27,29,38,43,-43,7,7,25,-63,62,21,-19,-7,38,-3,36,-21,-18,31,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.143","t":"Michael: …and then my Mom asked me about getting a job. Therapist: What went through your mind when she said that? Michael: Oh, that’ll never happen Therapist: So what does that mean to you? Michael: Like I said before, it means I’ll be unemployed forever. Therapist: So if you are unemployed forever, what would that mean to you? Michael: [pause] That my family will keep looking down on me. Therapist: And what would that mean? Michael: [pause] Obviously, it means that I’m no good to anybody. I’m just a burden to my family. [starts crying] Therapist: [pause] That’s a powerful belief, Michael. Can we talk about this a bit more? Michael: I guess so. Therapist: What I understand is the thought that you will be unemployed forever is associated with a belief that you are a burden to others, especially to your family. Michael: Yes. Therapist: Is this one of the reasons why you sometimes think that life is not worth living? Michael: Yes, my life is pretty worthless. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 125","e":[25,7,-129,-61,38,64,-1,23,34,-21,-78,13,31,20,-6,13,-30,-33,-26,64,-47,-37,-54,15,22,20,-24,37,-51,23,63,-29,-19,-20,-84,-36,26,105,61,-34,10,-6,10,-114,-1,-48,52,62,8,-39,15,-103,39,47,82,1,35,2,-39,-26,110,51,-40,74,39,-33,-45,21,-30,-17,44,-7,-8,34,-25,81,-46,18,31,16,41,-4,24,-5,30,28,34,7,-7,102,-11,27,-27,32,-94,8,-22,-24,-1,-53,-55,-49,-22,-48,64,64,-27,-52,1,10,-45,42,-47,-32,-21,-4,62,-69,27,54,9,33,-8,45,23,61,-21,20,-15,16,25,-25,-38,31,-10,37,-14,-41,-33,11,67,-28,-10,13,1,-38,22,-36,-58,-4,-16,45,-14,-8,49,-44,-31,-6,51,17,28,36,6,21,-7,-34,12,38,10,15,5,-52,-2,-31,57,-37,9,27,-15,-34,40,-37,76,3,11,-1,-6,-11,-40,-48,-8,24,-36,20,-35,-22,54,-50,13,-44,0,13,-19,21,-64,35,32,-11,-54,-17,66,-49,-14,30,6,-8,-8,-30,-43,31,22,13,29,7,23,18,-72,-15,10,3,1,-103,75,50,-3,31,-12,32,32,69,5,30,12,-22,-39,9,21,-36,14,25,15,20,-1,35,46,-49]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.144","t":"Therapist: You had not told me about the belief that you are a burden to your family in previous sessions. This is new information to me and sounds pretty important. Perhaps these beliefs are something that we can work on together. The therapist then went on to discuss when Michael might have developed this belief and under what other circumstances he views himself as a burden.","e":[42,31,-133,-76,32,54,-1,-36,8,-20,-68,-3,28,63,-23,11,13,-29,20,63,-63,0,-45,8,6,39,-1,16,-61,19,78,-35,4,-55,-63,-17,5,80,31,-38,32,-14,-40,-143,16,-36,43,42,26,-6,46,-93,-18,-1,101,-19,8,6,3,-35,112,50,-35,48,38,-37,-51,46,-33,2,62,-13,39,4,-21,13,3,25,24,5,87,-1,83,-18,27,37,4,33,21,122,16,-10,-4,31,-65,-6,-56,5,-13,4,-52,-15,0,-22,49,15,-17,9,-18,21,-48,38,-32,-19,-20,-36,65,-79,26,28,-57,21,-10,82,12,47,-30,17,-2,-27,0,-38,-11,25,14,22,7,-27,1,12,83,60,-18,-10,17,-32,39,-56,-45,27,17,31,-32,44,19,-59,-45,10,51,-11,46,49,0,22,13,-34,14,81,33,4,1,-49,-3,-20,57,3,57,-3,40,-22,20,-18,42,-10,-30,-44,33,-25,-39,-44,-14,20,-2,-20,-74,-60,29,-21,41,-20,-14,11,-33,53,-58,59,-9,-40,0,-48,59,-50,-13,7,-28,0,-1,14,-56,18,-12,-14,11,6,36,-4,-39,-24,-20,-8,14,-92,69,53,37,29,-31,49,18,57,15,25,44,-36,-62,10,25,-30,-2,32,-18,2,8,12,6,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.144","t":"Core Belief Modification Oftentimes, more than one core belief emerges during the course of In choosing the particular belief treatment. In this instance, the therapist and patient collaboratively to address, the therapist decide which belief should be the focus of treatment. In choosing the identifies the core belief that is particular belief to address, the therapist identifies the core belief that is most strongly endorsed by the most strongly endorsed by the patient, is relatively enduring, and/or is patient, is relatively enduring, most clearly associated with the patient’s presenting problems. Patient- and/or is most clearly therapist collaboration in identifying and modifying specific beliefs is of critical importance, and there are several strategies to facilitate this associated with the patient’s collaboration (see strategies below). presenting problems.","e":[17,33,-157,-65,46,3,21,32,44,16,-8,-11,42,20,-16,3,-14,-37,3,63,-93,-43,7,-62,18,21,-3,20,-23,13,58,-11,45,-55,-34,-99,54,41,39,-24,2,29,13,-108,27,-35,35,-17,36,-6,22,-52,21,-40,101,58,-12,62,-6,-66,91,33,-74,59,34,-9,-55,51,-35,-29,34,1,27,39,-27,-5,-8,-11,5,30,65,-45,79,-37,33,29,-9,35,4,72,36,-2,-3,21,-127,-8,-20,-29,-33,9,-57,-34,19,-6,6,43,17,34,-18,22,-55,21,-14,-32,-2,-24,86,-29,5,12,-18,-15,-27,113,12,27,-62,-36,46,15,-12,-44,-18,-3,12,47,9,13,4,56,30,17,24,9,8,-73,23,-44,-25,43,42,55,-5,43,8,-38,-41,-4,47,15,55,20,-23,44,8,-15,11,36,35,36,-32,-49,2,5,98,24,77,-32,7,-6,-7,-30,8,43,-5,17,26,-46,-52,-30,-25,9,-20,5,-64,-70,21,1,35,-51,-5,22,-46,65,-36,61,-5,-4,-39,-8,55,-21,-24,44,-33,10,-21,22,-42,44,32,-3,5,-1,6,-7,-44,-2,11,28,-20,-94,49,28,34,15,-21,29,40,51,-4,17,34,-16,-59,54,24,-26,4,60,-17,31,-25,-11,64,-48]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.144","t":"Strategies for Modifying Core Beliefs 1. Completing a Core Belief Worksheet in which evidence that contradicts the core belief and supports a more adaptive one is noted (J. S. Beck, 1995) 2. Writing down the beliefs and rating fluctuations in the degree of certainty of these beliefs over the course of a session, day, or week (J. S. Beck, 1995) • Modifying 3. Simply writing down the modified core belief core beliefs 4. Completing a Thought Record 5. Developing a “Reasons Why” coping card 6. Using the cognitive continuum 7. Restructuring perceptions of early experiences that contributed to development of the core belief 8. Making behavioral changes that support a new, more adaptive core belief","e":[16,11,-140,-55,42,-12,27,5,51,-3,-13,-22,52,94,21,27,-28,-17,7,66,-33,-63,-11,-40,-8,12,-40,18,-12,53,43,-1,24,-78,-16,-91,63,-7,36,-26,3,25,38,-86,58,-15,73,-43,40,-4,29,-52,47,-30,83,42,-12,38,15,-70,122,0,-60,24,22,5,-47,81,-57,-32,80,17,-6,9,-30,-23,-16,9,23,52,68,-18,93,-38,43,23,-12,25,6,54,1,-21,11,9,-84,7,-23,-9,-31,31,-56,-48,29,-9,-23,46,-16,6,-4,25,-78,-3,-1,-17,-9,-12,95,-17,4,42,-55,10,-21,96,9,21,-60,-54,56,-1,7,-34,-60,15,20,41,-3,20,21,47,29,-3,52,2,10,-84,-14,-60,-19,28,35,40,6,47,32,-46,-34,30,48,20,67,-29,-21,68,8,23,6,69,27,53,-20,-36,-4,-12,87,20,83,-49,-18,-16,8,5,18,55,14,-31,52,-7,-53,-21,-4,3,-52,-3,-67,-94,2,-1,35,-60,6,2,-30,45,-8,34,-6,-10,-15,-10,64,20,-33,42,-18,48,-6,14,-7,7,-2,-35,-20,26,27,6,-21,-2,12,24,-4,-107,33,12,53,3,-22,41,41,12,-4,17,44,-3,-55,29,20,-54,4,72,23,66,-22,-20,77,-35]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.144","t":"The Core Belief Worksheet (J. S. Beck, 1995) is a tool that allows patients to (a) articulate the “old,” unhelpful core belief and a “new,” more adaptive core belief, and (b) accumulate evidence over time that supports each of these beliefs. It is hoped that the longitudinal evaluation of the old and new belief allows patients to see that the old core belief was overly rigid and negative. The procedure for using the Core Belief Worksheet is as follows. First, the patient writes down the “old” core belief and, using a scale of 0–100, indicates the percentage that she believes the old belief at that moment, the most that she believed the old belief in the past week, and the least that she believed the old belief in the past week. In addition, the patient writes down the “new” belief and, using the same scale, rates the degree to which she believes the new belief at that moment. Not only does the Core Belief Worksheet help patients to clearly articulate their beliefs, but it also allows them to observe fluctuations in their degree of certainty about these beliefs over the course of a week, which provides evidence that these beliefs are not necessarily 100% “true” or “fixed.” To facilitate belief change, patients are encouraged to document evidence that contradicts the old core belief and supports a more adaptive one. This approach of strengthening the new","e":[20,43,-186,-115,26,-20,34,17,-8,-7,31,9,32,25,6,28,-38,-17,-6,57,-49,-29,-35,-47,20,32,-63,24,-42,58,42,4,63,-44,-24,-94,51,10,40,-8,-25,34,29,-93,48,1,42,-26,39,-17,-35,-54,75,-1,85,60,-9,41,-32,-63,89,24,-35,41,26,-11,-47,46,-26,-34,45,-6,-4,32,-34,-12,-22,1,19,26,88,-33,73,-12,60,8,-26,15,-19,80,5,-13,-32,18,-97,27,2,-18,-49,44,-82,-65,22,13,3,36,-27,31,-13,10,-47,19,-34,-12,-3,-38,91,-7,-3,5,-21,13,13,125,8,21,-59,-31,14,-18,-13,1,-63,-13,34,40,18,10,-18,48,26,-2,22,9,34,-72,-1,-53,-23,63,-4,17,-16,30,17,-42,-46,8,57,12,72,17,-5,47,-7,-29,-4,65,45,42,-20,-32,8,-18,61,21,66,-25,12,-5,-5,1,22,19,-4,0,42,-36,-44,-37,-27,-13,-82,18,-68,-83,8,-3,40,-62,-4,5,-17,39,-36,33,9,-11,6,22,69,33,-5,30,-20,30,-9,-7,-29,-16,41,-6,17,13,37,-14,-39,-8,-27,5,-25,-125,26,12,43,-17,-20,21,64,34,18,24,-14,-25,-43,20,1,-49,43,83,-8,34,-21,8,64,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.145","t":"Patients can also observe fluctuations in the degree of endorsement of a particular belief and evaluate the meaning of those fluctuations without using the Core Belief Worksheet. If changes in the degree of belief are observed only in given situations, the therapist and patient may agree to modify the belief so that it more accurately reflects reality. Sometimes, when patients write down their beliefs, they notice that their written belief does not accurately capture the underlying belief. In this case, patients are encouraged to modify the written belief so that it is more accurate. This strategy often leads to shaping highly dysfunctional beliefs into more adaptive ones, because they are revised to be less extreme or less pervasive.","e":[45,21,-180,-79,55,-2,13,48,48,-19,5,5,56,55,-7,21,-5,-49,-23,39,-63,-30,-54,-25,-8,22,-22,1,-28,42,28,30,17,-52,-35,-67,42,32,64,-4,7,32,-6,-90,36,-5,78,-20,41,-4,24,-60,26,26,124,69,-4,31,19,-91,108,14,-62,32,25,5,-87,33,-39,-44,47,37,-8,37,-24,13,-10,-17,1,28,44,-30,88,-32,65,19,42,24,-5,70,33,-36,14,21,-123,4,-16,-20,-16,-2,-69,-28,-5,-3,4,28,-2,17,4,3,-57,3,-25,-38,17,-39,75,-32,-22,33,-11,2,-4,123,8,40,-20,-36,42,-19,7,-19,-48,7,18,45,35,-7,1,30,24,1,40,-18,13,-74,10,-27,-4,40,26,24,14,32,30,-40,-24,13,58,31,76,3,-34,54,-1,-23,14,82,-2,32,-49,-46,6,-43,81,18,45,-20,1,-5,12,-7,22,1,38,0,28,-30,-63,-32,0,30,-69,-9,-76,-76,9,-6,39,-37,6,17,-21,25,-42,36,-21,-11,-50,-41,60,-1,-28,53,-36,21,-5,-7,-25,11,38,-32,13,2,13,-17,-72,-12,7,14,-16,-94,61,8,46,-10,-31,37,73,15,-1,7,2,9,-46,35,26,-30,5,62,21,50,1,-5,31,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.145","t":"In the following dialogue, Michael and his therapist continued to evaluate his core belief that he is a burden to his family by noting fluctuations in the degree to which he believed that belief, depending on the particular aspect of the belief he was considering, and modifying it to reflect his reality as accurately as possible.","e":[54,25,-151,-74,56,52,13,-8,40,-3,-45,0,47,65,-21,8,-14,-35,22,68,-61,-4,-58,-17,29,34,-5,32,-60,35,73,-23,-8,-44,-75,-56,31,93,53,-44,13,-3,-28,-110,30,-29,16,10,22,-14,30,-69,14,-14,101,26,6,31,17,-69,116,25,-47,39,49,-35,-49,49,-33,-10,62,-35,15,37,-8,7,7,22,10,6,62,-3,75,-14,39,34,12,30,17,102,26,2,3,25,-93,1,-40,-5,4,2,-66,-7,12,-29,35,44,-2,19,-2,14,-64,8,-31,-21,10,-27,81,-63,-7,34,-43,22,-42,94,-9,39,-33,20,-15,-11,-1,-51,-9,-3,8,48,11,-21,-21,17,59,18,-19,-13,15,-41,36,-42,-30,11,24,63,-23,44,16,-48,-47,16,45,20,26,12,6,32,9,-21,30,68,33,-2,-17,-56,6,-18,93,-1,51,-26,33,-14,8,-19,35,8,-4,-28,35,-31,-45,-39,-10,24,-36,-14,-45,-74,46,-39,50,-43,-18,-2,-27,60,-77,66,-7,-33,-33,-50,66,-30,-21,37,-40,8,-14,14,-44,22,-5,-9,15,-3,21,-2,-61,-32,-5,16,10,-106,82,61,42,31,-28,53,28,48,4,51,31,-30,-48,5,40,-32,-10,41,-19,21,0,31,28,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.145","t":"Therapist: Would it be OK if we talk about your belief of a burden a bit more? Michael: OK. Therapist: I’m going to write down this belief on a sheet of paper so that we can focus on this more objectively. [writes “I am a burden to my family”] Is that correct? Michael: Yes. Therapist: How much do you believe this on a scale of 0 to 100, with 0 meaning that you do not believe this at all and 100 meaning that you believe this 100%? Michael: I completely believe that this is true, so 100. Therapist: [writes down 100] Have you always believed this to be the case? Michael: No. I started feeling this way when I realized that I couldn’t concentrate while I was working and decided to quit. Because I’m not able to work, I think I’m a burden on them. Therapist: So you only have believed you are a burden since being unemployed. Do you believe you are a burden because of financial concerns? Michael: Well, not completely. As you know, I receive support from the government for my head injury. It’s more that I feel like an emotional burden, I guess. Therapist: What do you mean by that? Michael: I have these periods of ups and downs. Sometimes, everything is fine and then at other times, I become irritable, frustrated, and depressed. At those times, I’m not the easiest person for my family to be around. Therapist: I see. Maybe, we should change this statement that we wrote down because it is not exactly right. What if we were to write down, “I am an emotional burden to my family.” Would that be more accurate? Michael: Yes, it would. Therapist: [writes down the revised belief] There. So I understand that you have periods when you are very upset, irritable, and frustrated. Is it only during those times that you believe you are a burden, or do you believe that all the time?","e":[70,39,-135,-97,29,32,4,-13,29,-15,-48,-15,21,45,3,23,6,-46,-11,70,-69,-4,-64,2,23,58,-40,11,-81,23,69,-50,-12,-56,-105,-33,0,92,46,-35,82,-42,6,-129,-6,-40,62,40,2,-21,31,-121,-4,27,92,-7,-7,1,-9,-46,110,38,-44,47,43,-9,-44,47,-23,-27,49,-5,21,20,-40,30,-26,10,63,18,61,-1,71,-30,34,22,21,23,27,109,9,-23,-11,34,-41,-1,-29,-20,-25,-3,-81,-23,-32,-33,29,20,-15,-24,-7,0,-36,30,-27,-50,-13,-1,86,-81,3,35,-54,11,-6,55,23,15,-33,31,-8,-9,4,-18,-18,22,8,41,14,-19,-15,22,79,36,-17,-13,22,-33,14,-45,-24,8,-4,27,-23,24,30,-54,-29,5,42,16,55,46,-18,38,35,1,-13,98,24,3,3,-36,-6,-20,52,-15,54,-2,13,-11,47,8,53,-19,-2,-8,43,-10,-32,-40,-1,16,-24,22,-70,-40,42,-58,20,-41,11,26,-22,25,-56,61,3,-27,-29,-40,83,-37,-19,43,-21,-3,5,5,-39,16,8,-13,42,10,26,-13,-60,-24,-20,-17,9,-99,78,19,36,27,-30,36,18,33,27,16,28,-28,-70,5,21,-33,0,41,2,-1,22,-6,44,-27]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.146","t":"Michael: Hmm…it’s only really during those times that I feel that way. Actually, I really only believe that after I get upset. Therapist: So, you are saying that you do not believe you are an emotional burden all the time, just during the time after you get upset. Michael: Uh-huh. Therapist: How would you change this statement, then, so that it better reflects what you just said? Michael: I guess I would say that sometimes after I get upset, I believe I am an emotional burden to my family, and at other times, I don’t. Therapist: Let’s write that down, OK? Michael: [writes down modified belief] So every once in a while I believe I am an emotional burden to my family after I get upset, and at other times, I don’t. Therapist: How often do you really get frustrated and upset that you end up believing you are a burden? Every day? Once a week? Michael: Let’s see….The last time I lost my cool was last Monday, but before that it had been a couple of weeks. Therapist: So every once in a while. Maybe we should re-write this sentence again to read, “Every once a while, I believe I am an emotional burden to my family after I get upset, and at other times I don’t.” Michael: OK. [writes modified belief] Therapist: After you get upset and believe you are a burden, what happens? Michael: I usually go somewhere by myself. Therapist: And then what happens? Michael: Then, I think about what I did and go back and tell ‘em that I’m sorry for being that way and that I feel really stupid. Therapist: And how do they respond? Michael: They say that they understand that I have my good days and bad ones, and that it’s OK. Therapist: I see. So it sounds like you have a very supportive family who is quite understanding. Michael: Yes, I do. Thank God for that. They really care about me. Therapist: So, is it that you really believe you are a burden, or is it that you feel badly about getting upset with your family? Michael: I guess it’s mostly that I feel badly about getting upset with my family. Therapist: If we come back to our original belief that we wrote down [points to the “I am a burden to my family” statement], how much do you believe that now? Michael: I guess it’s too extreme. There are only specific times when I’m an emotional burden. And my family really doesn’t even see it that way.","e":[58,-1,-135,-83,17,29,2,2,37,-33,-48,3,6,50,7,38,3,-30,-14,92,-80,-8,-49,15,6,68,-32,36,-101,56,72,-49,-9,-62,-115,-7,6,84,66,-34,98,2,6,-112,1,-75,50,17,-2,-37,27,-101,2,15,97,-4,15,12,-1,-70,95,34,-31,27,35,1,-67,35,-41,-44,59,-10,14,23,-30,32,-29,20,50,10,74,19,55,-52,11,14,10,32,-1,110,14,-20,-11,31,-31,-3,-41,-20,-29,-7,-76,-22,-34,-36,16,29,-27,-22,-4,-6,-42,23,-26,-33,-22,25,48,-97,8,48,-34,34,-26,45,49,11,-14,34,-22,2,1,-33,-15,23,-1,42,37,-8,-10,20,67,33,-17,-42,21,-33,14,-56,-50,2,-3,24,-27,47,26,-38,-27,28,68,12,35,27,-9,34,24,14,15,83,20,4,15,-61,-14,-30,29,-8,45,-13,3,-18,36,5,75,-37,8,-33,17,-11,-26,-56,8,36,-39,4,-56,-41,37,-67,-1,-48,24,5,-22,28,-56,39,14,-37,-52,-33,93,-30,-38,47,-24,6,-6,-15,-28,10,12,6,27,4,13,4,-26,-16,-8,-12,-1,-85,66,24,38,30,-44,21,41,29,43,35,23,12,-56,3,31,-37,11,25,13,12,23,-25,44,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.146","t":"This example illustrates the manner in which talking about a strongly In our experience, the gradual held belief can change over time. Notice that the therapist did not shaping of a core belief is less directly challenge the belief. Rather, he worked with Michael in trying threatening and often more to understand the circumstances that led to his endorsement of the effective in helping patients belief. In our experience, the gradual shaping of a core belief is less address their maladaptive or threatening and often more effective in helping patients address their unhelpful beliefs than direct maladaptive or unhelpful beliefs than direct challenging. challenging.","e":[53,44,-184,-89,31,39,34,27,33,-1,-12,15,49,56,21,13,13,-60,10,79,-69,-33,7,-43,-15,24,-8,-26,-36,20,79,-6,25,-22,-53,-83,55,28,30,-54,18,32,-1,-88,48,-21,29,2,12,-14,32,-82,38,-51,88,37,-2,51,10,-83,56,5,-52,60,0,-14,-57,19,-31,-35,51,-9,-7,-10,-10,22,-16,-30,5,23,51,-34,61,-21,69,25,2,61,18,86,32,-21,-23,23,-119,-11,-34,-8,-44,15,-69,-22,31,12,-1,27,-10,12,-6,19,-31,54,-37,-13,-13,0,88,-24,-6,11,-3,6,3,105,33,57,-38,-4,43,-22,-6,-12,-54,-19,1,54,-11,3,5,39,38,16,26,0,-9,-50,41,-56,-20,29,9,43,19,33,4,-15,-17,12,24,7,26,-5,-1,15,5,-15,24,44,9,3,-20,-29,11,3,72,23,61,-66,13,-22,13,-42,3,11,13,13,37,-24,-42,-42,-10,16,-83,18,-64,-57,42,3,42,-31,1,15,-28,39,-60,76,7,5,-15,-36,85,-28,-40,4,-56,-11,3,23,-43,39,0,2,-3,-2,7,-18,-18,4,3,12,-27,-128,33,45,54,18,-4,27,45,36,-3,9,20,-3,-56,9,41,-23,15,52,0,35,-14,-21,25,-52]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.147","t":"The core belief work done in session provides an important platform for patients to develop and articulate new, more adaptive core beliefs. However, it is equally as important for patients to gain practice with accessing the new core beliefs outside of session in their daily lives. Some of the strategies already discussed in this section of the manual can achieve this purpose. For example, patients can keep Thought Records in which they catch themselves reverting to their old, unhelpful core beliefs and use the cognitive restructuring skills they have gained earlier in the course of therapy to arrive upon the new, more adaptive beliefs. Completion of the Thought Record in this manner shows patients the frequency with which old, unhelpful core beliefs are activated and the situations in which they are manifest. It provides an opportunity to restructure those old core beliefs in the moment.","e":[1,33,-174,-96,39,-31,40,12,42,-22,-16,-10,8,31,5,8,-34,-37,-24,38,-42,-39,0,-19,6,43,-28,11,-30,34,65,-22,39,-26,-19,-102,67,9,26,-53,4,4,17,-101,62,8,64,-25,31,1,11,-57,18,-10,131,48,11,47,9,-79,105,16,-40,39,-4,-21,-57,64,-47,-14,36,11,-1,31,-37,16,-21,4,-3,32,67,-45,50,-16,50,34,3,12,-7,81,38,-39,-15,10,-121,19,-3,1,-43,66,-82,-74,18,-5,-6,64,-19,11,-11,31,-46,33,-37,-9,-16,-18,69,-7,19,1,-27,-4,14,107,32,67,-16,-42,35,3,-25,-38,-61,6,57,33,2,-10,17,56,35,19,-3,15,19,-76,26,-63,-39,47,-3,14,12,42,40,-50,-43,8,64,13,72,9,-35,29,-1,-36,8,46,18,-1,-26,-56,6,-19,87,8,70,-38,6,-35,-31,-28,-6,16,8,-19,51,-18,-42,-45,-30,3,-52,24,-80,-82,5,-1,37,-45,15,28,-56,18,-17,36,-6,-10,-30,-25,90,17,-11,33,-23,27,4,4,-8,39,41,-12,5,-6,-2,-5,-34,19,6,29,-48,-104,3,21,64,10,-26,46,37,50,18,13,12,-35,-72,27,5,-32,-14,52,26,25,-3,-49,53,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.147","t":"Coping cards can also reinforce new, adaptive core beliefs and remind patients of the evidence that supports them. One of us (AW) has developed the “Reasons Why…” coping card for this purpose. The therapist and patient collaboratively develop a title for the coping card that reflects the new, more adaptive core belief, such as “Reasons Why I am Successful” (to counteract the core belief, “I am a failure”) or “Reasons Why I am Lovable (to counteract the core belief, “I am unlovable.”). In session, they develop a bulleted list of evidence that supports the new core belief. The patient can consult the list in between sessions at times in which he notices that the old core belief has been activated, and he can add to the list when new evidence that supports the more adaptive core belief is identified.","e":[25,52,-167,-89,58,-15,11,2,39,-28,-62,20,53,61,17,31,-25,-36,-10,49,-65,-60,-19,1,3,39,-27,55,-55,15,42,-29,29,-81,-9,-49,66,20,40,-3,-9,11,43,-72,32,-7,48,9,43,-2,12,-91,26,7,99,26,5,28,-18,-49,58,31,-23,40,63,-11,-23,62,-58,-3,59,-24,-4,18,-29,9,-43,36,4,42,75,-53,28,-38,55,8,15,8,-48,59,9,26,3,35,-71,29,-10,-45,-57,13,-68,-15,34,13,-9,50,-3,3,-8,17,-41,43,-25,-22,-10,-24,73,-37,8,12,-25,26,-7,61,6,55,-29,-21,50,2,6,-34,-72,11,38,45,-4,-2,12,37,20,10,16,-21,-23,-85,36,-52,-43,25,-5,42,-8,55,59,-29,-47,0,60,-1,78,-22,-39,51,-4,-11,4,50,13,61,-38,-53,7,-20,89,-9,80,-16,-7,-56,24,-46,42,50,11,-12,35,29,-66,-38,-13,8,-60,-3,-82,-85,-9,18,14,-24,16,13,-34,13,-47,32,1,-3,9,2,59,0,-45,20,-12,42,8,-9,-39,24,34,-25,-5,3,3,12,-14,9,-23,-12,-38,-113,70,21,39,17,-15,54,19,49,11,23,16,1,-43,44,-1,-79,8,57,-16,37,-1,-32,43,-33]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.147","t":"Some patients have a particularly difficult time modifying unhelpful core beliefs when they compare themselves to others whom they perceive (usually inaccurately!) as being more successful or adaptive than they are. The cognitive continuum is a strategy that helps patients to perceive as accurately as possible where they stand on a particular dimension associated with a core belief. Using this strategy, patients often realize that their belief is much less “all or nothing” than they had originally stated and that there are many aspects of their lives in which they are doing quite well.","e":[20,39,-167,-84,58,31,31,2,43,15,23,-14,29,71,28,-23,-55,-26,14,59,-68,-27,-4,-30,24,53,-30,22,-41,13,40,16,40,-37,-29,-66,35,4,19,-4,-12,7,28,-85,46,11,47,-16,36,-12,-30,-60,26,4,113,28,-9,62,-4,-56,105,5,-17,39,23,8,-71,53,-41,-36,43,-48,28,16,-42,-19,-22,10,4,26,44,-47,41,-12,72,40,16,-3,-12,87,-4,-2,-9,36,-99,-5,-17,-23,-9,-2,-69,3,36,-1,-13,73,-12,27,-1,-8,-31,30,-29,-29,11,0,98,-10,13,11,-5,-29,10,100,0,64,-61,-35,41,9,-23,-11,-35,-24,-14,40,-3,2,8,67,20,-21,9,3,13,-93,11,-46,-5,12,1,73,14,30,28,-35,-20,20,17,-16,55,18,-23,34,4,-31,29,26,42,54,-38,-35,12,8,99,-8,74,-43,13,-32,-18,11,3,45,2,29,38,-4,-41,-38,10,-28,-48,16,-59,-82,18,1,32,-52,13,18,-22,47,-32,32,-3,-19,-45,-20,83,18,-1,15,-22,-3,8,-28,-15,38,24,-17,23,-7,27,-31,-24,0,-9,14,-17,-112,51,20,49,21,-8,36,37,34,-4,21,6,9,-73,25,9,-47,-12,34,20,29,-21,-37,80,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.147","t":"Consider Kate, who has the belief that she is a failure. In using the cognitive continuum strategy, her therapist drew a horizontal line on a piece of paper, in which the right end was labeled as “100% failure,” and the left end was labeled “0% failure.” The following dialogue illustrates the manner in which Kate evaluated the degree to which this belief is truly characteristic of her.","e":[47,14,-174,-45,63,59,23,0,11,14,-45,-16,87,84,-2,8,-2,-38,19,86,-59,-26,-62,-23,52,65,-48,1,-76,-2,39,-15,5,-69,-70,-22,31,-1,11,-25,23,18,36,-76,24,-38,31,44,22,9,-8,-43,47,-24,62,65,-20,15,17,-53,73,9,-39,47,62,-4,-72,89,-48,-43,52,-24,53,15,-37,10,-30,-20,-18,32,47,-51,56,10,73,31,23,23,-39,97,-3,19,22,36,-64,-18,-16,-16,-12,20,-84,-22,7,-24,24,59,25,10,-3,-14,-31,31,-32,-39,35,-26,79,-51,22,12,4,-33,3,52,-22,52,-56,-4,29,7,-48,-7,-32,3,1,67,21,2,-22,26,17,2,-8,-2,6,-68,49,-16,-17,12,-2,38,-6,8,5,-51,9,13,20,-15,55,36,-33,33,-15,-36,16,26,42,36,-49,-30,4,0,47,11,59,-10,28,-37,36,1,33,29,23,15,19,13,-48,-45,25,-2,-56,9,-60,-69,63,-4,37,-15,-7,27,-41,47,-69,29,-21,-2,-30,-10,68,16,-26,16,-30,-23,1,-31,-52,8,6,27,12,-20,45,16,-48,-7,-22,-20,-28,-98,44,-1,40,42,-39,26,9,35,-24,26,-17,6,-62,34,-3,-51,-5,56,20,24,33,4,73,0]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.147","t":"Therapist: Where would you place yourself on this continuum? Kate: [tearful] 100%. I really have failed at everything I’ve cared about in life. My children. My marriage. My career. The list goes on and on. Therapist: [writes “Kate” under 100%] So there’s not one person in this world who you would judge as more of a failure than you? Kate: [shrugs her shoulders] Therapist: Let’s start with the first area you mentioned—children. Are there any behaviors in which a parent could engage that would lead you to say, “That person is a failure as a parent?” Kate: [pauses] Well, I guess parents who abuse or neglect their children are really bad. Therapist: Would you consider them failures as parents?","e":[47,25,-131,-41,23,71,-10,-20,37,-21,-54,-13,73,76,-65,-17,27,-34,4,83,-41,-21,-34,34,35,56,-31,-3,-73,26,46,-2,-11,-65,-82,1,52,57,22,-59,53,11,-7,-85,-3,-105,41,41,22,-10,21,-89,17,-11,75,27,-1,19,27,-60,80,14,-65,67,24,4,-81,67,-20,-63,49,-22,78,17,-23,20,-54,-17,38,54,80,-15,66,-35,29,14,-4,56,-36,102,19,21,-6,12,-85,-9,-30,-20,-23,-28,-62,-4,-28,-36,65,19,33,9,-7,-12,-17,24,-26,-40,-2,-46,57,-92,10,48,-15,8,-3,23,27,55,-64,16,11,14,0,-37,-12,-22,2,79,19,-20,-15,-9,43,32,10,-5,26,-19,54,-4,-41,38,4,25,-21,1,22,-54,-3,19,46,8,64,35,-28,22,-7,-18,-1,44,20,42,-18,-54,8,-15,37,-9,42,-21,-1,-46,47,-7,45,-14,23,-16,-3,-41,-35,-26,37,24,-21,-9,-41,-62,29,-41,27,-24,-2,14,-34,39,-81,48,-33,22,-50,-32,83,-5,-37,55,-70,-28,-6,-30,-89,30,-14,31,28,-14,26,33,-30,11,-26,17,-40,-94,55,26,21,38,-72,5,-19,72,-1,48,13,4,-54,6,-7,-31,9,8,16,47,48,-12,48,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.148","t":"Kate: Yes, I guess I would. Therapist: Here’s an important question Kate. Have you ever abused or neglected your children? Kate: Gosh, no. Therapist: What does this tell you, then, about your failure as a parent? Kate: [hesitating] I don’t know. Right now my children don’t even live with me. That’s pretty bad. Therapist: Does that make you as bad of a parent as if you had abused and neglected them? Kate: I guess not. Therapist: [pointing to the cognitive continuum] Should we erase this mark at 100? Does this mean that you are not a 100% failure because there are people out there who have abused and neglected their kids, thereby making them more of a failure than you? Kate: Fine, put me at 99% then. Therapist: [erases her name under 100% and makes a tick mark labeled 99%] So right now you’re saying that you’re only 1% more successful than parents who abuse and neglect their children. Is that right? Kate: [tearful again] Yes. Therapist: Kate, is it your fault that your children are not living with you right now? That you did something so horrible—that you would consider failed parenting—that they no longer want to be around you? Kate: Well, no, I guess. All of this is just a big game that Kevin is playing. Therapist: Do your children seem happy to talk to you on the phone? Kate: [whispers] Yes. Therapist: Would children whose parent did something horrible to them be happy to talk to that parent on the phone? Kate: No. I can actually tell they look forward to talking to me. I didn’t see that in the past, but now I do. Yesterday, they even asked when they were coming home. Therapist: Would children whose parent is a 99% failure spontaneously say those things? Kate: [brightens] No, they wouldn’t. And you know what? I think Kevin is more of a failure as a parent than I am because he’s the one who is keeping them from seeing their mother. I would never do that to the children, no matter how bad my marriage was. I would always keep their best interest in mind. Therapist: Hmmm. Do we need to revise where you fall on this continuum? Kate: I guess we do. I would put Kevin at 90% failure. I guess I can’t call him 99% or 100% failure because he doesn’t abuse and neglect the kids, and there are times he can be a good dad. Therapist: But you’d judge yourself as more successful than he is, given how he is behaving right now? Kate: Yes, I really would. Therapist: Where are you now on the failure continuum? Kate: Like an 80 or 85%.","e":[66,29,-114,-50,25,66,-7,3,40,-8,-90,-27,51,58,-70,1,18,-44,-16,72,-52,-28,-36,22,45,55,-43,-5,-91,51,90,-12,-15,-62,-124,23,72,50,-9,-94,72,33,-9,-71,-12,-96,51,35,5,-26,17,-90,12,23,65,27,12,9,17,-64,86,20,-50,59,38,25,-55,66,-18,-64,28,-14,32,15,-7,42,-46,-29,39,50,62,-20,40,-34,1,11,16,32,-3,81,0,24,10,25,-25,-9,-15,-25,-30,-16,-46,-24,-28,-28,53,32,34,-9,-2,-5,-29,10,-20,-41,-2,-33,53,-106,23,39,-13,13,-9,-3,60,57,-77,22,4,-2,-21,-13,-9,-16,20,79,39,-4,-17,-6,46,27,-11,5,26,-9,50,12,-29,30,4,-2,-24,6,35,-58,-5,2,40,33,53,17,-15,26,21,2,15,42,11,30,-15,-64,26,-33,13,9,22,-19,-13,-25,67,-12,68,-18,16,-13,-1,-33,-6,-39,28,15,-67,3,-39,-40,38,-34,27,-15,-10,19,-11,15,-69,34,-10,20,-24,-28,67,-19,-27,72,-72,-28,-9,-32,-93,32,-12,43,36,18,15,26,-38,4,-44,30,-22,-98,55,23,8,61,-76,-3,-25,70,20,33,23,11,-50,1,-15,-37,1,17,23,43,61,-37,72,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.149","t":"that she needs to give herself credit for becoming a nurse, especially when she did not go to college right away after high school. She also realized that she performed her duties just as well as the other nurses and that her inability to get a job could be attributed more to the job market than to her abilities or credentials. Regarding her marriage, she concluded that she and Kevin were never a good match and that they both contributed equally to their marital problems. She also acknowledged that many people get married to someone with whom they are not a good match and that she would not necessarily regard them as failures. The conclusion of the cognitive continuum exercise was as follows:","e":[47,20,-163,-47,52,96,8,-13,44,-14,-68,10,61,78,-21,-33,-18,-58,-8,46,-100,-24,-47,-35,32,40,-19,7,-63,16,61,-14,28,-90,-47,-25,24,-5,17,-24,14,15,15,-70,18,-1,23,15,23,-5,-38,-36,17,28,72,59,46,50,36,-67,95,41,-44,83,36,-35,-45,70,-33,-2,6,-48,45,48,-40,-6,-12,-13,-21,16,35,-6,79,-7,52,44,18,-3,-8,82,8,61,-1,60,-55,-20,-19,-8,-35,-30,-58,-26,12,-10,34,8,-1,25,25,21,-48,22,-62,-24,20,13,75,-52,40,75,-17,2,1,59,-4,54,-58,-19,33,-17,-16,-17,-8,13,-32,25,-37,-7,-25,22,23,6,-10,-9,-22,-45,9,-40,-43,25,-3,31,-1,9,33,-25,-4,10,20,-20,81,-3,15,25,-18,-47,9,34,33,59,-60,-77,9,-42,50,-4,33,-43,-5,-24,42,-15,35,21,39,-9,5,33,-52,-63,7,19,-52,-23,-59,-58,32,9,22,-29,7,23,-6,58,-31,42,-16,-17,-34,-35,57,17,-40,33,-14,-35,-15,-51,-69,55,-4,-25,15,-29,31,-14,-27,-13,-27,21,-12,-82,61,28,12,31,-3,40,-9,34,-15,34,36,8,-40,21,14,-49,-27,20,26,6,1,11,51,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.149","t":"Therapist: What do you conclude about the degree to which you’ve had success vs. failure as a parent, as a wife, and with your career? Kate: [sighs] I guess I’m not a failure. Some things aren’t my fault. I always go there, thinking everything is my fault when it’s not. Therapist: Where would you put yourself on this continuum? Are you still at 80– 85% failure? Kate: No. Honestly, looking at it like this, I’d say I’m a lot like everyone else. Therapist: What do you mean by that? Kate: I guess everyone has successes and challenges in their lives. It’s all part of being human. My problems don’t make me more of a failure than anyone else. Not that I’d say I’m truly successful either. I have a long way to go. Therapist: So what percent failure would you indicate in this continuum? Kate: I guess what I’m saying is that I’m at 50%. Neither success nor failure, just average like most people. Therapist: Back when you put yourself at 100%, how did that make you feel? Kate: Lower than low. Totally depressed, where I would just throw my hands up in the air and say, “What’s the point?” Therapist: When you view yourself as 50%, as just like most people who experience some successes and some challenges, how does that make you feel? Kate: Much better. I’m not doomed to fail at everything in my life.","e":[39,14,-151,-15,19,60,39,-19,48,-13,-76,-25,68,51,-32,7,17,-72,-10,100,-63,-31,-44,5,29,70,-69,-21,-85,26,26,-29,2,-60,-97,9,39,57,60,-59,48,6,2,-82,4,-74,17,27,9,7,-8,-72,9,24,70,29,-29,17,27,-73,61,3,-48,84,43,-6,-57,58,-29,-59,30,-33,38,10,-45,18,-35,-17,31,33,48,-29,50,-31,28,0,10,25,-38,105,35,49,5,41,-77,-8,-6,-18,-1,-20,-49,-2,-16,-18,53,40,27,-12,3,1,-43,28,-34,-52,-21,-40,61,-76,-5,21,14,17,-16,20,15,56,-50,11,26,29,-7,-30,-40,22,3,99,23,-3,-22,-1,29,27,-7,4,-5,-51,51,9,-50,44,-3,14,-24,32,-1,-48,-13,9,55,4,42,7,-18,12,10,-10,-5,37,4,39,-14,-65,8,-17,34,-16,52,-12,-7,-19,96,-12,65,-18,21,2,34,-17,-34,-16,47,9,-52,1,-49,-40,57,-41,18,-12,2,32,-41,23,-50,55,-14,13,-20,-8,60,-39,-37,54,-30,-32,-3,-30,-73,21,6,20,4,1,33,37,-63,-3,-30,19,-30,-99,64,-2,16,44,-56,-5,9,101,-4,22,-9,22,-63,26,-6,-31,4,31,46,31,56,-16,56,-6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.149","t":"In some instances, therapists and patients work collaboratively to track the development of unhelpful core beliefs. When core beliefs are linked with specific experiences or interactions with others from the past, it can be helpful to apply cognitive restructuring strategies to the memories of these experiences. This process allows patients to evaluate the degree to which the messages they received or the expectations others had for them might have been unrealistic or inaccurate, leading to the development of a rigid, inaccurate, or unrealistic core belief. For example, Claire remembers her father saying that she must outperform the other children in all of her activities—academic performance, sports, theater—in order to be a “winner.” Through the course of CBT, she realized that she held rigid, and often unrealistic, expectations of herself, fueled by the belief that anything less than the best was unacceptable. In the following example, Claire and her therapist critically evaluated her memory of the message that she took from her father in order to reshape this core belief.","e":[42,30,-166,-81,48,8,41,29,38,0,-21,-1,58,49,-3,13,-30,-8,-19,37,-48,-34,-6,-5,8,44,-49,8,-48,25,81,-9,1,-56,-43,-69,45,30,28,-37,21,34,15,-88,34,4,96,-21,41,23,19,-49,37,-30,126,26,12,51,10,-52,92,26,-32,53,-3,-6,-63,51,-57,-34,30,-15,14,38,-42,-7,-34,1,2,24,75,-51,40,-4,32,49,11,41,-28,107,31,-5,-10,4,-81,9,-18,-31,-42,20,-93,-35,16,-26,-4,59,-17,24,3,0,-64,36,-18,-15,0,-5,83,-17,7,26,-3,0,-11,86,14,80,-50,-24,34,-8,-38,-30,-30,-10,-1,47,-8,3,8,59,23,-24,0,-15,11,-67,11,-29,-61,33,-7,20,6,27,21,-34,-39,3,40,-1,63,15,-1,23,-16,-19,15,41,48,39,-51,-27,-14,4,97,-8,32,-22,11,-29,-11,10,22,39,3,5,44,-7,-42,-55,-16,9,-59,19,-78,-68,6,-4,30,-65,4,7,-10,42,-40,25,-5,-15,-39,-22,49,22,-9,34,-40,9,11,-2,-27,30,4,3,13,-2,-11,-21,-27,-4,-4,0,-20,-110,49,35,59,34,-30,22,24,54,-8,43,10,-3,-70,-4,35,-25,2,42,-10,59,-10,-23,38,-42]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.150","t":"Therapist: What do you think is the origin of the belief that it is unacceptable to be less than the best? Claire: I’ve always been a person who strives for perfection, just like my father. Therapist: Do you recall your father pushing you to be the best? Claire: I don’t know if he pushed. We all just knew than anything less than #1 was unacceptable to him. Therapist: Can you remember a specific example when you took this message from him? Claire: [pauses] I remember a time when I was six years old and on a beginning soccer team. You know, one of those teams when the kids don’t know what they are doing, and they all run around in swarms chasing the ball? Therapist: What happened? Claire: I was the goalie, but I didn’t really understand fully what a goalie did. So when I saw all of the kids on my team chasing the ball, I went after it, too. Therapist: And then what happened? Claire: I wasn’t tending the goal, so the other team scored. When the half ended, I went to my parents to get a drink of water from the cooler they bought. And my father ripped into me. Therapist: [gently] What did he say? Claire: [with disdain] I remember him saying that I have no business being the goalie if I can’t do my job right. That what’s the point of being on my team if I don’t help the team to win? Therapist: How did that make you feel? Claire: I was totally embarrassed. My father yelled at me in front of the other kids and their parents. I was humiliated. Therapist: That sounds like a painful experience. Claire: Yeah, I guess it was, except that was how my father was a lot, so I got used to it. Therapist: Did you believe what he was saying to you? Claire: I did. I remember that it was at that point that I stopped enjoying soccer and started dreading it. I would get stomach aches before games, even before practice. I worried that I would let the team down if I didn’t do what I was supposed to do. [snorts] The problem is, at six years old, I wasn’t always sure what I was supposed to do. Therapist: How much did you believe that you had to perform at a high level, or else you were letting the team down? Claire: Oh, 100%. That was the only thing that went in my household. Therapist: Now, as an adult, how could you use the cognitive strategies we’ve developed in this treatment to evaluate that idea? Claire: [thinking] You know what, I was only six years old, for God’s sake! Aren’t I allowed to have fun? Therapist: It sounds like you’re starting to view the message you received from your father in a different light. Can you put that into words for me? Claire: Kids are allowed to have fun. They don’t have to win all the time. Sometimes, it’s OK not to compete, to just go out and enjoy yourself","e":[74,68,-151,-46,20,60,25,-1,20,-21,-79,-7,60,28,13,-18,-13,-71,-8,38,-73,-57,2,14,65,28,-59,-1,-102,59,40,-6,-30,-71,-48,33,16,62,14,-59,47,29,-5,-97,-11,-101,45,2,36,-23,29,-84,1,-31,80,26,-19,-7,25,-34,52,40,-81,39,38,2,-52,12,-47,-39,42,-53,7,16,-36,22,-55,-5,26,-17,55,-18,32,-55,27,28,43,50,-19,94,25,39,7,15,-61,22,-1,-8,-31,5,-69,1,-28,-20,22,41,17,-1,-1,-20,-15,31,-65,-80,-10,17,53,-41,20,6,-15,34,-26,32,68,51,-61,8,-23,3,-27,-9,-26,-26,-18,63,19,-8,14,4,27,31,16,-44,17,-40,16,-11,-75,0,0,23,8,20,19,-28,-31,43,27,6,46,35,-30,46,3,15,-8,44,51,30,-17,-44,2,-21,31,-37,20,-23,-73,-36,32,14,47,-7,23,8,21,-1,-24,-80,-12,43,-61,-13,-48,-41,30,-67,0,-11,-17,-15,-17,9,-25,46,-54,-1,-14,2,31,-18,-17,46,-48,-13,20,0,-27,68,-20,21,-1,16,-4,-14,0,7,-37,25,-17,-57,62,34,-9,43,-50,24,48,63,-31,64,-4,24,-37,22,22,-28,-4,22,9,43,44,-21,33,-27]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.151","t":"rather than striving to be the best and carry the weight of the team on your shoulders. Therapist: That’s a powerful revelation, Claire. How much do you believe that? Claire: If we’re talking about me as a child, I believe it at a high level, like 80 or 90%. But it’s different now. I’m an adult, and the stakes are higher. Therapist: Would you be willing to continue to examine this belief that it is unacceptable to be anything other than the best, to see if it needs to be maintained in all of your adult endeavors, or whether it can be relaxed in some of your adult endeavors that are meant to be fun and enjoyable? Claire: I’d be willing to keep looking at it. To be honest with you, it’s exhausting to think like this all the time.","e":[61,64,-162,-52,26,44,-15,-10,31,10,-41,-11,45,46,29,-11,-5,-93,28,10,-91,-56,-36,13,24,48,-28,-11,-64,34,31,-21,13,-60,-34,-19,11,89,32,-37,13,24,3,-99,-9,-96,81,-1,74,-37,7,-73,-10,-6,106,31,42,22,-12,-66,92,17,-61,57,36,2,-76,24,-44,-47,45,-32,27,20,-48,6,-29,-19,37,20,68,-53,66,-18,13,26,47,53,12,132,44,6,28,42,-73,-2,9,11,-40,-6,-51,-21,-10,-1,11,29,7,22,-39,-1,-37,15,-57,-26,-10,-12,65,-48,20,13,0,-1,-2,61,25,43,-54,-9,4,-16,-13,-10,-7,17,7,76,-5,-24,14,33,32,7,6,-1,-11,-61,40,-11,-30,12,16,39,0,-6,10,-33,-28,24,28,20,16,33,-57,35,-2,-21,-15,81,26,47,-36,-40,12,-18,91,-54,36,-25,-36,-33,32,-31,49,-4,21,-3,25,-11,-32,-26,-16,41,-35,18,-68,-58,36,-32,16,-21,-9,9,-26,24,-58,47,-43,3,-35,-31,70,4,-16,48,-37,-23,-5,-3,-38,69,6,-9,23,14,-15,-18,-36,-10,8,33,6,-65,59,34,20,30,-37,49,36,58,-6,31,23,-1,-45,51,27,-19,-19,41,5,16,38,6,19,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.151","t":"The best way to solidify a new, more adaptive core belief is to behave in a manner that reinforces it. Making small but steady behavioral changes advances a patient's adaptive behavioral repertoire so that maladaptive or unhelpful beliefs gradually erode (Layden et al., 1993). Many cognitive behavioral therapists have described behavioral strategies that facilitate the translation of adaptive beliefs into behavioral changes (e.g., J. S. Beck, 1995; Layden et al., 1993). Some of these strategies are as follows.","e":[45,27,-164,-53,55,-11,55,-2,50,-13,-38,7,58,97,23,13,-27,-59,7,47,-38,-31,18,-38,15,43,-24,51,-11,20,47,-13,9,-35,-14,-31,56,3,18,-44,-3,22,11,-74,57,-24,74,-39,46,14,31,-59,19,-32,108,48,-10,19,-11,-92,98,8,-60,4,4,36,-52,64,-66,-28,41,-4,-9,25,-28,8,-31,-12,11,13,46,-43,70,-26,65,39,19,16,-22,66,4,19,-14,20,-102,-4,-28,-26,-52,-16,-55,-28,21,10,-24,44,-18,-5,-20,43,-73,38,-12,-38,-38,3,81,-13,-8,30,-16,0,0,70,14,65,-54,-36,27,-11,7,-32,-16,-11,2,36,1,-6,4,56,42,10,37,19,-3,-58,16,-13,-3,25,9,45,15,14,31,-45,-17,15,44,-16,47,-10,-22,36,-15,0,-4,70,-2,42,-64,-17,9,-2,77,5,65,-45,-18,-41,-9,-10,18,68,17,-34,40,-5,-56,-64,-4,22,-72,10,-83,-76,11,-30,42,-60,21,10,-33,28,-22,23,-5,0,-27,-16,62,3,-32,11,-43,22,12,9,-9,8,6,-24,-16,15,13,-13,-26,-14,12,33,-23,-94,42,33,86,33,-30,53,28,27,18,37,41,-6,-61,15,12,-38,-7,43,26,32,-11,-41,40,-42]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.151","t":"Instruct patients to self-monitor any adaptive behaviors that occur in response to adopting more adaptive beliefs and to keep a log of these behaviors for future reference. Not only does this exercise promote awareness of behaviors that support the new core belief, but it also provides evidence that a new core belief can be activated and maintained and that it results in tangible behavioral changes that make a difference in patients’ lives.","e":[-1,31,-183,-52,61,-19,73,13,76,-22,-27,43,53,89,7,-5,-12,-63,-23,28,-31,-41,-20,-8,13,44,2,40,-20,19,52,-7,14,-47,-19,-49,45,12,1,-12,-8,29,0,-84,67,-20,55,-28,59,21,-2,-73,15,0,135,26,-12,21,7,-75,120,9,-51,-9,31,5,-47,46,-64,-11,54,-1,-6,29,-14,28,-21,16,-10,31,55,-20,78,-53,51,11,11,0,-20,51,41,21,21,33,-100,-15,-9,-10,-29,8,-56,-31,25,6,7,28,2,23,4,14,-37,39,-17,-18,-30,-1,84,-33,-11,25,-21,8,7,93,8,38,-27,-41,12,-10,1,-41,-50,-16,25,30,10,-6,18,21,23,28,13,26,-2,-65,17,-46,-23,33,0,30,-20,32,57,-41,-54,15,62,1,79,-8,-15,48,-41,-39,17,60,26,32,-45,-37,12,-18,84,14,49,-48,8,-36,5,-37,38,54,13,-50,12,-17,-80,-67,1,16,-47,-9,-71,-48,-3,9,35,-44,16,6,-42,26,-27,-6,1,-28,9,-66,73,0,-7,7,-20,33,4,4,-4,4,34,-36,-3,-22,11,-24,-43,-23,-1,17,-26,-98,45,17,65,30,-35,72,30,25,17,29,35,-11,-55,21,11,-39,-27,26,18,40,-12,-19,28,-34]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.151","t":"Role-play various scenarios with patients in session to improve interpersonal skills and to develop more adaptive ways of viewing themselves and others. When therapists use this strategy, they spend time helping patients to identify ways that the skills they gained from the role-play can generalize to their daily lives. When patients observe success as they implement these new skills, they are collecting “data” that refute the old core belief and support the new core belief.","e":[-10,28,-166,-56,46,-8,50,-17,48,1,-35,3,40,12,0,-16,-20,-64,-40,32,-51,-61,5,29,-12,44,-17,-20,-38,-8,63,-5,36,-34,-19,-38,49,40,1,-17,-28,27,8,-62,27,-69,74,-11,7,-3,40,-55,-16,-12,130,4,-1,17,36,-85,110,59,-81,36,19,-15,-60,59,-36,-34,33,-14,47,14,-22,-17,-33,-1,10,22,61,-27,66,-29,26,24,6,-1,-31,86,55,25,48,38,-123,17,-21,-4,-18,19,-56,-27,38,-21,26,63,-6,23,-12,39,-57,48,-24,-26,-20,2,41,-60,4,39,11,16,-35,57,13,74,-70,-37,-1,30,-1,-21,-68,-1,37,55,10,-30,40,30,52,4,-40,-18,-26,-66,22,-24,-46,45,7,27,4,39,39,-41,-27,15,59,17,52,30,-69,32,-31,-40,44,12,0,19,-6,-58,-27,-11,78,-15,62,-37,10,-34,17,-56,0,-10,14,5,40,-40,-33,-81,-5,38,-20,-29,-53,-65,11,-28,4,-17,-39,-17,-27,23,-37,41,-28,-13,-42,-19,67,6,36,31,-72,6,-15,-16,-37,26,13,-6,-35,-17,15,-16,-36,28,-9,42,-33,-82,22,38,51,-12,-35,41,30,39,8,36,11,18,-56,14,5,-66,-7,55,37,52,11,-7,13,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.151","t":"Encourage patients to “act as if” they are characterized by the new core belief. When patients adopt this strategy, they often find that behaviors consistent with their old core belief are self-defeating, and they teach themselves that they indeed have the skill and fortitude to carry themselves according to a different set of beliefs. They also see that their behavior has resulted in improvements in their mood and relationships with others. After completing this exercise, many patients who “act as if” they had a more adaptive core belief wonder why they clung so tightly to the old core belief. Although some patients worry that this exercise makes them “fake,” we find that most patients take home a valuable message and that, very quickly, the behaviors associated with the new core belief feel more natural to them.","e":[13,53,-178,-58,60,22,51,-2,82,-7,-35,31,13,82,-4,21,-2,-74,-1,62,-70,-35,-21,-17,19,16,-30,41,-35,-6,53,-4,59,-64,-25,-57,60,13,41,-41,4,38,0,-57,43,-15,49,-20,44,1,-18,-73,23,-13,118,35,-2,61,21,-55,67,20,-8,7,33,-6,-49,78,-49,-21,40,-2,-13,20,-25,30,-13,-1,-8,39,57,-30,78,-51,59,-3,15,-1,-15,70,29,-18,28,27,-103,-33,-17,-9,-55,-2,-57,-15,28,-12,-29,50,20,36,-28,11,-29,53,-18,-31,-20,2,81,-39,0,9,-16,-8,-11,89,30,30,-19,-23,34,-32,-8,-36,-72,-12,10,22,13,-13,3,8,24,30,12,22,-5,-76,11,-44,-26,54,-9,29,32,34,26,-40,-31,30,27,-41,86,-17,-5,25,-7,-21,10,64,8,39,-25,-5,-1,-20,85,-10,46,-64,-10,-37,3,-13,22,39,11,-28,42,-22,-61,-69,-19,39,-34,1,-59,-69,-1,6,27,-32,35,4,-4,20,-30,17,-9,-30,14,-39,76,6,-38,22,-18,26,3,-4,-31,11,21,-32,-3,-2,26,-23,-43,6,-24,8,2,-114,49,18,70,25,-45,53,44,31,22,58,23,2,-48,22,-25,-47,13,37,21,33,-9,-25,36,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.152","t":"In summary, when therapist and patients collaboratively focus on core beliefs, they are working at the most fundamental level of cognition that has pervasive effects on the patients’ subjective experiences of stressful situations in their daily lives. Cognitive behavioral therapists who use strategies other than those pertaining to core beliefs can make significant progress with their patients; however, it is often the case that the most lasting change arises from the modification of maladaptive or unhelpful core beliefs. It is often difficult for patients to acknowledge painful core beliefs, so attention to the therapeutic relationship is paramount during this phase of treatment. Once a core belief is identified in therapy, therapists and patients will usually orient their work toward that cognitive theme, rather than toward more superfluous or peripheral cognitions associated with everyday stressors.","e":[36,34,-149,-67,48,-2,47,6,27,-5,-12,0,27,31,9,12,-38,-4,2,47,-70,-32,14,-47,-16,56,-9,26,-22,20,62,7,30,-53,-44,-86,53,37,36,-21,3,14,15,-126,6,-32,51,-17,47,37,28,-73,29,-34,122,26,-22,70,-7,-74,116,33,-61,65,15,-19,-73,59,-57,-1,41,-18,12,51,-33,-6,-3,-21,20,26,78,-68,56,-21,48,31,-11,42,3,94,36,-18,-25,30,-95,-6,-1,-44,-20,-1,-75,-11,9,-16,-4,27,-27,2,-13,37,-55,48,-25,-27,-9,4,70,-32,4,13,-3,0,-14,108,11,67,-56,-34,27,9,-28,-50,-24,-14,-4,78,-19,15,8,70,31,11,3,5,14,-70,9,-44,-12,14,19,34,-2,45,26,-24,-63,8,41,0,41,21,7,15,14,-20,19,49,29,35,-42,-42,-14,-3,98,28,54,-27,21,-24,-11,-13,18,36,11,29,34,-24,-41,-23,-27,1,-24,31,-74,-99,-8,-13,48,-60,-18,20,-36,40,-51,63,-2,-14,-48,-52,37,-14,-17,46,-23,5,-16,5,-42,52,33,-7,11,11,3,-10,-48,-1,18,25,-19,-97,63,52,45,33,-23,44,38,58,12,9,29,-10,-64,47,-13,-28,-15,59,-4,36,-31,-13,52,-40]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.152","t":"Problem-Solving Strategies Assisting patients in acquiring problem-solving skills is one of the hallmarks of CBT. Some patients have difficulty solving problems because they do not possess the skills • ITCH problem- to do so. When a therapist determines that a patient is characterized by such a skills solving strategy deficit, she can apply systematic steps to help the patient work through problem. This strategy involves a series of four steps, called ITCH, that the therapist and patient can follow during the session. ITCH Problem-Solving Strategy 1. Identify the problem 2. Think about possible solutions 3. Choose a solution to implement 4. How well does it work?","e":[26,58,-166,-46,76,0,30,8,31,-10,-47,-19,69,18,-16,-1,-10,-72,-27,11,-24,-41,27,-16,-9,43,-50,31,0,4,35,-34,13,-52,-47,-15,95,-8,-8,-8,53,-24,13,-102,19,-22,59,23,19,-21,39,-85,21,-54,96,51,6,28,21,-28,89,59,-55,52,20,-43,-24,73,-34,-4,44,-26,64,2,-78,-17,-38,6,-7,48,17,-24,47,-17,56,23,-12,-6,-33,71,-25,20,12,3,-95,14,6,-17,-20,-47,-70,-31,-5,-24,10,75,20,-9,2,25,-50,5,-31,-27,2,43,19,-39,4,25,-22,-15,-23,39,39,83,-64,-45,51,9,-30,-10,-11,-10,-5,44,22,-16,33,20,32,-6,-2,12,-3,-10,-28,-23,-55,-10,-36,28,12,5,73,-47,-11,30,56,-15,36,-28,-60,46,-7,-30,-6,42,7,55,-31,-53,4,21,90,18,89,-3,-3,-46,40,-44,37,71,12,25,17,-44,-23,-38,25,33,-51,-27,-51,-52,35,3,29,-52,-19,25,-49,13,-48,47,-40,33,-9,-20,48,-14,-5,32,-71,-19,12,-19,-55,31,23,-12,-56,-11,20,11,-27,-9,-26,17,-7,-71,46,-10,39,-8,4,17,13,47,9,15,42,35,-58,49,2,-54,-23,38,41,5,9,-20,28,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.152","t":"Step 1. Identify the Problem. This first step in teaching any problem-solving strategy involves recognizing that a problem exists and that attempting to solve the problem is a worthwhile endeavor. It is crucial that the patient perceive that the therapist understands his problem(s) before assisting the patient in trying to generate possible solutions (Step 2). The therapist should clearly understand the difficulty and the manner in which this difficulty is leading the patient to feel unhappy, sad, or anxious. Listening carefully to the patient and providing periodic summaries of the problem are critical to establishing a good collaborative relationship.","e":[31,64,-158,-45,66,1,41,-11,29,1,-30,3,60,46,-11,3,30,-88,-61,19,-34,-16,8,-16,-5,49,-52,-7,-24,4,41,-29,16,-64,-70,-42,50,34,11,4,33,-35,11,-104,-5,-66,47,5,37,14,53,-78,4,-14,80,66,4,23,36,-52,88,55,-63,15,37,-23,-34,51,-30,16,51,-22,72,20,-52,-19,12,0,25,26,38,-10,93,-62,46,9,-25,-1,-34,87,-11,38,35,16,-105,-4,-36,25,-29,-50,-33,-18,-21,-33,13,50,37,7,-20,13,-69,36,-25,-41,6,19,79,-31,31,42,-29,23,-9,41,51,43,-61,-21,51,35,-32,-24,-15,10,8,65,9,-5,20,23,41,21,-6,1,-8,-20,-9,-46,-40,4,0,39,-11,29,54,-61,-25,12,67,-17,54,-1,-70,34,8,-20,27,26,26,27,-25,-56,-11,29,78,9,77,-3,1,-13,54,-48,44,22,7,-1,19,-27,-42,-34,9,55,-46,-14,-35,-49,41,-26,15,-19,-21,18,-31,27,-58,73,-29,-4,-25,-8,16,-45,-13,24,-58,-31,5,3,-52,27,10,-23,-47,-11,4,31,-61,-18,-37,18,-19,-73,44,27,48,-27,-26,32,34,66,-6,10,34,41,-62,41,29,-47,-9,23,23,-5,20,-13,29,-32]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.152","t":"On occasion, patients may describe more than one problem with which they would like help. If there are several problems listed, the therapist should write down the problems and briefly review them. The therapist then asks the patient for feedback in order to determine which problem has the highest priority. This process is similar to the agenda setting process that was used during the beginning of the session.","e":[42,11,-146,-73,43,0,24,3,37,3,2,-9,61,31,-7,-32,35,-79,-27,1,-9,-31,-62,-11,-15,64,-3,-20,-42,23,41,-12,2,-39,-51,-58,49,31,-26,-12,50,-14,1,-115,15,-62,77,30,-11,-27,51,-44,-40,-18,80,28,11,46,67,-47,104,39,-75,74,46,-20,-35,46,-22,14,24,-3,58,14,-41,23,9,3,12,28,37,-32,108,-46,40,20,-8,41,-24,84,4,26,15,23,-105,22,-25,-29,-38,-54,-57,-19,2,-35,37,20,8,37,-29,4,-40,26,-30,2,16,-11,101,-35,18,63,-27,-10,-23,30,27,58,-34,-2,45,20,-37,-11,3,-4,-5,74,13,-29,17,-22,55,5,-6,8,12,-13,35,-10,-23,15,15,4,10,0,62,-42,-16,12,52,3,44,11,-77,71,4,-37,15,36,27,30,-27,-60,28,-5,85,48,73,-20,43,-29,26,-41,14,37,2,3,32,-58,-36,-48,14,60,-8,-2,-38,-25,52,-60,9,-26,-27,26,-38,28,-75,66,-17,3,-37,-51,41,-35,2,46,-60,3,-23,-8,-32,35,2,-39,3,-14,3,13,-76,1,-8,11,-50,-85,62,1,37,-12,-44,47,15,54,-24,25,51,13,-87,0,10,-30,-3,25,-1,9,11,12,35,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.152","t":"It is important that the therapist approach this process with a positive attitude and view the situation as an opportunity or challenge. The therapist models the problem- solving strategy by approaching the situation with confidence and with a willingness to devote some time and effort to finding an appropriate solution to the patient’s problem. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 134","e":[16,24,-160,-68,72,15,48,-43,39,4,-10,-5,47,5,13,-31,-10,-73,-33,14,-39,-51,-32,-33,8,51,-46,39,-29,4,29,-15,3,-38,-35,-47,51,61,2,-17,44,-26,-5,-92,-7,-39,97,16,5,-25,38,-82,-2,-47,112,16,0,34,-11,-58,105,51,-67,39,47,-39,-56,46,-53,-19,39,1,35,20,-67,12,-24,-11,-27,7,47,-6,50,-70,60,5,13,8,-29,57,0,24,21,38,-112,2,-33,-1,-17,-40,-37,-30,-18,-31,-9,47,10,-9,-8,-5,-80,38,-10,-14,-8,22,67,-40,7,57,13,8,2,14,-1,37,-67,-26,39,-4,3,-13,-9,1,10,31,-9,-25,7,20,52,0,-13,30,-12,-11,-14,3,-42,-17,-21,33,6,19,40,-72,-30,38,29,-6,49,15,-49,11,11,-22,6,37,33,26,-35,-64,-10,-12,104,9,53,-4,8,-19,15,-52,43,17,-25,-24,36,-49,-44,-49,32,55,-24,-3,-74,-45,60,-17,25,-25,-2,49,-22,21,-56,43,-17,21,-23,-53,28,-35,8,37,-46,-6,9,23,-52,18,28,-8,-17,-4,-11,17,-62,-7,9,11,2,-87,43,16,31,26,-24,46,23,54,22,44,44,46,-65,45,0,-46,7,30,24,-1,-5,-21,26,-41]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.153","t":"The following dialogue illustrates the manner in which Jack’s therapist (a) concluded that he lacked the skills to solve problems that required interaction or negotiation with others, and (b) identified the specific problem that was of highest priority for him to solve. This dialogue demonstrates that two problems were identified—the skills that Jack lacked and the most important problem in his life that he wanted to address.","e":[36,36,-130,-37,55,65,9,-19,65,5,-67,-12,40,40,-10,-13,40,-84,-29,23,-35,-37,-18,-12,16,17,-26,-4,-44,12,41,-52,-32,-41,-75,-51,74,62,1,-20,19,-14,-9,-112,49,-44,20,52,20,-46,67,-61,-2,-28,101,77,19,19,44,-46,65,37,-81,61,29,-33,-7,53,-46,-17,15,-41,44,19,-53,11,8,13,7,23,27,-10,86,-58,30,41,11,9,-6,87,-4,50,16,18,-100,23,-33,-5,1,-26,-45,-51,5,-25,54,50,21,24,-23,23,-59,27,-33,-24,17,-49,67,-43,23,30,-57,23,-37,39,31,66,-23,23,30,17,-39,-17,9,22,-14,55,-8,-28,0,12,92,11,-11,-9,-3,-37,9,-14,-66,11,19,23,0,31,22,-21,-11,14,47,9,12,-3,-28,28,8,-48,11,12,36,59,-17,-65,29,0,89,23,80,-37,8,-21,37,-57,31,25,4,7,26,-46,-20,-52,-18,44,-31,-45,-14,-68,77,-29,6,-6,-13,4,-27,17,-73,63,-32,23,-39,-43,33,-15,-25,29,-34,-44,-7,6,-37,16,-25,-15,-22,1,8,17,-35,-12,-44,37,-38,-94,61,44,22,17,-14,49,33,66,-28,23,11,14,-41,34,1,-47,-8,38,-3,23,5,-5,31,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.153","t":"Jack: Boy, this week has taken the cake. Just when I thought things couldn’t get any worse. [frustration escalates] I’m behind on my truck payments, and it might get repossessed. My refrigerator is crapping out even though it’s still under warranty. My wife just announced that her nagging sister is going to be staying with us for a week. And… Therapist: [gently intervening] It sounds like you are facing a number of problems that require your immediate attention, Jack. Jack: I sure am. And no matter what I do, it’s not going to work out. It never does. Therapist: What do you mean that it never works out? Jack: Just like I said. I really can’t think of a time when I’ve had a problem like these and it actually works out in my favor. Therapist: Let’s take the example of, say, something like the refrigerator crapping out. Have you ever had an appliance break down in the past? Jack: [thinking] Yeah, about five years ago, our washer broke, and there was water all over the basement. Therapist: What did you do about it? Jack: I cleaned up the water before it did any more damage! Therapist: Fair enough. And what did you do to solve the problem of the broken washer? Jack: [frowns] I got screwed as usual. I called the store where I bought it, and they said they couldn’t help me, that I needed to call the 1-800 number for the manufacturer. And, just as I had expected, when I did that, I got the run-around. Nobody was willing to give me a straight answer. Therapist: So did you actually get the washer fixed? Jack: Nope, never did. My wife was taking clothes to the Laundromat for six months until we finally got a new one. [Therapist takes time to examine the precise steps that Jack took to try to resolve the issue with the manufacturer and concludes that his limited communication skills and inappropriate expression of anger likely interfered with working effectively with the manufacturer of the washing machine] Therapist: What I’m hearing you say, Jack, is that you handled the immediate problem—the water on the floor. And you came up with a solid solution to address the broken washing machine—to call the store where you bought it, and then follow up with calling the manufacturer. But where the process broke down was in your interaction with the customer service representative and then the manager with whom you asked to speak. It became so frustrating for you that you gave up, and you ultimately weren’t able to get the washing machine repaired. Jack: They were impossible to deal with! They call themselves customer service. Yeah right! They should be thrown in jail, those crooks!","e":[62,52,-163,-74,20,17,-5,9,41,-35,-78,-1,-6,23,-20,9,66,-29,-42,16,11,-55,-22,-10,-20,-4,-68,55,-25,77,33,-28,-67,-116,-98,-29,72,43,41,-36,60,34,-19,-96,50,-50,51,-1,15,-45,39,-83,-35,5,81,7,6,40,-18,-18,35,37,-14,86,34,9,-8,79,-31,-32,31,-26,42,-8,-25,52,-35,5,57,3,8,11,50,-48,0,4,21,73,-20,60,-9,37,-29,12,-70,-1,-3,-19,-31,-31,-55,-37,-31,-40,43,73,25,17,-15,-21,-40,13,-19,-12,15,4,76,-51,14,4,-19,47,-77,3,35,20,-50,64,17,20,-15,-16,-17,-10,-6,54,10,-33,4,7,91,-31,-2,19,46,-60,-6,-13,-65,15,-5,-4,-28,62,53,-32,-27,2,74,41,37,-26,-39,52,29,5,3,82,15,39,-10,-75,-18,3,17,46,40,-35,-4,-34,56,-18,76,3,-13,16,18,-26,-7,-60,12,64,-33,-10,-34,-45,49,-24,14,-48,3,-5,6,34,-42,44,-35,20,-32,0,36,-18,-18,22,-34,-35,3,23,-67,0,15,4,45,-32,19,24,1,-13,-41,16,-50,-67,46,12,-10,8,-33,3,13,70,-15,47,-8,18,-34,22,26,-42,54,18,54,20,41,-25,34,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.154","t":"Therapist: [using an even, soothing voice in response to Jack’s anger] Would it be worth it for the two of us to figure out a way to solve problems that involve interacting or negotiating with other people, like customer service representatives? Jack: You’re saying the whole problem is me? They’re the ones who have the problem. Therapist: [gently] Did you hear me say that you are the entire problem? Jack: [reluctantly] No, I guess not. Therapist: There’s a lot of truth in what you say about many customer service people being difficult to deal with. I know what it’s like to perceive that I’m getting the “run-around.” But what is preferable—going without a washing machine or a refrigerator for six months, or figuring out a different approach to dealing with these people so that you can solve your problem or get what you want? Jack: I’m tired of not getting what I want. Therapist: Would you like to, then, work on developing some skills for solving these kinds of problems? Jack: OK. Therapist: You mentioned three problems—being behind on truck payments, the refrigerator crapping out, and your sister-in-law coming for a long visit. I have a feeling that, to be solved, each of these problems will require some interaction with others. Which of these would be most important for us to address today? Jack: You’ve actually already made me think about some things for when I deal with customer service jerks. So maybe we can talk about what to do about my sister-in-law. I tell you, you will have to lock me up in the loony bin if I have to entertain her for three weeks. Therapist: OK, we’ll focus on that. Let’s make this problem even more specific. Is your goal to not have her visit or stay with you at all, or might the goal be to set some clear boundaries regarding her visit, so that you are sure to have some space and not be expected to spend time with her 24/7? Jack: She’s coming. I can’t stop that. So I guess it’s how to set those boundaries so that we don’t kill each other.","e":[42,53,-154,-58,7,22,-2,-22,51,-11,-84,8,-3,31,-1,2,59,-71,-53,23,-14,-41,-21,-31,-11,22,-30,59,-43,75,40,-23,-25,-71,-89,-7,56,60,-13,4,47,-13,5,-133,56,-86,80,7,38,-30,20,-111,-51,50,81,16,22,56,-11,-57,60,40,-59,79,28,-21,-43,45,-30,-25,36,0,61,-15,-42,45,-33,10,53,20,9,-3,43,-93,14,25,32,24,-24,48,-32,36,2,-13,-53,6,-16,-30,-7,-43,-61,-18,-6,-15,9,45,2,22,-4,-18,-40,27,9,-21,-12,13,60,-45,32,11,-3,24,-52,12,45,43,-65,67,23,-10,-31,-19,-4,-5,-28,41,12,-63,12,23,100,19,-12,13,32,-34,-25,-17,-36,31,-7,52,-43,45,43,-33,-22,-14,69,9,35,-35,-23,14,18,1,0,69,12,37,-7,-64,-23,11,49,9,50,-51,-11,-55,29,-49,49,7,6,16,13,-40,12,-65,16,43,-48,1,-40,-35,63,-37,8,-64,-2,6,3,30,-58,61,-14,19,-28,-26,43,-47,-8,10,-21,-50,10,5,-80,35,33,-29,22,-25,2,15,-28,-13,-47,5,-53,-69,42,23,10,9,-18,33,15,54,3,44,7,42,-59,27,15,-36,2,11,27,-11,17,-23,30,-19]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.154","t":"Step 2: Thinking About Possible Solutions. After the patient and therapist agree on a problem worthy of further consideration, the therapist helps the patient generate possible alternatives by encouraging her to brainstorm possible solutions. This process often involves educating the patient about the purpose of brainstorming—that it is the creative generation of all possible solutions, even those that seem unrealistic, without evaluating or judging them at this point. Many patients have difficulty with this step, as they simultaneously dismiss potential solutions, often because they might involve some sort of discomfort experienced as they implement them. Thus, it is important to foster an open environment in which the patient can explore all possible solutions, patiently remind patients that they will have an opportunity to evaluate them later in the session, and identify and evaluate any cognitive errors (e.g., all-or- nothing thinking) that are interfering with the fruitful generation of possible solutions. It is our experience that, in many instances, the solution ultimately decided upon is a combination of two or more of the potential solutions generated, and that at least one","e":[34,58,-131,-57,59,-7,22,26,24,-24,-25,1,65,51,-24,6,10,-82,-22,11,-29,-52,-12,3,-3,40,-22,38,-60,12,30,-12,17,-47,-67,-56,62,19,17,-17,10,5,6,-123,23,-47,101,-22,25,-60,34,-32,14,-9,102,65,33,22,28,-22,99,51,-29,55,33,-36,-64,64,-23,-11,43,-18,49,13,-43,16,-9,-3,-3,19,46,-37,82,-42,23,26,-9,-4,-40,78,-17,25,31,9,-104,8,2,-12,-9,-35,-64,-5,9,-22,11,50,8,21,-2,4,-53,2,-36,-19,-3,-8,49,-37,52,47,-16,15,13,26,68,78,-47,-41,37,1,14,-13,-5,24,12,55,6,-39,-2,18,36,-23,10,13,-9,-27,8,-37,-48,26,-23,25,17,8,67,-67,-28,23,56,-8,83,4,-61,39,-14,-24,39,20,2,40,-26,-56,23,39,105,20,72,-24,2,-18,9,-43,22,42,15,-7,11,-21,-54,-30,15,37,-35,-17,-46,-47,34,-22,32,-23,-19,48,-74,28,-44,94,-14,20,-26,-18,45,-19,13,15,-68,-21,7,-18,-75,40,52,-9,-21,-15,19,20,-64,-23,-12,23,-16,-79,33,-4,38,-2,-19,24,21,76,17,45,22,40,-66,28,32,-44,-6,56,-3,-6,10,-8,15,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.155","t":"A common mistake made by cognitive behavioral therapists is taking a much more active lead than patients in generating possible solutions, which essentially leads to the therapist solving the problem for the patient. Some therapists have the urge to take the lead in generating solutions when they perceive that they do not have much time for a problem-solving exercise, or if they only see the patient infrequently and believe that they have to be as efficient as possible with the time in session. However, it is important to remember that solving the problem for the patient may give him a tangible plan of action for the problem under consideration, but it does little to ensure that the patient will be able to solve problems more effectively in the future. Thus, we strongly encourage therapists to give the patient space to grapple with the generation of potential solutions and allow them to articulate their experience in doing so, so that they have consolidated their learning about ways to generate possible solutions to problems they encounter outside the therapist’s office. If a situation arises in which a therapist decides that it would be beneficial to supply some potential solutions, then it is important to follow up with questions such as, “How do you think I came up with that solution?” or “Tell me what I just did there. How can you do something similar the next time you are faced with a problem?”","e":[45,59,-153,-39,72,26,84,1,46,-7,-26,-20,52,48,7,-10,20,-98,-33,23,-29,-49,-4,-18,10,33,-49,17,-44,-7,63,15,-12,-40,-84,-42,77,0,2,-5,29,21,8,-125,6,-67,88,5,29,-20,26,-70,13,-17,106,37,41,23,24,-53,96,38,-26,37,-12,-21,-48,61,-49,-7,33,8,77,36,-52,10,-26,9,24,24,35,-14,53,-73,48,32,4,27,-7,69,-9,-8,10,19,-95,2,-5,0,-32,-10,-50,-8,-22,3,-25,36,30,-16,-7,18,-44,23,-17,-24,2,33,74,-48,41,26,-6,-21,-36,22,41,71,-46,-23,58,-6,-46,-25,-24,-7,18,69,-2,-26,20,39,33,-12,31,18,29,-44,4,-23,-33,36,-10,39,-14,28,75,-44,-42,2,39,-40,66,-10,-65,15,-5,-41,43,26,-11,20,-50,-16,19,-4,72,30,78,-48,29,-36,36,-25,11,21,33,17,0,-26,-45,-24,20,36,-38,13,-70,-69,36,-27,18,-8,-18,14,-47,14,-37,69,-24,33,-35,-33,60,-16,-21,20,-63,-44,-11,0,-55,56,22,-14,-2,1,-3,12,-56,-14,-1,19,-28,-62,42,21,70,16,-33,15,19,62,20,39,21,21,-71,56,28,-46,-21,41,3,20,26,-15,27,18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.155","t":"CASE EXAMPLE: JACK Jack and his therapist worked together to solve the problem of maintaining reasonable boundaries with his sister-in-law during her visit. At first, Jack was at a loss in generating any possible solutions. His therapist asked questions such as “What might you like to communicate to your wife before her sister’s visit to ensure that the two of you are on the same page?” and “What can you communicate to your sister-in-law to ensure that the two of you have your own space?” Jack immediately dismissed conversations with either woman about boundaries, stating that they don’t listen to him and do what they want anyway. Jack’s therapist gently reminded him of the purpose of brainstorming, asked him whether he was falling into a cognitive error (i.e., fortune telling), and reassured him that, together, they can practice ways to implement solutions that seem difficult. Jack visibly relaxed at this point in the session, and he generated three more possible solutions: (a) ensuring that he had somewhere to go for part of every day, (b) continuing to work on building his homemade computer in the garage (which simultaneously extended the behavioral activation intervention), and (c) avoiding “hot topics” of conversation that have caused conflict in the past, such as politics.","e":[77,58,-157,-57,20,21,7,-27,62,-13,-65,-22,25,67,-29,-12,35,-64,-46,22,-49,-10,-51,5,16,-14,-25,24,-48,13,33,-7,-36,-53,-69,-18,57,43,-25,-15,28,-4,-31,-120,71,-56,94,2,39,-38,37,-52,-2,-16,115,47,19,48,35,-57,60,43,-55,39,64,-2,-32,69,-43,-14,39,-22,45,8,-43,45,-4,8,-7,30,29,-52,50,-70,36,42,16,4,-36,57,18,23,15,14,-64,9,-20,-27,-19,-27,-64,-29,23,7,-7,52,0,17,1,21,-44,7,-25,-25,17,-18,68,-36,39,10,-32,15,-59,24,9,81,-70,21,8,-40,-20,-8,1,15,5,57,20,-59,13,4,83,-16,-14,-9,12,-41,-4,-36,-66,19,5,41,12,42,35,-25,-42,0,54,25,54,-30,-13,37,-23,14,27,62,11,41,-26,-76,-15,16,66,15,83,-57,0,-18,25,-27,28,6,0,1,32,-23,-23,-58,-19,21,-43,-33,-67,-62,67,-15,19,-30,-20,2,-19,35,-56,67,-10,30,-16,-39,40,-30,-26,31,-37,-31,22,10,-63,18,10,-17,-17,-22,10,0,-25,-12,-65,28,-66,-96,33,11,17,19,-23,48,22,44,1,47,-2,25,-49,44,5,-54,-2,36,30,13,8,-34,22,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.155","t":"Step 3. Choose a Solution to Implement. After a list of potential solutions has been generated, the therapist asks the patient to evaluate each one and choose the one solution that seems to be most likely to work and least likely to cause additional problems. Issues to consider in the evaluation of potential solutions are (a) the specific steps that would be involved in their implementation, (b) patients’ ability to implement those specific steps, (c) the likelihood that patients will follow through with the implementation of those specific steps, (d) barriers to implementing the specific steps, and (e) short- and long-term implications for the implementation of each solution. Because this is a substantial amount of information to organize and track, it is often helpful to evaluate each of these domains in writing, such as on a sheet of paper or on a whiteboard. After each of these domains is considered for each","e":[29,65,-128,-61,53,0,34,38,37,-7,-10,6,66,31,-56,-18,24,-102,-15,13,-23,-36,-52,-30,-10,55,1,20,-55,3,15,-6,34,-56,-68,-62,76,40,17,-30,21,2,4,-87,50,-44,90,30,41,-35,44,-23,24,-21,83,60,-3,31,44,-58,101,43,-64,30,52,-23,-23,52,2,-29,44,10,62,2,-63,-4,-13,-18,12,31,34,-18,85,-59,40,37,-11,4,-35,74,-30,48,32,6,-116,13,-5,-6,-11,-56,-37,-15,15,-12,-7,40,19,29,-25,10,-86,30,-27,-10,12,-11,68,-16,8,55,2,11,-2,34,43,41,-66,-27,52,19,2,-9,-24,6,-8,78,10,-44,-8,5,40,-25,-6,6,-4,-14,25,-18,-35,29,8,50,-4,-4,54,-65,-11,20,34,2,54,-5,-53,52,-8,-54,41,14,25,53,-25,-52,16,29,68,20,90,-27,12,-11,18,-45,8,30,-5,-6,36,-49,-46,-31,26,52,-33,-43,-46,-47,41,-43,32,-49,-4,48,-55,72,-62,68,2,5,-18,-27,47,-16,0,24,-33,-5,-16,-9,-50,28,34,-27,-13,10,21,29,-89,-9,-2,18,-29,-74,46,-6,36,5,-39,-3,6,66,-5,24,30,31,-53,12,34,-27,-1,50,0,25,19,12,15,-12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.156","t":"possible solution, the factors that carry the greatest weight to the patient can be circled or highlighted. Then, together, the therapist and patient consider the results of this evaluation and begin to eliminate potential solutions on the basis of this analysis. Some patients find that this approach to problem-solving is overwhelming; in these cases, the therapist can facilitate a straightforward pro-con analysis, which is described in the subsequent section.","e":[68,58,-134,-67,58,32,22,5,7,14,-7,-16,81,29,27,-31,31,-83,-13,20,-26,-44,-17,1,-16,54,-20,11,-58,0,9,-11,14,-80,-65,-31,76,55,22,-11,14,-11,16,-96,8,-36,96,17,28,-18,9,-28,3,-8,70,29,25,20,47,-38,94,45,-70,54,67,-44,-13,49,-34,-11,50,-23,58,-4,-42,16,2,-7,7,36,47,-47,79,-47,23,33,2,-15,-37,71,11,3,44,40,-100,17,-13,-13,-71,-78,-24,3,3,-23,17,29,31,17,-7,9,-78,24,-36,-31,20,-33,85,-38,22,22,-27,8,-16,44,1,66,-69,7,44,-31,11,-3,-2,9,13,90,-21,-7,2,-13,39,22,-12,8,-12,-16,26,-19,-39,20,20,60,-21,14,30,-64,-11,3,27,-8,53,22,-54,15,-12,-41,33,36,11,31,-34,-60,9,36,83,20,83,-28,25,-1,16,-18,37,31,23,-4,11,5,-54,-40,6,29,-11,-26,-68,-51,45,-16,35,-34,-31,28,-48,35,-51,64,0,9,-37,-35,30,-22,-32,44,-51,-26,-33,12,-50,60,21,-13,2,-9,5,29,-73,2,-11,17,-9,-77,59,1,29,-14,-15,49,-8,77,10,44,16,2,-47,43,22,-33,11,66,-11,24,21,18,25,-4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.156","t":"At times, patients find the problem-solving process discouraging when they arrive upon a solution that does not seem optimal to them. It is often helpful to assess patients’ expectations for the result of problem-solving and to use the cognitive restructuring strategies described earlier in the manual to ensure that their expectations are realistic (e.g., that most solutions are not ideal and have some potential drawbacks; that they cannot guarantee that their solution will result in the desired outcome). What is most important about a systematic approach to identifying a solution to a problem is that the patient acquires skills to be able to do it on her own, outside of therapy.","e":[39,70,-144,-46,54,-21,45,17,40,7,1,-18,80,46,-11,-22,-7,-78,-28,30,-10,-43,-7,7,-2,52,-33,-27,-11,15,34,-10,13,-42,-94,-57,82,26,18,-1,24,-19,48,-97,27,-4,80,-10,37,-15,40,-55,-13,-5,94,59,7,42,30,-73,79,61,-61,37,12,-41,-37,52,-38,-3,31,-13,53,26,-62,-16,-5,14,-26,32,46,-47,78,-37,43,60,39,1,-18,84,-3,21,21,6,-120,23,-24,-19,-37,-32,-48,-5,-5,-25,5,61,16,44,3,-7,-45,23,-21,-29,24,24,79,-4,38,39,5,-5,11,34,46,59,-47,-13,66,14,-26,-16,-38,13,13,66,-4,7,15,45,49,5,1,14,-17,-49,-13,-4,-62,15,-34,10,9,8,36,-41,-16,22,26,-21,83,-7,-46,59,-39,-44,28,13,22,40,-19,-37,24,11,104,16,109,-21,14,-16,20,-19,25,17,21,-3,38,1,-47,-34,32,23,-52,-2,-64,-52,38,-9,7,-32,-21,40,-40,14,-46,42,-15,-1,-29,-29,30,-4,9,30,-38,-42,13,-14,-34,61,18,-35,-39,12,34,-1,-57,-12,-22,26,-16,-92,51,21,59,9,-16,-3,26,43,-7,22,1,29,-70,18,41,-37,-34,21,8,29,-5,-15,39,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.156","t":"CASE EXAMPLE: JACK Jack continued to dismiss the potential solutions of communicating his desire for boundaries during his sister-in-law’s visit, stating that the facts that he is not a good communicator and that there is already a great deal of tension with his wife would be barriers to implementing that solution and would decrease the likelihood that he would follow through. However, he admitted that the long-term implications of that solution would be substantial, in that he would develop a way to reestablish his relationship with his wife, which could contribute to repairing their relationship in the future. Although he indicated that he would not adopt that solution for this particular problem, he was open to revisiting his treatment goals and working on developing effective communication skills to enhance his relationship with his wife and other family members. In contrast, Jack was enthusiastic about implementing the other three solutions they had identified—having a place to go once a day, working on his computer in the garage, and avoiding hot topics. He estimated that there was a high likelihood that he would implement these solutions and that there were important short- and long-term implications, as they had the potential to minimize the likelihood that his sister-in-law would “get on his nerves.” Two of the solutions were straightforward to implement, as his workshop in the garage was already set up to work on his computer, and he could easily avoid hot topics. Jack and his therapist, then, began to work on the steps to implement the solution of having somewhere outside the house to go each day.","e":[64,51,-154,-54,-11,45,2,-34,58,-27,-76,-18,34,82,-33,-6,42,-67,-29,13,-35,-5,-63,-32,10,-3,1,19,-42,30,18,-38,-49,-65,-73,-32,50,30,1,-38,37,-33,-18,-94,93,-55,59,24,56,-35,44,-60,-4,-11,95,52,17,53,39,-61,67,44,-64,52,45,-22,-29,42,-34,-12,31,-25,16,-18,-52,47,-5,1,-7,40,23,-26,59,-76,35,48,26,-5,-38,45,18,42,24,26,-64,-5,-32,-13,-15,-22,-52,-37,31,28,-24,55,-11,20,1,19,-52,5,-33,-11,16,-8,57,-43,46,23,-38,27,-53,33,33,58,-86,20,32,-36,-16,-10,-16,33,22,50,16,-51,15,-1,91,-8,0,-15,10,-31,-23,-29,-66,7,4,46,4,60,19,-24,-44,5,52,17,42,-28,-5,43,-20,6,4,44,11,55,-35,-74,-16,15,60,-12,94,-67,-12,-36,24,-24,19,13,0,-7,48,-30,-32,-52,-20,36,-61,-47,-63,-47,67,-11,19,-31,-16,4,-7,39,-60,58,3,23,-7,-37,44,-42,-39,22,3,-40,21,18,-54,22,20,-30,-28,-9,23,22,-35,-13,-85,38,-49,-101,37,18,1,20,0,35,25,36,-8,31,-13,7,-49,28,11,-36,-11,32,40,19,7,-8,29,-9]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.156","t":"Step 4. How Well Does It Work? After deciding on one or more solutions to the problem, a logical homework assignment is for patients to follow through with the implementation of that solution. As with any homework assignment, it is crucial to review it in detail in the subsequent session, evaluating the degree to which the solution was helpful. Factors to consider in the evaluation of the solution include: (a) Did it achieve the desired goal? (b) To what degree did the patient exhibit skill in implementing the solution? (c) To what degree can the patient generalize the problem-solving skills obtained to other problems in his or her life? and (d) What barriers did the patient encounter in implementing the solution, and how might those barriers be overcome in the future?","e":[48,42,-120,-55,47,-3,33,3,12,-8,-6,17,71,55,-45,-5,14,-66,11,-4,-1,-1,-61,-26,35,11,-49,-21,-52,29,4,-20,-13,-65,-110,-51,60,42,1,-28,4,3,-1,-68,60,-22,52,-38,58,-34,3,-53,4,34,96,88,-5,30,45,-28,100,55,-52,56,16,-27,-27,63,-17,11,20,-20,56,-15,-82,10,3,9,24,48,45,-29,68,-29,27,22,-16,-20,-34,100,-1,19,22,11,-105,1,5,16,-36,-49,-50,-13,-13,-8,34,59,28,35,-10,7,-60,5,-20,5,18,13,73,-18,42,57,-5,-7,5,34,49,34,-44,-3,19,1,-3,-21,-26,21,-24,71,-16,-18,10,-34,61,-4,-21,25,-2,-19,16,-16,-57,35,-28,16,22,-17,45,-43,-6,-9,38,8,49,-9,-62,69,-20,-12,27,31,30,69,-26,-44,28,18,56,5,69,-10,2,-30,32,-50,5,6,-25,-22,47,-15,-71,-16,8,29,-13,-52,-51,-65,28,-10,16,-42,-32,31,-10,61,-72,54,-8,-6,-23,-10,51,12,1,28,-31,-29,-24,4,-68,-11,2,-38,18,4,29,40,-61,4,-27,39,-23,-57,44,-3,17,17,-3,13,24,65,-18,39,13,-4,-67,6,41,-40,-20,37,14,-13,-7,39,3,0]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.157","t":"If the solution indeed achieved the desired goal, it is helpful to relate that to the patient’s overall treatment goals and reinforce a sense of hopefulness that treatment will be effective. In contrast, if the solution did not achieve the desired goal, then the therapist and patient can revisit Steps 2 and 3, refining the brainstorming and selection processes. We encourage therapists to normalize this experience for patients, reminding them that solutions are not always guaranteed to work and that they nevertheless made significant progress in the acquisition of problem-solving skills. Patients are often able to articulate important “lessons learned” even if the solution did not work well. In the event that the solution does not achieve its desired goal, and the therapist determines that it is due to a skills deficit in the patient’s ability to implement the chosen solution, then reasonable courses of action would be to (a) revisit the criteria for selecting an appropriate solution, given that the patient lacks particular skills, and/or (b) address the acquisition of those skills in treatment.","e":[31,55,-136,-17,63,5,33,18,59,-9,-47,13,75,20,-38,10,35,-95,-17,50,-11,-26,4,-21,1,34,-21,15,-68,-2,25,9,5,-68,-66,-47,77,37,31,-53,31,-7,-6,-100,42,-23,77,-1,39,-41,55,-33,-19,-18,120,68,12,17,7,-34,81,48,-26,45,41,-31,-33,44,-28,-15,36,-1,33,1,-69,8,-15,-9,-30,29,31,-39,73,-35,44,36,10,8,-7,87,-21,9,37,30,-118,-2,-12,-8,-35,-13,-53,-17,12,-39,7,63,48,25,2,0,-55,7,-9,-34,-11,-7,51,-24,26,68,-26,-7,-9,30,58,47,-58,-31,50,17,-11,-42,-26,37,-12,55,27,-16,11,10,54,1,14,9,-32,-46,20,-17,-57,26,-28,23,25,40,47,-67,-17,28,47,-18,103,-2,-55,32,1,-30,17,-1,-9,45,-26,-52,16,27,102,16,80,3,-2,-52,3,-30,22,24,8,-4,21,-30,-48,-17,24,55,-32,-20,-49,-65,43,-18,35,-22,-13,51,-58,15,-71,55,-19,13,-4,-8,23,-5,-22,20,-58,-40,8,4,-55,39,7,5,-28,0,47,25,-65,-18,-24,35,8,-84,31,4,26,25,-5,-1,52,78,0,15,22,18,-66,54,23,-39,-8,51,32,34,26,0,18,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.157","t":"CASE EXAMPLE: JACK Jack’s sister-in-law arrived the weekend in between his sessions, and at the time of his subsequent session, she had been staying at the house for four days. Jack was successful in implementing two of his solutions. Each day, he left the house mid-morning to have coffee at a local diner, and later in the afternoon he retreated to the garage to work on his homemade computer. Jack’s therapist took care to assess the degree to which these strategies (a) were perceived as successful solutions to the problem, (b) resulted in a positive impact on his mood, and (c) would be likely to be used in the future. Jack expressed relief that he did not have to be “trapped” in the house with his sister-in-law all day. Although he was reluctant to say that these strategies were associated with an improvement in mood, he admitted that he was much less irritable during this visit than during previous visits. Jack was partially successful at implementing his third solution, which was to avoid discussion of hot topics with his sister-in-law. Two nights ago, he “blew up” at her when he perceived her as “preaching that liberal baloney.” Jack and his therapist put this incident on the agenda, and together they identified the cognitions that contributed to his frustration and subsequent behavioral response and ways to respond more adaptively, both cognitively and behaviorally. Jack agreed to practice these new skills over the following week, as his sister-in-law’s visit would still be ongoing, and he agreed that it would still be a worthy goal to stay away from hot topics of discussion.","e":[55,40,-182,-55,-14,13,-12,-39,47,-31,-79,-9,43,65,-17,-23,50,-58,-51,-4,-39,-4,-66,-29,12,-2,-30,20,-34,42,17,-48,-43,-58,-70,-10,39,30,-9,-41,27,-11,11,-92,75,-50,65,15,11,-38,24,-61,-6,-17,108,50,13,70,28,-36,88,6,-76,43,42,-9,-27,60,-48,-9,34,-27,22,-26,-42,55,-2,0,-13,40,15,-19,56,-72,38,11,29,6,-23,30,10,34,17,35,-83,2,-26,-14,-21,-7,-59,-49,3,12,12,57,-22,29,-18,-7,-62,6,-2,-6,7,5,39,-70,29,2,-32,37,-52,41,41,58,-90,26,19,-23,-22,-19,-20,32,17,37,43,-55,24,2,93,-13,0,-4,28,-40,-10,-26,-62,34,1,38,10,67,37,-26,-46,11,45,28,37,-45,2,28,-15,15,10,55,14,44,-35,-76,-34,-6,54,-18,68,-71,-6,-41,16,-35,0,25,8,-4,61,-21,-48,-54,-18,14,-42,-12,-63,-52,67,-19,4,-32,-15,-17,1,28,-66,75,-2,18,-25,-32,36,-20,-15,15,7,-25,10,23,-43,30,37,-30,-41,-33,24,18,-24,10,-82,12,-67,-89,42,11,5,13,-13,39,29,31,-18,51,-23,33,-66,38,18,-55,8,54,39,20,0,-37,22,3]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.157","t":"Thus far, we have discussed the application of a problem-solving approach for patients who lack the skills to do so on their own. However, it would be an erroneous assumption to conclude that all patients lack problem-solving skills. In some instances, patients have the requisite skills, but depression, anxiety, or other symptoms interfere with their implementation. This is regarded as a performance deficit rather than a skills deficit. As was illustrated earlier in the dialogue with Jack, therapists first determine whether a patient is characterized by a skills deficit or a performance deficit. If the therapist determines that a performance deficit more accurately characterizes the patient’s difficulties with solving her current life problems, then strategies that can be considered include (a) evaluation of the manner in which strategies that the patient had used for previous problems in her life can be applied to the current problem, (b) cognitive restructuring of unhelpful attitudes or beliefs that interfere with problem-solving, and/or (c) behavioral strategies for increasing motivation and energy to solve the problem, such as graded task assignment. CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 139","e":[34,31,-163,-56,62,40,69,-7,63,-25,-13,-8,35,32,-9,-2,7,-73,-56,14,-30,-9,-14,-15,7,59,-54,-17,-29,30,24,-8,0,-50,-57,-30,85,41,31,-1,4,-27,14,-102,-8,-23,91,30,10,-14,60,-93,16,-34,105,31,-17,39,11,-60,113,50,-67,43,29,-51,-36,61,-39,-31,34,-11,42,23,-60,17,-28,25,-5,23,59,-13,87,-32,79,2,-5,6,-18,94,-14,34,19,25,-76,6,-28,-16,-15,-22,-61,-29,2,-35,15,61,6,1,-25,21,-48,35,-20,-32,-8,-7,51,-23,-10,41,-26,10,15,14,33,67,-37,6,54,14,-19,-32,-11,4,6,29,5,-26,4,13,52,4,-10,1,-6,-20,7,-18,-79,12,-9,30,5,10,74,-41,-14,31,49,-15,57,35,-39,49,9,-65,3,44,25,28,-42,-61,-2,-1,87,27,83,-11,0,-11,23,-36,27,36,3,-9,13,-41,-41,-57,19,62,-35,-26,-77,-57,45,-30,44,-49,-10,42,-10,17,-48,38,-33,12,-13,-43,40,-26,21,29,-34,-41,-11,-11,-46,7,4,-30,-43,5,17,10,-65,-2,-20,18,16,-94,49,1,49,26,-35,29,30,70,-4,36,18,44,-50,32,-6,-30,-21,12,-3,23,13,1,30,-14]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.158","t":"In summary, it is more important for therapists to use a guided discovery approach to improve a patient’s problem-solving skills rather than for therapists to solve the problem for the patient. Patients should be reminded that problem-solving is an acquired skilled. This four-step ITCH process will become easier to do the more often patients attempt to use it to address personal problems. A depressed patient may be inclined to view his therapist as an expert problem solver In summary, it is more and assume that the therapist was born that way, which is likely to be an important for therapists to use erroneous assumption. It may be helpful to point out that, like any skill, a guided discovery approach to practice makes perfect. Initially, this four-step problem-solving process improve a patient’s problem- may be unfamiliar and awkward for the patient and may require some solving skills rather than for effort, but in time and with practice, it can become a more automatic therapists to solve the problem way in which the patient comes to address his most difficult problems. for the patient.","e":[32,63,-153,-63,52,7,57,19,18,-17,-41,-18,77,10,-45,0,41,-89,-26,23,-56,-39,-28,14,-18,22,-48,-19,-19,22,62,-36,11,-18,-71,-41,89,45,21,-7,36,5,-10,-108,1,-41,47,11,47,-26,64,-55,10,-7,95,76,-10,32,36,-64,107,61,-53,39,23,-34,-13,54,14,-8,27,-26,79,36,-65,16,-1,-8,-14,40,30,-33,56,-55,46,6,-11,13,3,59,8,15,26,33,-104,19,-40,11,-22,-42,-60,-20,-11,-20,16,27,36,3,-11,16,-15,21,-31,-30,-16,16,42,-41,24,1,-24,10,-4,38,48,90,-36,-38,26,5,-49,-33,-19,28,19,69,-3,-3,-3,11,-2,22,-17,5,8,-4,-12,-19,-57,15,1,41,12,-1,51,-60,-18,19,52,-18,46,16,-39,63,1,-32,38,0,-11,16,-12,-25,22,-6,68,12,76,-55,24,-35,43,-74,30,40,40,23,26,-67,-12,-51,32,43,-56,1,-66,-25,30,-29,5,4,-40,38,-26,-10,-82,59,-26,10,-32,-15,31,-27,17,45,-46,-44,3,9,-49,18,31,-4,-16,-12,0,15,-74,-9,-20,22,-8,-88,55,1,73,-4,-31,-7,18,62,-3,20,34,29,-69,27,9,-35,-15,22,25,23,11,-21,27,12]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.158","t":"Evaluating Pros and Cons When patients are confronted with problems, it can be very difficult to decide on the best option, and they may be plagued by indecision. At times, the patient is forced to choose between two equally good options; at other times, she is forced to decide • Evaluating pros and cons between two choices that both have drawbacks. Patients may waver back and forth between different alternatives and may feel paralyzed in settling on a specific course of action. A problem-solving strategy to assist patients in deciding between two options is to evaluate the pros and cons of each option.","e":[20,80,-110,-35,57,39,-2,12,34,-1,-1,4,57,34,1,-42,-20,-57,5,13,-15,-23,-56,-5,-9,43,-23,-4,-66,40,20,28,69,-55,-67,-39,63,35,26,-28,25,-19,77,-95,53,-52,54,29,45,-16,32,-29,-14,-11,103,15,17,56,43,-49,87,37,-59,27,90,-34,-25,27,3,7,28,-11,39,1,-59,19,24,19,6,45,49,-49,72,-12,52,22,19,-43,-27,58,-35,44,40,52,-109,14,-17,-9,-14,-38,-41,2,-1,-1,28,40,28,21,-27,-16,-67,18,-10,-42,36,15,70,-26,-6,53,22,27,-33,35,13,57,-46,-2,45,10,-3,-12,10,-3,-11,54,27,-30,-28,-6,69,5,-15,10,-14,-37,12,-1,-59,26,25,36,5,47,37,-70,-9,45,12,-12,72,34,-55,57,-26,-19,28,15,27,59,-26,-50,12,8,123,3,68,-18,34,-7,-7,-10,-29,31,46,-21,26,-21,-81,-52,58,4,-23,-41,-52,-67,62,10,33,-42,-19,22,-8,30,-61,52,-17,4,-33,-37,26,11,-16,44,-24,-27,16,-8,-20,57,37,-24,3,0,16,-7,-55,8,-32,6,-18,-91,99,24,19,3,1,16,16,4,-3,24,28,39,-63,-13,42,-43,24,38,24,21,4,11,20,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.158","t":"There are two approaches that the therapist can adopt to evaluate the pros and cons. In the most straightforward approach, the therapist and patient draw two columns and list all of the pros and cons for any one decision. Alternatively, the therapist and patient draw four cells, in which they list the pros and cons of both decisions in a manner that facilitates easy comparison. After all of the pros and cons have been listed, the patient evaluates the strength of each point raised and makes a decision based on all of the available information listed. Exhibit 4.10 on the next page shows the manner in which Claire evaluated the pros and cons regarding her decision of whether to look for a new job.","e":[27,37,-125,-59,34,12,20,4,3,-1,-17,-14,103,23,-5,-33,-18,-86,5,6,-40,-34,-77,11,12,56,-33,26,-90,38,25,29,22,-61,-44,-21,65,46,-3,-31,6,8,41,-98,25,-66,83,-2,13,-1,16,-39,-30,20,98,18,14,35,67,-47,74,69,-70,54,88,-17,-23,50,-12,4,5,-8,55,16,-66,18,14,1,0,56,43,-49,88,-41,37,28,25,-7,-15,60,-53,62,37,52,-101,28,-23,-19,-36,-26,-48,-17,-9,-20,23,9,26,-19,0,-11,-70,19,-31,-16,40,-4,86,-45,-3,48,10,28,-26,30,-5,53,-59,-16,0,-1,-13,-13,7,18,-1,81,7,-37,-19,-13,53,-2,-34,-1,-23,-33,30,3,-28,17,36,24,10,34,49,-65,-3,32,12,19,62,18,-30,52,-18,-28,6,29,27,46,-8,-53,15,-25,85,-12,42,-20,31,-7,30,-15,-2,29,23,-28,20,-9,-51,-61,36,19,-60,-27,-58,-69,35,-9,26,-46,-39,23,-12,41,-63,50,-5,-10,-39,-35,15,1,-8,43,-37,-9,-23,-10,-38,35,21,3,24,-7,15,11,-67,13,5,13,-32,-84,68,0,8,-7,-6,54,8,20,6,23,20,17,-69,-15,54,-34,24,47,28,45,25,22,11,4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.159","t":"Exhibit 4.10. Claire’s Pros and Cons Looking for a new job Pros Cons I might get a higher salary. Finding a new job takes a lot of I can use skills that I don’t use in time and effort. my current job. I won’t be doing what I truly I would experience fewer hassles love. because of my medical condition. I might have to go back to school I would have certainty regarding in order to advance, and that my employment situation. would seem like starting over. It would be a new challenge, and I like challenges. Staying at current job Pros Cons Being a pilot has been my dream The hours are irregular. as long as I can remember. I might continually have to fight I’m on a “fast track” to being the “system” to show that I can captain. fly. I’m good at being a pilot. I experience some gender bias I like my co-workers. because there are few female I will overcome adversity by pilots. piloting even though I’m an The work I need to put in to amputee. advance seems all-consuming.","e":[-24,21,-141,-7,21,69,-16,-34,32,-28,-41,20,54,81,44,-17,-40,-95,5,-20,-15,-63,-44,18,39,26,-42,-15,-85,37,36,7,19,-84,-10,-23,13,68,20,-16,20,-19,42,-97,38,-48,87,25,36,-46,7,-32,-67,46,75,-22,21,32,28,-83,83,66,-39,75,37,-17,-26,39,-19,-11,-8,-16,7,65,-76,19,-25,-15,9,19,47,-12,34,6,39,20,54,-10,-5,65,7,68,26,53,-66,0,12,0,-21,-16,-19,-43,0,65,24,-12,11,-31,32,7,-40,21,-25,-33,-23,-5,57,-57,-4,48,3,-5,-4,34,26,61,-36,-12,24,26,-18,-25,-31,70,20,10,-41,-32,-13,15,94,2,0,-18,-49,-56,28,4,-23,-8,12,32,16,16,25,-39,-7,62,22,-4,83,15,-7,47,-38,-25,-31,33,-3,52,-28,-20,42,-48,70,-54,19,-22,-32,-65,53,-81,5,31,8,-11,15,16,-80,-82,2,-20,-52,-13,-66,-94,56,-17,-43,-43,-26,31,18,3,2,38,25,-29,-37,-9,51,-19,-20,26,36,-22,10,-10,-21,58,26,-44,-3,4,-1,-22,-30,-24,-4,6,24,-64,78,-4,11,-11,34,58,-4,18,-14,33,28,-53,-25,-22,22,-12,-9,56,29,20,37,61,-20,-10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.159","t":"After completing the comprehensive pro-con analysis of continuing her fight to remain serving as a pilot versus getting another job, Claire weighed the strength of each of the items that she listed. Although she was able to recognize some sound reasons for looking for another job, the items that carried the most weight in her decision were that she has strived to be a pilot for her entire life and that she truly enjoyed flying. Thus, Claire ultimately decided to continue to await the decision of the medical board regarding her reinstatement as a pilot. However, she acknowledged that this exercise relieved anxiety because she identified many advantages to working in a different position in the event that she is not cleared to fly. This realization had the effect of modifying Claire’s view that it would be terrible if she could not resume work as a pilot. From this example, we hope therapists will see that effective problem-solving not only helps patients to settle on a specific solution to their problems, but it also has the potential to create cognitive change by dispelling all-or- nothing thinking surrounding less desired solutions.","e":[51,40,-163,-22,48,46,-13,-8,37,-18,-54,-5,62,73,43,-3,-22,-78,-13,-50,-39,-81,-42,0,22,48,-15,-12,-79,22,64,-29,11,-88,-29,-28,27,84,11,-20,21,-33,17,-100,20,-36,84,4,23,-42,21,-31,-34,27,79,26,29,37,26,-56,75,19,-38,75,42,-50,-46,39,-36,-7,34,-37,19,75,-64,7,5,-12,-1,3,58,-47,58,-12,36,39,34,-35,-31,66,31,51,12,46,-73,8,16,-7,-70,-41,-45,-18,6,31,16,9,19,-12,10,12,-51,20,-34,-12,3,-10,71,-61,16,35,-20,-4,-17,42,27,65,-46,-6,33,-2,-7,-19,-26,58,10,22,-37,-33,-7,20,56,-13,-6,-2,-13,-47,33,7,-35,0,-13,20,18,17,23,-36,-19,32,44,31,98,19,4,39,-36,-15,-16,20,19,47,-45,-53,32,-35,107,-26,67,-10,-11,-40,45,-33,20,24,45,-5,34,22,-85,-71,-14,25,-71,8,-98,-69,41,-27,-6,-21,-24,15,1,0,-53,43,21,-57,-24,-24,50,-13,0,46,1,-32,4,-19,-17,48,13,-14,-24,-9,6,19,-27,-28,0,-2,3,-84,43,19,30,2,-4,67,-4,38,-11,50,32,-18,-41,33,10,-15,-14,52,5,4,33,29,24,-11]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.163","t":"The main focus during the later phase of this treatment is to evaluate patients’ progress toward their treatment goals and whether they have learned and can apply specific skills that may help to reduce or prevent a relapse of depression. Usually, the later phase of treatment occurs following an adequate dose of treatment (usually 12 to 16 sessions). However, given the flexible nature of this protocol, the later phase of treatment may occur after patients have attended a fewer As with other aspects of CBT, it number of sessions, or it may occur after the patient has attended more is recommended that the than 16 sessions. In this part of the manual, we present some guidelines termination or tapering of CBT for assisting therapists in determining whether patients are clinically sessions is collaboratively ready for the later phase of treatment. As with other aspects of CBT, it decided between the therapist is recommended that the termination or tapering of CBT sessions is and patient. collaboratively decided between the therapist and patient. There are three main tasks that the therapist undertakes in the later phase of CBT for depressed patients: (a) reviewing progress toward treatment goals, (b) summarizing and consolidating skills learned during the middle phase of treatment, including the preventing future lapses of depression, and (c) additional treatment planning.","e":[24,3,-160,-50,51,-29,55,-17,19,-33,-58,8,62,-16,30,-52,-9,-62,-40,42,-59,-5,-51,-49,-11,82,-5,30,-19,29,55,-6,10,-27,-59,-60,78,30,-21,-31,61,4,18,-107,12,-47,83,40,-2,-36,50,-4,-18,-64,96,26,-44,20,13,-47,130,59,-48,67,44,-41,-41,21,-42,-25,40,5,25,38,-22,-9,-31,-27,-17,12,19,-24,45,-39,16,24,-8,23,-25,62,17,-1,20,45,-96,5,6,10,-14,-41,-56,-18,23,-34,7,45,-3,-36,-3,-8,-71,18,-43,-12,-5,27,31,-42,7,30,7,-29,18,5,26,77,-33,-1,48,18,-12,0,-15,30,12,63,-9,-20,-23,13,32,-7,-8,19,13,-11,24,-20,-37,21,-12,5,53,9,45,-59,-32,-21,51,24,51,-12,-42,51,-34,-19,14,14,28,14,-49,-59,-38,-8,99,58,78,3,1,-40,30,-27,12,68,19,-17,24,-70,-44,-55,30,41,-56,-16,-90,-3,42,-23,10,-49,-21,35,-49,36,-64,85,-5,16,-44,-9,52,-13,18,8,-47,20,4,5,-26,33,33,23,-23,-35,30,9,-47,8,-20,24,-22,-80,7,-19,-2,17,-10,-2,19,70,-3,19,57,21,-84,48,3,-18,8,49,-3,8,19,34,44,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.163","t":"Reviewing Progress Toward Treatment Goals The initial step for determining if patients are ready for the final phase of CBT • Reviewing involves the consideration of a patient’s progress toward the treatment goals. Thus, progress the therapist and patient review the treatment goals established during the initial toward phase of treatment as well as any additional treatment goals agreed upon during the treatment middle phase of treatment. Because these goals were operationally defined in goals observable and measurable terms, the therapist and patient can use objective “data” to facilitate their assessment.","e":[30,3,-128,-29,42,0,50,14,36,-4,6,24,80,1,35,-71,13,-73,-22,28,-13,-37,-30,-21,6,68,-4,25,-37,16,40,18,24,-36,-29,-62,85,2,-35,-71,53,4,-14,-112,37,-20,57,12,4,-3,30,-2,-22,-16,109,60,-10,13,-6,-40,100,47,-53,72,71,-50,-18,0,-26,-3,28,13,49,65,-39,-9,-48,-12,-30,-6,20,-32,63,-21,37,4,-17,28,-50,67,-7,0,17,23,-107,12,-29,-14,-10,-49,-65,-27,11,-35,44,53,-6,-13,-8,-14,-49,30,-43,18,-15,13,82,0,-3,69,43,-15,2,20,-8,82,-66,-21,61,32,-17,-4,8,-4,-17,61,8,-14,-10,-13,35,-31,20,22,10,-19,52,-12,-37,20,11,8,21,7,36,-42,-13,23,51,10,24,5,-50,44,-29,-35,-8,-18,24,27,-28,-55,3,22,98,39,75,18,-11,-57,30,-44,58,78,8,7,23,-44,-33,-28,26,54,-61,-10,-40,-12,27,-19,12,-79,-21,47,-74,44,-58,66,1,22,-11,-5,34,-24,-6,26,-29,-10,-6,-11,-45,37,8,-20,-19,10,18,12,-65,-6,1,35,-20,-49,28,10,8,-3,7,34,42,64,-17,33,54,14,-65,26,7,-21,2,52,33,51,19,28,28,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.163","t":"CASE EXAMPLE: KATE Kate’s goals for treatment included (1) improving her depressed mood by increasing engagement in at least one pleasurable activity per day and sleeping no more than eight hours per day; (2) re-negotiating a satisfying relationship with her children, including regular telephone and in-person contacts; and (3) improving adaptive functioning by getting a new job, paying bills on time, and maintaining frequent contact with family members and friends. Thus, Kate and her therapist should review the progress that was made with respect to each of these specific goals.","e":[-10,22,-151,7,-13,27,-1,-20,48,10,-63,-15,123,48,-23,8,-12,-29,-63,60,-4,-42,-33,-28,9,73,23,46,-62,46,16,-9,-20,-48,-41,-17,85,56,2,-42,61,-4,17,-47,20,-83,72,0,-2,-28,2,-42,15,-33,88,52,0,15,-5,-46,122,15,-64,74,68,-48,-33,51,-61,-34,45,18,0,19,-17,-2,-41,-13,-8,32,57,-39,37,-60,36,10,30,35,-13,55,-2,36,14,17,-78,-3,-6,-3,-19,12,-72,-37,31,1,25,52,-15,24,2,-5,-49,11,-26,-28,13,-17,22,-41,-11,14,9,-3,26,39,21,57,-70,3,6,25,-20,-20,-48,55,-11,60,14,-12,-34,-1,54,4,-10,-3,-34,-35,32,-9,-33,45,-11,-4,51,7,34,-46,-25,23,40,16,81,20,-35,67,-24,-10,11,44,-22,56,-44,-75,-19,4,60,10,74,-21,-5,-34,48,-66,49,41,-33,-2,15,-47,-72,-28,15,22,-50,1,-64,-26,49,-21,11,-47,-31,35,-47,57,-12,59,39,2,23,-19,39,-25,-3,17,-24,-16,-18,-14,-49,-10,20,-15,-27,1,27,-7,-37,10,-20,10,-24,-74,28,-7,7,49,-39,18,-12,61,-19,38,20,17,-60,51,-25,2,-42,77,5,45,40,-13,70,-31]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.163","t":"One fundamental issue to consider in evaluating a patient’s response to CBT is whether the patient is less depressed. The therapist and patient review the changes in scores on the BDI since the beginning of treatment. Sometimes, the therapist plots the scores on a graph for each session to measure the patient’s progress. Generally, a patient is considered to have successfully responded to treatment if his BDI total score has been reduced by at least 50% or if the BDI total score is in a minimal range of severity (10 points or fewer). Although the BDI has been shown to be a sensitive measure of treatment response, therapists may also evaluate the degree to which depression has remitted in other ways. For example, the therapist may consider the following questions: (a) Does the patient spontaneously report that he is feeling less depressed? (b) Is the patient engaging in more activities during the week? (c) Does","e":[45,15,-159,-49,65,18,75,14,38,-44,-25,45,65,-19,3,-48,-14,-82,-21,27,-54,-23,-64,-13,19,50,-24,57,-54,58,30,25,35,-35,-55,-7,69,50,21,7,27,-21,-5,-98,31,-13,108,43,8,-24,8,-52,11,-25,107,25,-73,38,-19,-45,77,19,-45,35,79,-37,-20,38,-42,-24,47,0,46,52,-47,-10,-44,-37,-33,5,40,-24,28,-23,78,8,3,17,-23,87,44,-10,44,37,-92,24,-10,-34,-44,-43,-51,4,-15,-25,29,49,5,-13,-7,-14,-71,-2,-37,-35,22,8,65,-51,-35,49,14,4,3,34,17,43,-62,6,59,12,-44,-5,-8,5,-10,53,7,-1,-34,-2,36,-13,-4,27,15,-11,47,-7,-43,25,4,12,40,-2,36,-72,-28,24,34,11,35,-1,-24,45,24,-36,-1,26,37,43,-50,-81,0,-24,64,25,46,6,36,-40,27,-28,47,33,13,-15,41,-48,-43,-40,27,44,-53,-6,-65,-24,19,-5,31,-40,-23,47,-3,7,-63,57,-12,14,-20,-47,38,-24,-11,29,-44,11,-14,-12,-32,5,8,-21,-2,-12,42,19,-67,-16,10,14,17,-84,33,-25,8,20,-29,5,27,39,-8,27,28,40,-65,34,-21,-31,6,20,-21,21,14,21,61,6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.164","t":"the patient report that other people in his social network notice a change in her mood or in her behavior? (d) Are the key symptoms less severe than were initially recognized as a problem by the patient? Thus, the therapist may choose to focus on a variety of indices and sources of information, including standardized measures like the BDI, in determining the degree to which her patient’s depression has remitted.","e":[47,14,-180,-43,69,23,60,-8,33,-48,-30,43,77,0,-8,-30,-20,-67,-36,44,-62,-50,-77,-19,4,67,10,6,-41,22,15,16,0,-36,-33,-13,39,68,31,48,27,3,-20,-92,11,-29,74,27,63,-29,35,-50,-17,-21,108,15,-33,38,8,-44,90,19,-67,38,71,-17,-35,39,-37,-29,31,35,36,57,-37,21,-17,-14,-21,5,66,-39,69,-39,80,41,-12,32,-10,88,56,4,29,44,-110,-24,-26,-25,-10,-63,-39,-9,-27,-6,36,31,-25,-2,-1,-5,-51,16,-15,-15,26,-36,51,-53,-24,50,-8,2,13,81,30,40,-30,29,17,-4,-18,1,-21,10,-9,56,-7,-24,-22,12,73,29,-15,-16,-25,-15,30,-12,-31,29,-1,14,-3,12,16,-62,-39,25,60,-13,35,8,-27,45,7,-57,15,36,22,62,-62,-49,-32,-8,74,28,41,-23,60,-29,3,-50,41,9,11,-33,30,-66,-53,-35,-17,50,-41,2,-51,-40,12,-32,20,-37,-28,17,-32,20,-47,68,-4,8,-31,-44,33,-48,13,-3,-36,21,-4,-13,-25,0,15,-18,-7,-19,34,14,-76,-2,6,11,-13,-99,33,15,20,7,-54,5,22,4,-26,-1,14,34,-57,38,5,-37,9,20,-17,12,7,21,43,-20]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.164","t":"Regardless of overall improvement in the level of severity in depression, the therapist should specifically consider two additional symptoms: hopelessness and suicide ideation. As discussed earlier in this manual, hopelessness and suicide ideation are Items 2 and 9, respectively, on the BDI. If the patient continues to report hopelessness or suicide ideation on the BDI, or spontaneously expresses hopelessness or suicide ideation during the therapy session, the ending or tapering of treatment is likely not to be clinically appropriate even if the patient has made progress in other areas of her life. Treatment should be continued and/or other treatment (e.g., medication) added until the hopelessness and suicide ideation have resolved.","e":[43,26,-157,-65,69,-1,26,18,8,-29,-36,45,67,36,-7,-24,10,-63,-18,38,-71,-52,-63,-16,16,100,-15,40,-37,44,30,-11,4,-16,-76,-29,56,55,56,-8,24,-20,18,-68,-18,-14,108,45,62,-31,67,-54,42,-22,74,59,-20,7,-15,-53,50,28,-10,42,79,-35,-36,36,-23,-18,71,20,27,35,-54,59,-25,-22,-10,22,20,-29,80,-38,71,24,26,42,-27,69,-15,22,-5,55,-98,-19,-23,16,-23,-45,-60,2,-31,-22,17,40,14,0,2,-18,-74,34,-46,-45,55,-14,34,-52,20,30,-30,-4,26,34,44,12,12,3,23,-20,-11,-22,-34,38,-2,54,0,-10,-44,2,43,-25,-5,19,-30,-54,49,-10,-58,-10,-4,15,36,-17,-14,-53,-63,28,41,-7,26,14,-34,63,-4,-42,-11,42,27,45,-28,-61,15,11,88,17,39,-13,29,-52,26,-30,26,5,6,-41,33,-32,-42,-29,14,56,-52,-7,-52,-17,46,-35,39,-38,-16,39,-36,-5,-80,72,-29,33,-26,2,48,-38,17,-35,-18,11,-8,-11,-34,14,29,-10,12,-4,29,45,-78,-14,-1,-9,-24,-98,60,-5,-16,-4,-15,-10,20,52,-33,29,24,21,-56,55,-27,-23,7,48,-33,5,-18,44,48,22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.164","t":"Review and Consolidation of Skills Once the therapist and patient have determined that adequate progress toward the • Review and treatment goals has occurred, the next step in the final phase of CBT is to review all consolidation of the skills that were learned and practiced during treatment. This comprehensive of skills review is appropriate when (a) the severity of patients’ acute symptoms of depression have diminished; (b) patients perceive that most, if not all, of the issues that brought them into treatment have been addressed; and (c) patients have demonstrated that they have acquired skills for coping with future distress or a potential relapse in depression.","e":[36,-9,-151,-48,48,7,49,6,29,-21,-26,2,65,0,17,-45,-26,-54,-22,30,-32,-13,-15,-25,3,77,-12,17,-12,-7,57,3,7,-37,-40,-43,75,-11,-13,-50,67,25,2,-119,35,-21,89,5,23,-40,43,-25,-16,-57,127,68,5,14,11,-50,85,53,-42,63,54,-37,-31,58,-13,-25,22,11,58,40,-54,-20,-30,-22,-27,5,23,-27,64,-12,28,-15,-12,-2,-40,77,14,3,5,44,-87,18,-9,-9,-16,-55,-60,-49,23,-41,42,67,-31,-13,-10,1,-65,40,-21,-14,1,1,42,-9,-17,47,4,-23,6,12,29,81,-21,2,55,-13,-27,1,11,22,-5,46,-22,-33,-14,20,38,-17,1,27,11,-28,31,-6,-62,22,-12,-6,43,-18,44,-42,-25,-6,82,18,40,-6,-50,57,-15,-35,-10,0,42,41,-48,-49,8,-19,79,40,88,-33,4,-59,15,-23,45,67,27,4,30,-36,-28,-32,21,47,-60,-4,-77,-21,44,-14,-3,-79,-5,43,-30,40,-51,82,-5,18,-25,1,40,-14,19,22,-39,-11,-13,-27,-53,26,-12,3,-30,-4,22,10,-60,-2,4,16,-4,-73,5,-6,16,28,-14,34,19,66,5,52,48,-29,-68,41,13,-9,22,50,-5,35,21,39,44,-28]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.164","t":"To facilitate the review and consolidation of skills, the therapist asks the To facilitate the review and patient which skills were most helpful in reducing his depression as consolidation of skills, the these skills were applied during the course of treatment. Reviewing the therapist asks the patient learned skills may be a useful homework assignment because it allows which skills were most helpful time for the patient to reflect upon the skills or aspects of treatment that in reducing his depression as he found most beneficial. If it becomes evident the patient is having difficulty generating a list of specific cognitive and behavioral coping these skills were applied during strategies, it is likely that he is not ready to move out of the middle the course of treatment. phase of treatment.","e":[25,-4,-145,-69,39,0,52,11,25,-18,-30,-21,78,20,3,-13,-11,-66,-33,17,-32,-37,-19,-4,4,53,-20,-20,-26,7,41,-8,-22,-37,-51,-30,69,9,-15,-25,25,13,13,-93,62,-16,63,-27,31,-29,49,-52,-21,-30,148,38,21,7,36,-43,100,62,-65,54,42,-22,2,62,-23,9,32,26,62,24,-58,-11,-18,-9,-19,4,51,-51,55,-41,44,24,-23,-4,-41,74,-8,22,18,49,-94,45,-14,-18,-23,-52,-48,-41,45,-37,49,66,-19,-9,-24,5,-40,49,-33,-34,29,3,44,-6,15,21,-27,1,-17,16,26,87,-32,1,34,6,-14,-16,-16,25,-17,57,-40,-46,5,12,64,2,-7,10,-14,-16,8,-15,-75,23,-18,-6,30,-18,62,-45,-10,0,64,39,32,16,-44,65,7,-43,10,14,33,39,-37,-65,14,-21,75,36,94,-22,21,-33,31,-45,40,40,7,1,33,-18,-58,-37,3,34,-38,-24,-81,-43,36,-23,-2,-53,-54,27,-26,9,-69,73,-2,12,-13,-13,28,-16,29,27,-42,-7,-33,-7,-46,24,-17,-16,-15,13,24,17,-63,17,-7,19,-37,-72,26,14,39,9,-31,38,4,64,-8,28,58,-17,-69,56,10,-18,11,45,-7,34,-9,26,40,-26]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.164","t":"For patients who have made progress toward their treatment goals and who are less depressed, it is helpful to discuss the potential for relapse of depression. This discussion might include the identification of specific issues or circumstances that are likely to trigger an increase in depression. Typically, when patients experience a setback, such as a relapse in depression, they will often experience hopelessness. This pessimism is often associated with an all-or-nothing thinking pattern that leads patients to conclude that treatment was ineffective. This belief is especially dangerous because patients may generalize this setback to indicate that any treatment will not be helpful which, in turn, could prompt patients not to seek future treatment.","e":[35,29,-172,-39,77,35,3,25,38,-5,-34,24,61,21,11,-6,11,-33,-14,43,-34,-57,-47,-33,-53,87,-7,-2,-42,36,27,-22,-5,-21,-57,-13,61,38,60,-24,28,19,5,-81,-4,5,72,40,47,-42,60,-66,4,-54,72,57,6,16,7,-39,71,28,-12,39,63,-39,-38,28,2,-26,49,16,-34,9,-49,40,-15,-13,-12,-10,56,-17,65,-33,60,33,36,4,-57,62,27,-11,39,34,-116,-14,-23,-6,-43,-22,-57,-12,5,-33,10,58,-14,2,8,-7,-56,60,-34,-52,29,11,54,-44,15,35,1,-2,25,65,5,46,7,-13,58,-4,-16,-21,-54,35,16,36,-2,-11,-33,5,77,-9,9,-2,-14,-57,35,-18,-40,9,-18,10,11,-4,11,-69,-64,4,45,-29,83,5,-36,12,-38,-31,28,28,3,31,-21,-56,12,-7,119,19,89,0,1,-63,27,-32,42,26,-5,-2,28,-31,-63,-73,3,37,-24,2,-18,-21,51,-4,16,-22,-11,23,-44,12,-84,49,-2,14,-40,-10,57,-36,43,-1,-14,-12,12,-15,-28,25,12,17,-37,-1,61,26,-47,2,-12,4,-29,-107,26,-10,17,-2,-15,9,10,28,-30,35,29,27,-35,15,-4,-29,17,23,16,0,-7,38,53,-10]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.165","t":"patient should review the skills that would be most helpful in dealing with such setbacks or future crises. Patients should be encouraged to To prepare patients for possible work on a “survival kit” that includes many of the skills or other tools setbacks or lapses, unrealistic that have been helpful to them in the past. Items for the survival kit may expectations should be include coping cards, Thought Records, or activity schedules that were addressed, along with potential completed during treatment, as well as blank forms and other sources of strategies for dealing with information (e.g., self-help books) that are likely to be helpful in setbacks. preventing relapse. The survival kit usually includes only those items or tools that patients have found to be helpful in the past.","e":[-30,16,-175,-32,45,4,-10,26,36,-20,-5,-20,56,0,7,-19,14,-46,-21,31,-37,-75,-23,7,-30,68,16,43,-52,8,69,-17,-3,-65,-40,-30,73,18,3,-16,18,23,32,-101,51,1,66,-6,40,-5,57,-70,-6,-21,122,16,28,7,19,-60,81,41,-71,36,25,-11,-29,59,13,-1,85,21,24,44,-55,24,-45,10,-20,23,52,-18,68,-37,46,23,15,16,-37,60,-6,31,40,32,-55,80,-36,-17,-31,1,-21,-51,28,-28,14,36,2,13,-10,-2,-34,30,-28,-13,-3,14,79,-30,33,35,6,8,41,39,51,53,-38,-18,58,-5,-3,-24,-73,12,29,50,-11,-16,40,-8,71,33,-16,-24,-8,-61,15,-14,-56,20,-9,24,-15,44,49,-31,-24,7,58,5,80,-16,-78,68,-31,-54,28,24,20,39,-10,-60,18,-5,71,13,92,-20,-14,-70,44,-72,41,52,-7,-29,33,-22,-45,-61,36,22,-55,-18,-27,-47,53,0,18,-29,-29,33,-39,20,-68,64,-15,-16,-24,-29,48,-8,3,13,-1,4,-15,-6,-43,17,-14,8,-37,-47,33,16,-36,-4,10,-10,-34,-97,37,-22,15,11,-13,6,27,8,-8,50,47,-5,-48,30,-9,-32,-3,25,15,20,-18,0,19,-25]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.165","t":"Additional Treatment Planning After the successful completion of the review of treatment goals, the consolidation of treatment skills, and relapse prevention, the therapist and patient discuss four treatment options: (a) continuation of treatment, (b) tapering treatment sessions, (c) referral for additional treatment, and (d) termination of treatment.","e":[38,16,-138,-43,31,-27,20,-18,49,4,-42,-18,79,26,2,-26,7,-83,-14,5,-67,-42,-23,-38,-20,59,18,15,-36,11,31,-8,27,-27,-33,-75,80,13,-58,-64,21,16,-8,-85,37,-36,72,17,33,-23,59,11,-41,-16,71,21,-16,18,35,-19,90,37,-57,39,58,-53,-29,43,-17,-26,49,-7,32,2,-33,-6,-25,-8,-23,25,4,-12,81,-26,-2,34,6,23,-56,33,-23,27,11,28,-100,9,-4,-18,-8,-63,-61,-15,45,-41,41,36,18,21,19,31,-50,13,1,-25,-5,-14,75,-54,40,38,-3,-39,31,24,15,39,-18,-17,37,24,14,-29,-23,58,-11,28,11,-34,-6,18,53,-2,0,32,-31,-28,31,-15,-27,6,11,5,21,44,34,-46,-31,-1,55,40,72,-27,-49,79,-21,-10,25,30,-10,25,-7,-35,10,-12,128,31,77,-22,-11,-45,20,15,33,81,28,-11,24,-32,-26,-48,36,86,-21,-36,-50,-22,47,-18,16,-39,-16,47,-71,12,-36,73,-33,27,-25,-11,62,-17,47,22,-15,-28,19,-16,-50,46,19,-6,-33,-27,21,21,-55,13,5,24,-19,-107,7,-16,25,-10,-14,41,17,62,-1,45,65,-18,-69,45,20,-10,15,63,14,20,6,26,42,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.165","t":"Continuation of Treatment Occasionally, patients may make substantial gains in improving their depression. However, despite these treatment gains, there may be other issues or problems that are not associated with depression but that could be addressed using CBT. If there are • Continuation other issues to be addressed, the therapist and patient may revisit the treatment goals of treatment for the continuation phase of treatment and negotiate the number and/or frequency of sessions. Once new specific treatment goals have been collaboratively established, the therapist and patient continue to work toward these goals using a similar session structure that was described in Part II. Because patients may no longer be depressed, the therapist and patient may decide that the weekly completion of the BDI is no longer necessary, and they may decide to complete the BDI less often. In addition, it might be helpful to use other standardized measures or mood rating scales on a regular basis that measure the symptoms or problems that have become the focus of the continued treatment. The administration of such measures or ratings is important because they provide for an objective measurement of treatment progress.","e":[52,12,-156,-58,21,-5,46,-7,32,-34,-27,38,36,-8,7,-43,-18,-71,-38,55,-42,-5,-21,-41,-4,76,1,33,-27,37,46,5,43,-31,-26,-27,83,40,23,-18,73,-2,-21,-104,34,-44,84,20,16,-40,52,-31,-7,-28,75,29,-30,31,-15,-56,104,30,-29,60,71,-61,-38,33,-55,-32,51,38,42,55,-39,17,-6,-18,-43,9,27,-30,41,-51,64,28,-6,43,-32,89,7,-4,25,60,-102,-11,-11,-14,-39,-26,-62,-8,29,-11,26,46,7,0,2,13,-70,7,-26,-14,-1,29,34,-56,-23,49,-20,-19,26,25,29,58,-33,-3,58,-2,-26,3,-21,40,17,45,-3,-6,-4,10,52,-18,5,43,4,-17,38,-33,-49,18,-2,13,36,21,29,-63,-38,10,62,5,57,-3,-33,37,1,-31,-13,24,3,35,-66,-51,-9,-10,91,42,56,-13,22,-78,13,-14,53,30,-2,14,1,-61,-45,-37,27,65,-47,2,-88,-28,40,-11,14,-38,-19,43,-42,21,-36,53,-12,-2,-26,-37,37,-31,-7,14,-36,1,-9,-26,-45,35,6,-2,-8,-22,27,23,-55,-4,2,25,3,-120,12,-14,15,21,-12,14,23,78,14,5,54,18,-44,48,-6,-10,26,41,12,12,26,29,54,-24]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.165","t":"Tapering Treatment Sessions If the therapist and patient agree that the specific treatment goals that were established during the initial phase of CBT have been reached, then they may also • Tapering treatment agree that meeting on a weekly or biweekly basis is no longer necessary. Instead of sessions terminating treatment at this point, however, the therapist should consider whether it would be advantageous to continue with occasional treatment sessions for several reasons: (a) to monitor the patient’s clinical status, (b) to discuss CBT strategies for maintaining treatment gains or preventing relapse, or (c) to focus on other specific issues associated with ending treatment. For example, the therapist and patient may decide to taper the frequency of the sessions by scheduling biweekly or monthly meetings instead of weekly visits. On occasion, the therapist may find that he is one of the few supportive persons in the Veteran’s social network. When this occurs, the therapist should be keenly aware of and assess the patient’s reactions following any discussion about ending or even tapering the frequency of therapy sessions. Working toward expanding the patient’s network may help to ease the Veteran’s sense of","e":[37,10,-153,-58,46,-23,19,-29,62,-16,-44,6,30,27,-4,-50,-49,-82,-51,21,-55,-20,-26,-42,-5,51,5,52,-16,24,66,-3,12,-20,-42,-46,61,29,-20,-44,66,4,28,-107,43,-52,81,35,5,-33,45,-62,-59,-23,92,-5,-24,48,-12,-53,102,5,-64,80,24,-24,-36,12,6,-32,44,-3,28,17,-29,33,-15,-6,-60,32,-5,-31,35,-34,40,30,27,13,-24,81,-4,-5,37,58,-77,15,20,-17,-21,-40,-47,-17,-13,-12,-10,23,10,-6,16,-7,-76,16,-29,2,7,25,64,-64,37,28,-6,-38,-5,52,19,80,-33,-6,40,-9,-18,-2,-22,49,22,25,-11,-48,15,5,44,-14,7,25,-28,-13,-6,-61,-11,29,-4,35,7,34,33,-66,-52,11,54,41,39,-29,-46,9,-23,-14,-5,33,11,-15,-14,-37,-16,-16,104,40,69,-8,-7,-46,12,-12,45,30,16,15,25,-40,-25,-46,14,45,-50,-19,-80,-46,77,22,4,-49,-21,19,-61,23,-29,41,-26,-20,-55,-48,70,-40,-22,15,-32,0,27,1,-45,62,44,12,-24,-25,19,-12,-47,-7,-10,16,-20,-100,-8,14,5,28,-1,35,36,57,30,15,36,0,-96,24,-7,-25,-11,6,14,21,19,4,56,2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.166","t":"dependency on the therapist. In addition, when changes in the frequency of visits are being considered, it may be helpful to consult with other providers who are providing care for the patient or with the patient’s family members. Other providers and family members may assist the therapist in determining if changing the frequency of visits is clinically appropriate as well as in helping the therapist to choose the best approach for handling this issue with the patient.","e":[6,44,-155,-50,28,13,26,-15,56,-10,-15,5,72,26,-24,-23,15,-43,-18,24,-55,-9,-53,-31,-11,25,57,22,-51,6,80,31,40,-70,-23,-39,30,61,10,10,40,33,10,-94,29,-86,71,24,24,-1,42,-51,-62,4,103,16,-5,64,18,-50,127,43,-67,34,31,-13,-46,45,8,-37,-5,-36,59,4,-42,35,9,-22,7,30,44,2,89,-36,19,36,18,41,24,78,21,-7,39,33,-87,-12,-18,-12,5,-46,-50,-1,6,-23,31,13,32,27,-4,17,-54,23,8,-32,12,-49,42,-56,1,55,-18,-53,-27,57,-9,36,-72,21,30,-7,3,-25,8,28,22,58,32,-25,16,6,43,32,14,-16,17,17,22,-39,-26,17,13,40,-20,31,35,-69,-18,31,23,6,69,0,-33,40,14,-15,31,45,5,14,-9,-48,6,-24,79,20,49,-44,6,-27,3,-66,13,2,21,-10,21,-70,-53,-37,9,-1,-4,-28,-55,-39,14,-13,10,-51,-23,18,-25,36,-46,57,-26,-9,-59,-36,61,-29,12,35,-62,7,-36,-6,-44,54,35,20,38,-12,6,11,-61,-12,3,18,-26,-77,30,45,35,41,-20,24,43,30,34,6,39,9,-81,-11,-27,-25,3,45,31,12,5,4,19,-6]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.166","t":"Referring for Additional Treatment On other occasions, a patient may need further treatment that is beyond the expertise of the treating therapist. In such instances, the therapist would consider the specific • Referring for diagnoses or problems requiring further treatment and seek out providers with the additional appropriate area of expertise. When referring a patient to other providers, it is treatment important to ensure that there is a continuity of care. This may be accomplished by discussing the patient’s expectations for additional care, assisting with scheduling an appointment with the new provider, determining if the patient attended the appointment, and evaluating the patient’s reactions to the additional treatment.","e":[10,50,-139,-76,33,11,0,8,43,7,-38,15,51,18,8,-29,30,-57,-10,18,-73,-19,-7,-23,-21,8,21,21,-45,8,50,17,35,-39,-35,-63,45,65,-33,6,22,-1,3,-101,25,-43,55,46,24,-35,32,-42,-28,23,98,5,10,42,20,-23,99,42,-54,9,47,-60,-51,36,-25,-12,50,-11,57,15,-28,4,-18,-10,-16,37,49,-4,100,-42,-2,30,-8,39,-1,56,9,7,17,24,-95,-1,-15,-40,-40,-71,-60,7,14,-35,46,41,32,50,-8,-4,-22,27,-12,-29,-4,-5,52,-43,39,8,3,-36,9,59,33,58,-16,-17,53,3,3,-43,-17,23,0,18,-5,-30,3,18,44,7,27,22,5,3,6,-12,-25,9,15,32,-11,55,73,-23,-27,-3,40,5,73,6,-40,62,15,-13,32,26,-35,33,-18,-31,20,-21,109,47,92,-40,15,-60,-9,-35,14,34,-17,-7,-15,-61,-23,-39,12,62,-1,-1,-60,-13,10,-18,-5,-44,-28,37,-38,27,-24,76,-40,7,-23,-43,53,-33,42,37,-22,-18,17,-32,-54,47,49,-16,47,-15,-3,6,-63,41,-1,34,-24,-83,28,15,11,4,-8,29,7,68,0,49,36,17,-86,24,24,-8,-22,63,-13,6,8,0,47,-13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.166","t":"Termination of Treatment The termination of treatment may be considered when the treatment goals have been met, the patient is no longer clinically depressed, the specific CBT skills learned during treatment have been reviewed, and strategies for dealing with relapses or setbacks have been discussed. Even though patients may be doing relatively well at • Termination of the end of treatment, some patients may continue to have concerns about the treatment possibility of a relapse of a depressive episode and may want the option of “checking in” with the therapist without having to initiate another course of CBT treatment. One treatment option for use after therapy has terminated involves the use of booster sessions. These sessions provide the opportunity for a mood check and the assessment of depressive symptoms (such as the administration of Even though patients may be the BDI), an assessment of any ongoing treatment of other mental doing relatively well at the end health or substance use disorders, an assessment of any specific of treatment, some patients circumstances or stressful life events that may be associated with may continue to have concerns relapse, a review of the patient’s implementation of the skills learned about the possibility of a during therapy, and the assessment and general reinforcement of the relapse of a depressive episode sustained gains that have been accomplished since the termination of and may want the option of treatment. Booster sessions may be scheduled many weeks or even “checking in” with the months after the final session or they may be provided on an as-needed therapist without having to basis. If the booster sessions have not been scheduled, it is important for initiate another course of CBT the therapist and patient to agree upon the specific circumstances or treatment. indicators for scheduling such sessions. Listing some of these indicators is important so that the patient may recognize them and return for an appointment before a relapse of a full depressive episode. These indicators might include the emergence of a few key symptoms that may signal impending relapse such as feeling depressed or a lack of interest in activities that are usually pleasurable, a sense of hopelessness or isolation, or other depressive symptoms. It is helpful for the therapist to keep in mind the advantages of scheduling a booster session as opposed to waiting until a full relapse of depression has occurred. Patients who have scheduled a booster session may see it as a prompt for continuing to practice and implement the acquired","e":[50,23,-158,-54,29,-19,26,11,52,-30,-46,36,50,-9,35,-37,-1,-70,-60,23,-54,-41,-61,-26,-4,68,10,52,-14,30,23,-19,37,-11,-47,-16,67,42,-3,-38,65,-4,-8,-80,11,-37,80,59,9,-50,58,-27,-31,-54,84,12,-14,27,-12,-61,94,45,-29,30,62,-49,-29,19,-30,-32,42,19,24,65,-19,20,-35,-13,-26,6,43,-11,52,-39,45,33,21,18,-51,59,-1,-6,15,45,-95,24,2,-13,-36,-54,-35,-15,3,-33,18,41,14,-22,-3,-11,-77,26,-40,7,11,20,59,-60,-4,41,12,-10,14,26,58,62,-25,-4,19,2,-42,-26,-32,38,16,47,45,-42,-14,-17,48,-4,-6,20,-25,-16,38,-28,-38,43,-11,20,43,22,29,-54,-54,6,50,27,54,-15,-56,41,-34,-28,2,12,31,5,-68,-45,-8,-34,93,35,85,-14,-16,-70,28,-16,68,41,27,-15,31,-42,-50,-40,46,65,-44,-19,-104,-28,62,0,15,-33,-3,37,-56,11,-49,45,5,10,-52,-21,56,-27,31,13,-30,26,7,-27,-14,31,17,-9,-19,-33,30,24,-53,5,-20,-5,-16,-97,11,-11,9,2,-3,-9,10,62,5,26,26,24,-86,27,-20,-33,20,17,10,24,29,42,60,9]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.168","t":"CONCLUSION The aim of this user-friendly treatment manual is to describe and illustrate the application of CBT for depression with Veterans and Military Servicemembers using a short-term approach (i.e., approximately 12 to 16 sessions). This manual represents one of the first therapist manuals focusing on the use of CBT with Veterans and Military Servicemembers that utilizes illustrative case examples.","e":[10,14,-179,-87,37,-12,54,-31,4,-5,-26,4,26,-16,14,-72,-21,-43,-55,0,-27,-28,-55,-50,22,55,-41,52,-22,0,31,-10,10,-10,-22,-58,42,46,-14,-6,33,-38,29,-79,-5,-26,94,43,9,-31,38,-60,15,-69,118,-27,-48,9,-4,-46,128,35,-66,71,48,-32,-30,26,-21,-20,46,-22,37,36,-60,-14,-49,-21,-35,13,50,-16,35,-77,50,-5,3,18,3,42,-12,17,-6,48,-86,-11,-23,4,-5,-34,-41,-30,9,-25,21,61,10,-10,22,-22,-87,36,-6,13,-25,10,31,-17,11,35,4,-14,26,6,4,16,-58,7,24,-11,-18,1,-11,2,14,41,-27,-38,-41,12,39,-44,-33,31,-4,-7,6,-15,-34,0,-4,22,23,7,50,-48,-37,1,36,22,40,14,-54,23,-4,-26,-14,26,50,17,-39,-72,-41,-14,77,18,60,-26,-3,-36,27,-50,22,34,-11,-13,21,-78,-47,-50,16,23,-24,-13,-100,-11,71,-5,3,-52,9,65,-19,17,-29,46,0,16,-22,-36,56,-15,26,17,-25,4,9,9,-50,15,49,31,-10,-21,22,9,-51,1,14,-4,-19,-68,8,-21,-30,19,-3,20,-9,51,28,20,49,28,-102,7,-21,-35,29,51,-15,10,-7,1,44,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.168","t":"CBT is a structured, time-limited, present-focused approach to psychotherapy that helps patients develop strategies to modify unhelpful cognitions and behaviors in order to assist them in resolving current problems and managing mood. The treatment is based on clinical observation and substantial research that reveals that patients with depression exhibit negative thoughts and beliefs about themselves, their world, and their future. Helping patients to acquire cognitive strategies to identify and evaluate such negative thinking styles will lead to improved mood and a decrease in the severity of depression. CBT is also based on extensive clinical observation and research that patients with depression often disengage with their environments. Depressed patients may not have sufficient pleasant activities or mastery experiences, and this behavioral pattern often leads to low motivation and other depressive symptoms. Assisting Veterans and Servicemembers in recognizing and changing such behavioral patterns in their lives is important for treating depression.","e":[29,14,-151,-79,75,16,57,-12,26,-30,-3,19,71,-27,8,-56,-40,-6,-27,34,-52,-18,-12,-25,-13,67,-33,43,-2,20,36,-10,-6,-17,-38,7,57,40,13,12,21,-22,2,-107,-8,-15,110,39,-11,-21,27,-66,42,-87,128,-3,-31,46,-28,-54,96,55,-45,78,39,-66,-60,24,-45,-5,53,-5,15,38,-34,-13,-27,-32,-17,7,53,-53,10,-36,65,-9,-5,6,-9,51,9,-28,0,40,-91,25,-22,-49,-20,-17,-55,-21,-1,-20,-8,74,-31,-26,8,-2,-73,31,-9,-22,-22,6,50,-25,7,23,48,18,-2,22,9,75,-43,-8,46,-15,-27,-10,-20,-8,12,44,-16,-22,-20,35,31,-19,-8,48,17,-14,15,-28,-40,-2,-11,8,37,10,61,-42,-19,28,48,8,48,34,-45,15,-18,-31,3,35,47,38,-60,-58,-18,0,90,31,56,-7,-6,-44,-6,-7,33,43,3,19,6,-54,-13,-71,31,28,-32,20,-93,-38,22,4,26,-57,-16,32,14,20,-52,48,-13,7,-21,-16,45,-25,30,17,-36,18,-8,-27,-57,4,46,7,-14,-1,25,21,-38,-1,8,13,-12,-68,26,15,16,46,-13,12,0,66,9,42,25,31,-79,7,-2,-31,-7,12,-10,13,-8,-16,58,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.168","t":"The protocol presented in this manual emphasizes the use of a case conceptualization approach to implementing CBT for depression with Veterans and Military Servicemembers. [For additional information on adapting CBT for depression in older patients, see Karlin (2011)]. In this protocol, cognitive behavioral therapists use the CBT theoretical framework to develop an understanding of the patient’s clinical presentation and to identify stressful situations, automatic thoughts, and maladaptive behaviors that contribute to the patient’s depression. The case formulation approach allows for the treatment to be implemented in a flexible manner so that the specific cognitive and behavioral strategies employed are tailored to the patient’s individual needs and goals for treatment. In the case conceptualization process, therapists apply an empirical approach to each case, meaning they generate hypotheses about the cognitive, emotional, behavioral, and situational factors that contribute to, maintain, and exacerbate a patient’s mental health problems. Chronic and recurrent unhelpful thoughts and behaviors are also conceptualized by identifying core beliefs and intermediate beliefs that become apparent during stressful periods and that are maintained or reinforced by long-standing compensatory strategies.","e":[45,-1,-150,-78,66,4,46,-6,17,-32,-14,-20,70,15,3,-56,-25,-23,-24,12,-52,-17,-29,-21,6,67,-39,59,-21,26,42,12,14,-32,-32,-46,64,35,-5,-4,19,3,18,-80,-4,-13,85,19,8,0,40,-63,50,-55,110,7,-15,58,-19,-72,121,67,-46,51,27,-33,-57,46,-35,-28,47,-8,23,39,-53,13,-41,-15,-9,21,88,-41,60,-68,53,5,1,4,-19,60,-1,-7,-2,48,-77,13,-34,-15,-19,-30,-65,-18,2,-4,-15,57,-23,-23,0,15,-97,39,-33,9,-1,30,26,-31,0,36,9,6,23,2,12,70,-61,-27,42,-37,4,-6,-6,-13,-3,24,-11,-23,-25,33,59,-30,-2,29,10,-2,-2,-36,-38,0,-18,39,24,-3,72,-32,-40,27,32,19,42,9,-42,45,-12,-33,4,44,19,16,-51,-67,-19,16,103,39,61,-19,-2,-25,-3,-16,32,36,11,-16,37,-43,-49,-38,17,44,-50,7,-96,-39,31,-23,12,-53,-11,40,-7,17,-60,47,-11,-2,-26,-27,28,-30,16,26,-34,19,-8,-14,-62,10,38,0,15,24,10,18,-49,26,21,21,-8,-72,38,7,19,48,-48,12,36,58,23,45,36,32,-53,14,-20,-26,-8,43,-3,18,-13,-16,63,-27]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.168","t":"This protocol also emphasizes the importance of the therapeutic relationship, recognizing that the therapeutic relationship is a key contextual variable in CBT. A strong therapeutic alliance is an important component of CBT and is enhanced by a warm, empathic understanding of the patient’s problems in light of the CBT model. Moreover, a solid therapeutic alliance is critical to success of CBT and to realizing substantive patient gains.","e":[9,45,-166,-44,53,-13,4,2,63,-4,-19,6,54,-33,30,-15,-26,-20,-21,25,-86,-40,-10,-21,5,48,-8,28,-73,-14,76,-23,55,-34,-59,-29,47,68,2,-32,39,24,-1,-74,17,-50,41,-5,10,-4,8,-42,-4,-50,124,28,7,52,-33,-49,74,29,-58,38,87,-2,-55,24,-21,-7,40,-19,52,49,-16,-26,-26,-11,11,13,64,-6,73,-31,25,15,8,-7,-8,58,56,12,-7,48,-117,4,-35,-8,-67,-6,-39,6,15,24,8,22,-1,3,-17,21,-76,36,-35,-27,-3,-33,41,-55,-6,27,18,5,-20,47,-14,33,-44,1,21,-16,-22,-52,-12,-6,-23,78,3,-3,-13,55,35,26,4,-10,-8,-29,14,-2,-16,14,13,35,-37,36,-22,-55,-3,-6,45,39,19,27,-39,-38,-1,-38,39,32,28,62,-41,-37,-16,3,104,13,51,-4,13,-42,1,-21,19,12,-26,5,18,-30,-44,-22,29,30,-46,-21,-60,-28,31,6,54,-34,-15,34,-34,70,-31,70,-45,11,-46,-47,44,-8,-37,7,-44,-38,-4,-30,-50,42,45,13,-9,-34,-14,-7,-31,5,-17,23,-30,-52,54,46,29,20,11,50,-11,65,33,33,20,11,-59,56,-21,-67,6,17,8,31,25,-22,22,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.168","t":"Other key features of the present protocol include the use of a structured session format that facilitates the delivery of the therapy. This includes a brief mood check, the use of standardized measures of depression to measure progress, conducting a CBT for Depression in Veterans and Military Servicemembers: Therapist Manual 148","e":[-7,-10,-180,-91,59,-20,53,-23,26,-54,-4,4,39,-2,19,-83,1,-58,-25,22,-40,-45,-52,-47,39,83,-10,29,-39,-15,49,-19,38,-20,-25,-64,42,35,-16,-3,43,-6,-11,-70,2,-23,87,4,-17,-17,38,-74,13,-52,131,-14,-21,38,30,-63,114,50,-67,54,58,-20,-34,19,-44,-19,46,-5,48,31,-52,15,-34,-26,-16,27,35,-13,62,-47,55,1,13,19,6,78,-17,-10,2,55,-114,14,-13,11,-6,-36,-39,-25,7,-27,8,69,-18,-19,-18,-19,-53,60,-14,18,-13,-23,49,-23,-18,38,8,-10,25,34,-11,60,-45,1,25,-13,-8,3,-39,-8,-4,63,-29,-32,-10,8,29,-16,-38,15,0,-3,21,-15,-26,5,10,26,8,40,41,-49,-12,-2,36,49,30,-1,-66,20,-17,-54,20,54,35,22,-33,-50,-28,7,79,31,48,-10,41,-49,15,-16,23,36,-22,-17,26,-91,-51,-39,-3,28,-51,-35,-76,-26,37,-22,12,-38,8,49,-9,26,-60,61,-5,22,-22,-30,60,-23,24,0,-24,20,-14,-13,-47,23,41,8,-4,-22,30,27,-46,10,3,-3,-26,-69,18,4,11,19,-20,49,30,48,23,6,60,26,-74,26,-31,-22,21,31,9,-2,-2,7,18,-5]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.169","t":"summary of the previous session, reviewing the homework that was assigned during the previous session, setting a prioritized agenda of topics to be discussed during the session, assigning homework, conducting periodic summaries, and obtaining feedback during and at the end of each session. The treatment uses a collaborative approach to identifying treatment goals, agendas, specific cognitive and behavioral strategies, and homework assignments.","e":[70,-16,-145,-44,49,-25,48,-27,17,14,-7,-12,81,84,-3,-71,-7,-38,-33,34,-11,-22,-30,-11,12,54,-27,-21,-10,1,16,3,3,-26,-31,-52,83,10,-42,-34,8,17,0,-92,46,-26,56,-31,24,-6,30,-26,-35,-15,85,36,4,19,60,-27,148,61,-67,65,49,-30,-33,58,-40,1,34,19,86,3,-60,-21,-9,-17,4,19,39,-33,76,-37,46,33,-20,13,-51,94,-7,6,15,18,-85,22,-9,3,-55,-40,-74,-6,37,-40,54,49,6,20,-16,11,-53,38,-35,15,22,-2,86,-30,20,40,-23,-67,-5,23,-4,69,-56,-34,20,2,-27,-25,-25,42,16,65,-45,-20,-5,-13,60,-19,-29,43,-10,-2,23,-26,-32,7,13,32,13,13,38,-42,-40,2,22,24,68,-14,-42,61,-34,-20,7,41,34,37,-45,-47,5,15,78,57,65,-17,15,4,33,-42,40,23,-3,-18,24,-15,-55,-31,5,47,17,-32,-68,-45,25,-33,17,-54,-27,23,-66,52,-33,76,-10,-9,-14,-7,53,6,16,32,-26,15,-30,-29,-40,33,-12,-39,11,-26,45,25,-55,15,-29,34,-33,-94,11,-2,30,13,4,33,0,89,-45,32,45,-25,-84,48,32,-41,-29,43,30,14,1,9,16,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.169","t":"The application of CBT also includes an initial phase, a middle phase, and an ending phase. During the initial phase, the therapist identifies the patient’s motivation and expectations for treatment. Educating Veterans about the structure and general approach used in CBT and addressing any negative expectations for treatment helps increase the likelihood that treatment will be successful. Identifying specific treatment goals in behavioral terms and obtaining feedback on the helpfulness of treatment also helps the patient succeed in therapy.","e":[4,-10,-159,-46,67,-20,42,-18,48,-14,-16,15,62,16,22,-66,5,-64,-21,9,-59,-31,-38,-41,-2,61,-48,41,-15,13,64,6,39,-35,-39,-51,26,19,-53,-21,53,-15,18,-62,7,-24,72,37,-2,9,37,-46,-7,-35,108,20,-17,26,8,-59,104,57,-76,89,47,-32,-43,30,-42,-27,44,-5,42,27,-38,9,-45,-25,-31,43,43,-27,46,-50,42,21,9,7,-38,69,-17,39,-11,31,-104,7,-30,0,-5,-44,-46,-29,19,-42,0,53,16,-28,4,-13,-95,38,-38,10,-18,24,76,-20,20,28,20,-1,-3,6,-1,68,-61,-47,17,-5,4,-12,-1,-13,24,53,1,-20,7,17,41,-24,2,20,-5,-4,13,-17,-33,0,-11,38,34,20,54,-61,-18,-4,39,29,48,1,-24,37,-28,-66,1,10,49,16,-10,-54,-23,11,98,33,68,-2,23,-1,23,-29,18,56,5,-20,28,-19,-74,-50,27,47,-57,-6,-91,-20,28,-16,10,-42,6,35,-38,32,-60,57,-11,17,-35,-20,60,-22,-11,29,-56,6,19,-9,-29,39,39,-5,-1,-24,0,23,-40,-8,-7,-1,-13,-75,45,9,21,7,-4,14,30,64,-5,31,51,22,-105,26,17,-59,0,33,4,31,6,4,26,-22]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.169","t":"On the basis of the CBT case conceptualization, the therapist and patient collaboratively choose specific behavioral and cognitive strategies that are most likely to be successful in addressing the patient’s key automatic thoughts, beliefs, or behaviors. Behavioral strategies include Activity Monitoring, Activity Scheduling, behavioral activation, graded task assignments, and relaxation and breathing strategies. Cognitive strategies include identifying and evaluating key automatic thoughts using Socratic questioning, Thought Records, and/or coping cards. Core beliefs are addressed using the downward arrow technique, understanding the benefits and costs associated with such beliefs, and using reframing strategies to adopt more helpful beliefs. CBT focuses on resolving a patient’s current problems and aims to teach effective problems-solving skills.","e":[43,10,-142,-36,76,-19,74,-30,36,5,1,-14,72,36,-7,-30,-18,-40,-24,30,-36,-10,-22,0,11,52,-39,47,-22,4,48,-15,3,-39,-61,-41,68,-8,-37,-3,52,-11,41,-100,29,-9,81,2,8,18,37,-74,27,-63,117,32,2,83,-21,-61,110,53,-54,39,39,-38,-61,77,-50,5,55,-15,43,26,-50,5,-42,5,32,49,66,-84,61,-41,81,18,1,23,-31,83,-7,1,28,36,-79,37,-29,-32,-29,-20,-81,-17,-6,1,-7,50,-22,-16,-22,50,-68,26,-23,7,-16,21,72,-36,28,25,33,9,-5,21,17,96,-90,-40,39,-20,-13,-42,-24,1,-8,34,9,-19,7,23,44,-6,0,36,2,-37,-21,-55,-34,20,14,12,16,17,67,-48,-32,31,37,27,40,-9,-33,46,-20,-30,32,45,33,30,-44,-76,-15,11,104,32,67,-26,6,-25,9,-1,14,58,16,-18,20,-20,-28,-53,41,24,-59,-5,-103,-65,35,4,30,-49,-19,11,-24,32,-46,57,0,-18,-27,-33,56,6,-14,41,-37,24,-10,-29,-43,4,20,-18,-30,3,-9,10,-50,12,12,9,-22,-75,30,-3,40,34,-26,22,33,54,0,59,29,21,-75,29,-8,-29,-14,49,6,54,-11,-27,59,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.169","t":"During the later phase of treatment, the CBT therapist and her patient review progress toward the treatment goals established during the initial phase of treatment, summarize and consolidate the skills learned during the middle phase of treatment, and plan for the continuation or termination of treatment. We hope this manual will be helpful to clinicians new to CBT, as well as to those who are interested in enhancing their CBT skills. Although the primary aim of this manual has focused on the treatment of depression, it is our expectation that the core CBT competencies described in this manual can be adapted and applied to treat other mental health and behavioral health conditions.","e":[19,-7,-139,-44,50,-10,52,-3,33,-31,-25,12,57,-17,27,-49,-15,-45,-17,28,-38,-16,-34,-27,-6,68,-21,22,-22,14,41,11,20,-38,-33,-48,66,12,-36,-31,52,-4,2,-122,8,-38,80,18,-13,-20,53,-30,4,-56,130,24,-18,25,0,-81,122,65,-62,93,51,-52,-52,24,-66,-3,53,19,43,47,-26,-20,-27,-22,-11,20,16,-26,42,-38,35,17,-33,1,-43,65,13,24,8,35,-110,9,-26,-13,8,-42,-68,-19,51,-9,29,63,-6,-40,-9,-5,-61,23,-29,0,-28,31,50,-18,16,46,19,-5,12,24,8,82,-48,-15,47,13,-12,-6,-11,7,-1,74,-10,-21,-1,23,25,-22,1,31,22,-17,27,-11,-35,29,-13,8,27,13,51,-34,-13,4,53,5,52,18,-35,43,-6,-32,-5,-7,41,38,-27,-50,-35,14,108,49,75,10,-11,-54,25,-33,17,52,6,-5,15,-44,-50,-48,21,52,-44,-10,-88,-37,37,-19,5,-50,-23,44,-49,32,-78,65,-1,9,-19,-20,43,-10,25,36,-45,3,-21,-9,-38,25,13,16,-27,-12,12,13,-46,-3,14,12,-11,-82,26,0,14,23,-1,25,6,80,-9,34,58,10,-74,30,2,-26,15,64,12,28,5,28,47,-43]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.169","t":"Although CBT has been used for decades with mental health patients, it is now being implemented more systematically (along with other evidence-based treatments) in VA facilities as well as other clinics, hospitals, and practices across the country. Countless patients have expressed the gratitude for the opportunity to receive CBT, many observing that, for the first time in their lives, they have developed strategies and tools for managing their mood, solving their life problems, and enhancing quality of life. Use of an active, structured treatment approach such as CBT allows for the efficient treatment of patients, which not only helps patients to see change in their lives rather quickly, but also allows therapists to see more patients because the course of treatment is time-limited. As a result, therapists and patients, alike, develop a renewed sense of hope and optimism for treatment success.","e":[23,4,-162,-58,72,-43,23,39,67,-9,-7,-2,49,-14,-9,-54,-29,-36,-40,11,-59,-17,1,-55,-14,45,-36,73,5,17,76,-10,34,-39,-30,-31,44,28,20,-15,66,17,6,-98,8,-37,100,8,5,-22,1,-59,6,-25,153,4,-41,50,-6,-65,94,54,-30,42,61,-14,-51,28,-29,5,48,-27,55,23,-35,4,-62,-30,-26,31,72,-56,27,-73,67,2,21,19,-12,58,15,10,-14,49,-117,-10,-35,-38,-22,-20,-72,-19,17,-6,8,43,-7,-15,-30,6,-67,30,-5,-3,-21,21,46,-36,5,16,27,14,-5,14,-2,62,-61,-33,50,-5,-27,17,-20,-18,1,64,-2,-25,1,31,41,-30,-7,55,12,-5,-20,-31,-45,13,-5,48,32,30,27,-42,-5,22,38,18,34,20,-44,2,-10,-50,9,34,26,25,-42,-38,-15,15,111,-12,80,-21,16,-46,18,-35,23,24,4,36,11,-57,-30,-64,17,35,-51,29,-80,0,36,-8,13,-30,-26,48,-18,35,-45,68,-2,-18,-22,-33,73,-1,0,24,-59,17,-21,-39,-57,37,37,-10,14,-19,29,3,-66,-19,16,13,-11,-50,33,6,5,37,-20,7,13,64,25,39,27,35,-56,-3,-9,-41,-7,34,-10,13,2,-10,40,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.173","t":"Addis, M. E., & Martell, C. R. (2004). Overcoming depression one step at a time: The new behavioral activation approach to getting your life back. Oakland, CA: New Harbinger. American Psychiatric Association. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. Arlington, VA: Author. Basco, M. R., & Rush, A. J. (1996). Cognitive-behavioral therapy for bipolar disorder. New York, NY: Guilford Press. Beck, A. T. (1967). Depression: Causes and treatment. Philadelphia, PA: University of Pennsylvania Press. Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York, NY: Basic Books. Beck, A. T., Freeman, A., Davis, D. D., & Associates. (2004). Cognitive therapy for personality disorders (2nd Ed.). New York, NY: Guilford Press. Beck, A. T., Rector, N. A., Stolar, N., & Grant, P. (2009). Schizophrenia: Cognitive theory, research, and therapy. New York, NY: Guilford Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. Dallas, TX: The Psychological Corporation. Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York, NY: Guilford Press. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press. Beck, J. S. (2005). Cognitive therapy for challenging problems: What to do when the basics don’t work. New York, NY: Guilford Press. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. Bouton, M., Mineka, S., & Barlow, D. H. (2001). A contemporary learning theory perspective on the etiology of panic disorder. Psychological Review, 108, 4–42. Burns, D. D. (1980). Feeling good: The new mood therapy. New York, NY: Nal Penguin. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31. Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory and therapy of depression. New York, NY: Wiley. Craigie, M. A., & Nathan, P. (2009). A nonrandomized effectiveness comparison of broad- spectrum group CBT to individual CBT for depressed outpatients in a community mental health setting. Behavior Therapy, 40, 302–314. DeRubeis, R. J., Hollon, S. D., Amsterdam, J. D., Shelton, R. C., Young, P. R., Salomon, R. M., …Gallop, R. (2005). Cognitive therapy vs. medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62, 409–416. Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F., …Parloff, M. B. (1989). 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Long Island City, NY: The Hatherleigh Company.","e":[34,30,-138,-22,56,-3,50,-3,0,16,-20,1,79,19,1,-54,-17,-12,-43,7,-38,-18,-40,-38,16,55,-46,8,-80,-10,24,-3,-10,-30,-45,-11,73,58,27,17,37,9,22,-75,-25,-36,76,11,12,-18,24,-39,63,-60,82,-4,-22,42,-25,-37,95,60,-22,18,53,-4,-40,68,-21,-30,86,-7,22,44,-55,0,-31,-62,8,3,65,-9,52,-99,47,-26,-42,10,-19,22,16,32,-9,63,-29,15,-32,-71,-37,-48,-53,-19,36,6,50,24,-2,-49,-44,42,-45,62,30,-37,0,-10,39,-18,-10,40,4,-11,3,6,-3,-9,-14,7,-3,1,-25,-16,-40,33,-7,20,14,-1,7,-16,41,-9,-29,24,7,-10,-4,4,-44,11,9,25,18,28,18,-71,-16,20,23,26,40,30,-34,83,22,-29,1,25,47,56,-74,-63,11,-15,63,28,78,-19,48,-63,71,-15,48,29,-5,2,-7,-7,-49,-32,0,27,-50,21,-51,-35,57,-44,49,-20,-23,58,-24,18,-39,80,13,-7,13,-22,13,-40,21,9,-19,6,-42,-32,-16,-28,-10,22,-3,11,19,20,-65,8,16,40,-62,-57,33,-43,4,31,-25,28,7,91,3,44,-5,16,-62,5,-43,26,2,33,4,24,-1,11,71,18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.174","t":"Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the Working Alliance Inventory. Psychotherapy Research, 16, 12–25. Heimberg, R. G., & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York, NY: Guilford Press. Hirsch, C., Jolley, S., & Williams, R. (2000). A study of outcome in a clinical psychology service and preliminary evaluation of cognitive-behavioral therapy in real practice. Journal of Mental Health, 9, 537–549. Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. Annual Review of Psychology, 57, 285–315. Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. Karlin, B. E. (2009). Dissemination of evidence-based psychotherapy in a health care system: National strategy and initial evaluation outcomes. Plenary presentation at the Department of Veterans Affairs National Mental Health Conference. Baltimore, MD. Karlin, B. E. (2011). Cognitive behavioral therapy with older adults. In K. H. Sorocco & S. Lauderdale, (Eds.), Cognitive behavioral therapy with older adults: Innovations across care settings (pp. 1-28). New York: Springer Publishing Company. Karlin, B. E., Meuller, L., Adler, L., Beaudreau, S., Kauth, M. R., Kuhn, E., …Walser, R. D. (2009). Department of Veterans Affairs: Bibliotherapy resource guide. Washington, DC: Department of Veterans Affairs. Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., Resick, P. A., & Foa, E. B. (2010). Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23, 663-73. Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working efficiently with clients in cognitive-behavioral therapy. New York, NY: Guilford Press. Layden, M. A., Newman, C. F., Freeman, A., & Morse, S. B. (1993). Cognitive therapy of borderline personality disorder. Boston, MA: Allyn and Bacon. Lewinsohn, P. M., Sullivan, J. M., & Grosscup, S. J. (1980). Changing reinforcing events: An approach to the treatment of depression. Psychotherapy: Theory, Research, and Practice, 17, 322–334. MacPhillamy, D. J., & Lewinsohn, P. M. (1982). The Pleasant Events Schedule: Studies on reliability, validity, and scale intercorrelations. Journal of Consulting and Clinical Psychology, 50, 363–380. McQuaid, J. R., Granholm, E., McClure, F. S., Roepke, S., Pedrelli, P., Patterson, T. L., & Jeste, D. V. (2000). Development of an integrated cognitive-behavioral and social skills training intervention for older patients with schizophrenia. Journal of Psychotherapy Practice and Research, 9, 149–156. Meyer, B., Pilkonis, P. A., Krupnick, J. L., Egan, M. K., Simmens, S. M., & Sotsky, S. M. (2002). Treatment expectancies, patient alliance, and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 70, 1051–1055. Mineka, S., & Zinbarg, R. (2006). A contemporary learning theory perspective on the etiology of anxiety disorders: It’s not what you thought it was. American Psychologist, 61, 10–26. Persons, J. B. (2006). Case formulation-driven psychotherapy. Clinical Psychology: Science and Practice, 13, 167–170.","e":[16,30,-157,-34,48,13,26,3,32,21,-2,-25,50,13,17,-39,8,-11,-38,1,-67,-31,-21,-29,28,74,-57,10,-74,1,45,35,-23,-14,-58,-12,82,25,40,-3,44,47,29,-81,-19,-30,72,4,31,31,19,-17,75,-31,69,-46,-20,37,-9,-43,72,36,-70,23,71,-3,-44,75,-33,-42,45,-1,53,42,-60,17,-14,-47,14,25,71,-10,34,-67,52,-34,-35,-5,-16,61,5,60,-51,42,-40,30,-38,-67,-71,-6,-59,-6,23,-1,-9,-24,-7,-36,-36,43,-86,71,-5,15,14,-48,37,-32,1,4,9,-17,-14,17,28,20,-79,-2,-13,-19,-19,10,-26,32,-11,42,-12,20,17,2,45,9,0,10,23,-24,-5,-16,-46,12,-25,51,3,25,-22,-55,-43,-11,51,52,45,8,9,45,5,-48,36,16,33,47,-81,-52,9,-3,35,25,73,-16,39,14,63,-34,70,19,-3,-7,23,-12,-73,-43,14,28,-89,-8,-64,-63,57,-51,52,-59,-30,33,-33,42,-27,69,-10,0,-21,-38,24,-38,24,39,-28,-6,-11,-27,-31,19,6,14,2,5,18,25,-52,15,21,45,-32,-85,16,-25,-1,9,-5,46,20,53,-10,38,-1,42,-54,40,-32,-19,22,26,0,35,13,19,43,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.175","t":"Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325–334. Shapiro, A. K., & Shapiro, E. (1997). The powerful placebo: From ancient priest to modern physician. Baltimore, MD: Johns Hopkins University Press. Stanley, B. & Brown, G. K. (with Karlin, B., Kemp, J. E., & VonBergen, H. A.) (2008). Safety plan treatment manual to reduce suicide risk: Veteran version. Washington, DC: U.S. Department of Veterans Affairs. Retrieved from http://www.mentalhealth.va.gov/College/docs/VA_Safety_planning_manual.doc. U. S. Department of Veterans Affairs (2010). Cognitive behavioral therapy with depressed Veterans: Therapist training video [DVD]. St. Louis, MO: Employee Education Service. Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. Washington, DC: APA Books. Wenzel, A., Jeglic, E. L., Levy-Mack, H., Beck, A. T., & Brown, G. K. (2008). Treatment attitude and therapy outcome in patients with borderline personality disorder. Journal of Cognitive Psychotherapy, 22(3), 250–257. Williams, J. M. G., Barnhoffer, T., Crane, C., & Duggan, D. S. (2006). The role of overgeneral memory in suicidality. In T. E. Ellis (Ed.), Cognition and suicide: Theory, research, and therapy (pp. 173–192). Washington, DC: APA Books. Wright, J. H., Basco, M. R., & Thase, M. E. (2006). Learning cognitive behavioral therapy: An illustrated guide. Washington, DC: American Psychiatric Publishing, Inc. Zanjani, F., Miller, B., Turiano, N., Ross, J., & Oslin, D. (2008). Effectiveness of telephone- based referral care management: A brief intervention to improve psychiatric treatment engagement. Psychiatric Services, 59, 776–781.","e":[24,32,-162,-44,76,6,44,-4,7,11,-30,-29,42,37,-5,-45,17,-37,-25,42,-72,-59,-21,-36,28,50,-48,22,-37,12,21,30,-43,-26,-84,-24,74,49,11,1,18,11,37,-74,-28,-11,72,-9,23,-40,-12,-46,46,-51,68,-26,7,32,-21,-44,91,53,-32,23,79,-17,-56,63,-57,-31,54,2,0,29,-47,34,-41,-22,0,13,43,-17,61,-63,31,19,3,36,-23,69,-16,29,0,63,-54,12,-26,-53,-31,-29,-86,-43,-5,-4,30,36,21,-43,-11,60,-36,48,-27,0,5,10,49,-47,32,43,-6,-11,17,28,-26,37,-29,-20,-44,20,3,-40,-63,7,-3,50,-21,-10,17,5,52,-32,1,0,-3,-37,-20,0,-38,-10,14,30,61,-26,25,-55,-74,-20,48,43,53,51,-72,50,23,-39,9,5,33,5,-37,-56,27,-23,86,-20,62,-8,50,-39,81,-32,58,22,-13,1,4,8,-68,-42,5,35,-39,-10,-77,-35,82,-35,66,-38,-41,43,-38,37,-41,73,-30,14,-50,-13,33,-3,28,21,-32,-7,-17,-29,-42,13,5,-4,11,6,6,3,-12,8,18,17,-65,-78,26,-4,17,31,11,44,16,54,-3,30,19,31,-48,0,-29,-24,30,16,0,4,4,10,41,3]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.179","t":"3Cs Approach: A simple mnemonic acronym—Catch It, Check It, Change It—developed to help patients understand and use cognitive restructuring. Activity Monitoring: The recording of behaviors by the patient that include ratings of mastery, pleasure, and mood. Activity Scheduling: Identifying activities that provide a sense of pleasure and/or accomplishment and choosing a specific point in time to do the activity. Agenda setting: A collaborative process between the therapist and patient in which they identify and prioritize the topics or issues to be addressed during the therapy session. Alternative response: An adaptive response developed to counter or modify an automatic thought after evaluation of the thought indicates that it is maladaptive or unhelpful. Automatic thoughts: Evaluative thoughts that arise in response to particular situations or events. Basic cognitive model: A model in which Activating events (“A”) influence automatic thoughts or Beliefs (“B”), which influence an emotional, physiological, or behavioral Consequence (“C”). Beck Depression Inventory-II (BDI): A 21-item self-report instrument developed to measure severity of depression in adults and older adults in the preceding two weeks and is used to gauge progress and assist in treatment planning. Behavioral activation: An approach to treating depression based on Lewinsohn’s behavioral model of depression, whereby the therapist encourages patients to identify and implement one or two actions that can make a difference in how they feel. Behavioral experiment: An agreed-upon protocol whereby a patient tests a prediction by trying out something and evaluating the outcome based on the “data” she has collected. Behavioral theory: A theory that postulates that a lack of positive reinforcement or aversive experiences influences depressive symptoms. Bibliotherapy: A homework assignment that usually consists of recommendations by the therapist for the patient to read published information such as self-help therapy workbooks or Web-based materials. Booster sessions: Therapy sessions scheduled as needed by the patient during the final phase of treatment and scheduled in response to the emergence of suicide ideation, an exacerbation of life stress, or a worsening of factors that initially brought the patient into treatment. Bridge from the previous session: A brief summary provided by the therapist or patient to ensure that the patient recalls the work completed in the previous session and to follow up on relevant issues as well as to identify any negative reactions that the patient might have had to the previous session. Brief mood check: An assessment of the patient’s mood since the previous session for the purpose of tracking progress. Case conceptualization: Individualized formulation of the patient’s presenting problems in order to guide treatment planning and intervention.","e":[53,18,-159,-104,56,-2,97,-14,17,-2,-4,9,109,0,2,-49,-8,-35,-53,20,-22,-32,-42,-17,12,65,-3,-1,-48,6,36,1,8,-14,-72,-27,57,78,-31,5,-4,31,12,-73,0,-43,93,-10,22,-2,12,-68,19,-6,115,21,7,39,-1,-47,95,52,-23,21,61,-32,-32,68,-28,-37,55,9,24,37,-36,8,-30,-24,30,9,40,-26,65,-38,76,9,-9,6,-20,65,-41,41,15,15,-103,21,-3,-25,-54,-28,-64,-17,-2,-40,-9,59,-6,-10,15,11,-47,50,-6,-27,13,-9,64,-18,28,32,30,0,-2,20,22,53,-73,-10,8,7,-2,-6,-24,11,7,55,15,-49,-12,27,35,-17,-19,39,-4,14,13,-39,-31,10,11,19,3,-8,48,-48,-45,12,30,39,44,15,-52,71,-29,-41,34,33,32,10,-63,-70,-11,-23,57,37,74,-35,11,-32,22,-33,47,12,-19,-8,25,-17,-30,-29,14,35,-10,-20,-93,-38,24,-28,54,-33,4,33,-27,15,-46,69,22,17,-7,8,48,5,28,23,-14,24,-6,-10,-23,-17,11,-25,9,-18,20,17,-60,-6,4,28,-39,-68,33,-16,41,32,-21,-4,-1,67,7,48,38,11,-85,13,5,-16,-15,17,-13,45,-6,-27,57,-2]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.180","t":"CBT session structure: The format of therapy sessions that often includes a mood check, bridge from the previous session, prioritized agenda, review of previous session homework, discussion of agenda items, periodic summaries, homework assignment, final summary, and session feedback. Cognitions: Thoughts or images including both automatic thoughts and goal-directed thoughts. Cognitive behavioral theory: A theory that postulates that emotional experiences are influenced by our thoughts and behaviors; extreme patterns of thinking and behavior are associated with mental health problems. Cognitive Behavioral Therapy: A structured, time-limited, present-focused approach to psychotherapy that helps patients develop strategies to modify dysfunctional thinking patterns or cognitions and maladaptive emotions and behaviors in order to assist them in resolving current problems. Cognitive distortion: A particular style of interpreting events and situations; also called a cognitive error. Mind reading, all-or-nothing thinking, and overgeneralization are types of cognitive distortions. Cognitive restructuring: A process whereby patients (a) identify unhelpful thoughts, beliefs, and images; (b) distance themselves from unhelpful cognitions before they act upon them; (c) evaluate the veracity of those cognitions; and, if necessary, (d) develop alternative cognitions that more realistically characterize the situation at hand. Cognitive theory: A theory that postulates that thought content and styles of information processing are associated with our mood, physiological responses, and behaviors. Compensatory strategies: Behavioral strategies that support or maintain core beliefs. Conditional assumptions: Rules or intermediate beliefs that are related to core beliefs. Coping cards: Small cards that include brief cognitive or behavioral strategies that are easily accessible. Coping cards may include automatic thoughts that are often experienced by the patient as well as adaptive responses. Core beliefs: Rigid and persistent beliefs that people have about themselves, the world, and/or the future. Dysfunctional thinking patterns: Unhelpful or maladaptive cognitions. Empirical approach: An approach whereby hypotheses are generated about the cognitive, emotional, behavioral, and situational factors that contribute to, maintain, and exacerbate a patient’s mental health problems. Feedback: The process of asking patients whether a specific intervention or session was helpful or how it was helpful; asking patients questions to ensure that they understand the therapist’s line of reasoning. Final summary: A review or recap of the most important issues addressed during the session by the therapist or patient; typically occurs at the end of the session. Graded task assignment: A technique for simplifying complicated behavioral tasks into smaller parts or steps. Guided discovery: The process of using Socratic questioning to guide patients to make discoveries on their own; usually more effective than directly lecturing or educating patients.","e":[49,25,-141,-98,58,-27,74,-20,25,-22,21,-4,54,35,14,-67,-31,-29,-20,26,-59,4,-8,-8,-3,87,-50,33,-18,-15,33,-28,13,-21,-72,-31,81,38,-15,-7,25,-1,12,-111,-1,-21,98,4,2,4,9,-48,36,-47,135,26,18,73,-5,-57,101,42,-52,56,29,-38,-70,67,-30,-14,60,-7,11,40,-39,-14,-41,-7,-7,32,45,-43,57,-28,70,8,-9,19,0,74,-28,-28,8,25,-71,17,-33,-40,-38,-20,-84,-17,6,-30,-6,61,-42,-13,-2,28,-79,35,-19,13,-16,-7,60,-11,34,34,34,-6,-6,34,9,96,-73,-18,37,-13,-2,-26,-1,13,8,48,8,-26,-2,36,36,-22,0,14,20,-27,23,-39,-26,-2,16,12,2,31,53,-26,-25,14,48,41,42,36,-63,33,-33,-49,17,48,27,18,-50,-51,5,21,71,52,76,-20,15,-22,9,13,38,25,14,-14,30,-24,-6,-44,36,26,-46,-9,-92,-74,26,-19,42,-42,-5,32,-36,29,-37,65,-30,8,-45,-24,56,-4,3,29,-33,6,-2,-33,-40,13,43,-19,-1,-4,2,15,-18,-2,16,36,-65,-65,33,-3,33,47,-3,6,21,75,28,54,35,13,-86,1,9,-45,-2,30,-7,25,5,-20,46,13]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.181","t":"Homework assignment: An agreed-upon assignment serving as an opportunity for patients to practice their cognitive and behavioral skills in their own environment. Intermediate beliefs: Inflexible and absolute rules and assumptions about the way the world operates. ITCH: A simple mnemonic acronym developed to help patients learn problem-solving skills. ITCH stands for (1) Identify the problem; (2) Think about possible solutions; (3) Choose a solution to implement; (4) How well does it work? Mastery rating: The degree of mastery or sense of accomplishment a patient received from an activity rated on a scale from 0 to 10. Mastery: A sense of accomplishment. Motivational enhancement: A process that uses some aspects of motivational interviewing to help patients commit to the therapy process and to making changes in their lives. Motivational interviewing: A directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve their ambivalence about treatment. Negative cognitive triad: Negative or pessimistic thoughts and beliefs that depressed patients have about themselves, the world, and/or the future. Periodic summaries: Brief recaps of the issues discussed in session that typically occur at the close of discussion of an agenda item. Summaries aim to ensure that the therapist and patient have a mutual understanding of the nature of the problem being discussed as well as the identified solutions. Pleasant Events Schedule: A checklist of potential activities that involves ratings of the frequency and pleasantness of the activities. Pleasure rating: The degree of pleasure or enjoyment a patient experiences during an activity rated on a scale from 0 to 10. Progressive muscle relaxation: A relaxation technique involving the systematic tensing and relaxing of the muscle groups in the body. Punishment: Person–environment interactions associated with negative outcomes and/or emotional distress. Response-contingent positive reinforcement: Person–environment interactions associated with positive outcomes or that make a person feel good. Runaway train effect: A cascade of thoughts where depressed and anxious patients report that one thought prompts another thought, which prompts another thought, which prompts yet another thought, etc., with each thought being more negative and distorted than the previous one. Safety plan: A prioritized written list of coping strategies and sources of support that patients can use during or preceding suicidal crises. Schemas: “Relatively enduring internal structures of stored generic or prototypical features of stimuli, ideas, or experience that are used to organize new information in a meaningful way, thereby determining how phenomena are perceived and conceptualized” (Clark & Beck, 1999, p. 79). Self-concept: A belief about oneself.","e":[56,30,-166,-73,65,-3,44,-8,7,-4,-15,-2,63,24,2,-26,7,-34,-25,53,-45,-34,-29,-6,-5,74,-25,-37,-41,4,-4,-23,-7,-25,-80,0,83,73,9,-14,11,-13,19,-97,8,-19,55,-29,31,-11,6,-87,26,-12,112,27,31,29,20,-26,89,45,-42,57,56,-20,-46,63,-35,-4,51,6,10,38,-64,7,-31,-8,25,15,36,-37,47,-23,69,9,-15,22,-16,81,-24,25,9,3,-101,26,-4,-7,-45,-38,-64,-36,21,-42,26,61,4,-25,-1,26,-34,52,-49,-22,36,-14,67,-26,30,25,16,-7,0,46,12,70,-40,-37,5,13,-7,-29,-46,27,-3,58,8,-48,-11,3,57,-27,-26,18,-7,-17,7,-12,-41,14,4,4,28,-26,46,-42,-40,-11,53,37,48,38,-47,61,-7,-31,15,38,30,34,-26,-68,23,3,68,20,103,-18,2,-28,46,-36,63,7,2,-13,31,-28,-51,-25,40,19,-15,-26,-85,-70,27,-13,47,-67,-14,33,-34,27,-56,67,-16,7,-8,1,40,-31,26,50,-38,-19,-13,-24,-37,-17,38,-27,-12,-6,24,16,-39,-6,-22,32,-41,-82,49,-12,37,18,10,21,13,81,0,18,25,18,-93,26,-9,-32,-5,26,11,20,-4,12,25,-15]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.182","t":"Socratic questioning: A therapeutic method to help patients evaluate their automatic thoughts whereby the therapist asks questions that stimulate critical thinking and accurate examination of the patient’s cognitions. Suicide risk assessment: An evaluation of the risk and protective factors for suicide that involves the determination of whether or not a patient is imminently or likely to be dangerous to himself. Target complaints: Primary problems that led the patient to seek treatment. Thought Record: A form for patients to record descriptions of situations, their emotions, and their automatic thoughts associated with a shift in affect (three-column) or a form for patients to record descriptions of situations, their emotions, their automatic thoughts, adaptive responses, and outcomes (five-column). Vivid images: Nonverbal thoughts and pictorial images in response to particular situations or events. Working Alliance Inventory (WAI): A brief measure for inquiring about the therapeutic alliance derived from Bordin’s (1979) theory of change-inducing relationships, which has as key components of the working alliance (a) agreement on the treatment goals, (b) agreement on how to achieve the goals (task agreement), and (c) development of a personal bond between patient and the therapist.","e":[68,21,-157,-87,68,-21,46,-23,39,43,15,-7,81,15,-8,-66,26,-59,-44,19,-89,-30,-51,16,58,44,-24,2,-39,8,22,9,23,6,-52,-60,95,43,-4,-10,-9,-53,20,-102,41,-29,56,-37,43,-38,13,-63,-2,-2,73,38,32,67,-44,-17,37,20,-34,8,86,-6,-36,24,-20,10,62,6,54,43,-47,17,-25,9,8,15,49,-65,62,-20,50,54,-13,-2,-15,65,-7,4,15,27,-109,35,-41,-36,-41,-2,-87,-26,4,-23,15,17,-11,7,-6,18,-27,44,-45,-23,24,-41,56,-27,45,-1,-3,44,-4,68,-7,43,-37,31,4,-9,15,-50,-45,13,-11,66,-3,-42,-9,5,69,0,-10,3,3,-43,12,-20,-56,-22,-10,30,-33,21,-1,-45,-33,31,45,31,35,14,-46,53,-19,-22,24,7,21,30,-41,-90,16,6,70,23,81,-56,21,-7,15,-28,53,-20,-5,-32,46,-28,-12,-54,12,20,-24,-29,-70,-51,42,-20,34,-44,-11,33,-79,46,-43,72,-32,-27,-20,-29,74,-38,12,24,-34,5,29,-17,-14,1,23,-34,-28,0,-3,18,-74,-4,17,34,-73,-75,30,11,7,17,8,47,21,32,5,26,-4,23,-69,29,0,-48,8,10,-10,34,-7,-16,50,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.187","t":"ACTIVITY MONITORING FORM Instructions: Please list the activities you did on each day of the week, whatever it may have been. Below each activity, rate the degree of pleasure (P) and mastery/accomplishment (M) on a 0 - 10 scale for each, where 0 is no pleasure or mastery/accomplishment and 10 is the greatest degree of pleasure or mastery/accomplishment. Please also rate your over all mood for the entire day on a scale of 0 - 10, where 0 is feeling the wor st you could imagine feeling and 10 is feeling the best you could imagine feeling. Sunday Monday Tuesday Wednesday Thur sday Fr iday Satur day 8:00 A.M. 9:00 A.M. 10:00 A.M. 11:00 A.M. 12:00 P.M. 1:00 P.M. 2:00 P.M. 3:00 P.M. 4:00 P.M.","e":[16,11,-218,-40,28,-23,63,-55,58,-67,-20,27,43,47,6,-35,-6,-82,-62,21,-8,-39,-28,-11,49,59,-6,-71,-27,33,-41,11,-8,-33,-33,-43,19,66,-3,-12,51,-31,31,-23,55,-12,75,-3,51,0,-16,-48,18,-18,80,36,-20,-25,42,6,116,14,-31,78,46,-18,-23,50,-40,10,14,-43,14,34,-56,26,-4,-33,41,14,51,0,115,-9,64,-42,-20,18,-17,76,10,-12,49,5,-92,23,-19,44,-7,-2,-30,-1,-16,-24,44,37,6,-5,1,-4,-16,13,-5,14,9,-1,54,-43,-5,41,17,-12,-17,56,-12,25,-13,12,-2,-25,24,-34,-45,-2,6,89,-21,-30,6,-14,25,-27,-15,-5,-39,-41,34,-60,-5,38,18,18,28,10,15,-87,-62,12,49,14,46,11,-14,48,-18,-62,-3,51,5,14,-51,-59,-9,-50,0,-10,22,-14,58,-34,44,-26,37,-10,-20,-76,44,-39,-55,12,28,22,-29,-67,-72,-16,41,11,-2,-44,-37,-6,-19,-3,-44,61,14,37,-7,-5,37,-17,-32,26,-23,-15,4,-12,12,8,14,-27,5,-27,32,45,-29,4,-17,43,-4,-89,23,5,-2,31,-13,42,18,39,34,20,19,1,-76,23,-25,15,-9,50,2,36,29,22,74,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.189","t":"ACTIVITY SCHEDULE Instructions: This is your personalized activity schedule. For each day, circle those activities that you actually did (or write in whatever else you did if you did something else). Please also rate your over all mood for the entire day on a scale of 0 -10, where 0 is feeling the wor st you could imagine feeling and 10 is feeling the best you could imagine feeling. Sunday Monday Tuesday Wednesday Thur sday Fr iday Satur day 8:00 A.M. 9:00 A.M. 10:00 A.M. 11:00 A.M. 12:00 P.M. 1:00 P.M. 2:00 P.M. 3:00 P.M. 4:00 P.M. 5:00 P.M. 6:00 P.M. 7:00 P.M. 8:00 P.M. 9:00 P.M. Overall Mood (0 - 10)","e":[0,-1,-193,-35,-2,-42,76,-61,33,-76,-7,29,40,63,-13,-15,2,-34,-34,42,-11,-61,-37,-12,19,63,-15,-33,-61,17,-24,0,5,-38,-45,-33,3,43,10,-5,48,-3,28,-21,37,-43,82,17,23,-8,-17,-36,-4,-53,72,40,-16,-3,39,22,130,21,-45,74,39,2,-23,42,-37,-14,51,-35,5,22,-68,17,21,-23,66,27,40,-13,84,-33,58,-35,-6,-3,-18,85,-1,-12,35,34,-58,18,-22,56,-5,-39,-46,-1,-26,-30,16,12,-24,3,6,-16,-30,17,-9,3,10,32,81,-57,22,44,31,-16,6,17,-9,13,-21,11,-18,-23,28,-25,-63,22,-15,56,-3,-63,0,1,36,-6,-47,-14,-49,-25,9,-56,-4,29,29,-10,29,19,-3,-98,-31,44,59,31,60,16,-23,43,-46,-45,5,74,-3,32,-50,-49,-30,-34,25,3,45,-12,44,-27,49,-15,36,-21,-17,-85,56,-46,-61,-20,28,34,-13,-49,-61,-40,29,4,-13,-20,-17,0,-22,25,-39,93,28,20,8,-46,57,-6,-13,33,-14,-5,2,-15,-35,33,39,-12,-31,-24,39,35,-23,12,-7,43,4,-84,24,-4,11,52,-13,17,-4,10,34,48,56,-4,-83,-4,-20,0,-16,66,-23,27,22,12,65,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.200","t":"Feelings Sometimes when we have trouble identifying or naming our feelings, it is helpful to look at them in terms of basic and general categories such as mad, sad, glad, etc. and then begin to define them more specifically such as annoyed, defeated, eager… MAD GLAD SAD SCARED ASHAMED HURT","e":[25,34,-141,-71,73,14,-17,-19,36,-46,-29,23,60,46,6,-26,12,-22,5,74,-45,11,-32,-17,-9,17,-34,-8,-44,56,-18,-2,33,-42,-52,-45,26,36,67,33,69,-22,18,-55,15,-29,19,32,106,-20,54,-75,29,-53,75,19,42,19,39,-33,70,55,-67,41,74,3,-62,16,4,-31,98,3,32,64,-91,15,-21,-14,49,9,69,-32,76,-33,68,29,-46,33,-6,65,-33,-3,23,38,-84,29,-21,27,-57,-34,-20,-5,-17,-53,42,19,-8,3,-9,-10,-67,72,-17,-7,24,14,63,-45,18,61,2,61,-2,57,51,-3,1,-15,30,-28,-3,-65,33,21,-40,87,-12,-9,-13,28,80,-3,14,-32,19,-48,-24,-46,-38,27,38,10,20,-4,17,-55,-9,49,40,14,27,34,-31,65,-5,-33,2,31,36,5,-40,-34,-13,10,58,29,67,-1,8,-24,25,-52,70,0,-28,-55,39,-39,-40,-33,24,32,-27,-41,-56,-69,-1,10,16,-16,4,-5,-42,16,-58,34,9,12,2,8,65,-50,-31,44,-43,11,-6,-17,-16,1,-5,-16,-27,-11,37,20,-3,19,-19,-3,-10,-92,121,7,-6,11,-10,22,1,38,-23,24,51,28,-90,43,5,-15,24,45,-17,28,11,-2,63,3]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.217","t":"RELAXATION PRACTICE LOG Directions: Rate your level of tension from \"1,\" least tense to \"10,\" most tense before and after the relaxation exercise. Record the time of day that you did the exercise and some comments regarding the prior stressful situation and whether the relaxation helped you. Do this each day. DATE TIME RELAXATION SCORE COMMENTS Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10 Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10 Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10 Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10 Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10 Before: 1 2 3 4 5 6 7 8 9 10 After: 1 2 3 4 5 6 7 8 9 10","e":[32,16,-193,-30,22,-54,73,-24,18,-59,-65,13,13,24,18,-50,50,-107,2,-10,-28,-42,-42,-45,-5,80,1,0,-62,-4,39,15,-6,-27,-41,-61,28,33,-10,-24,94,-25,58,-29,44,-46,60,6,18,11,27,4,-31,-45,73,54,7,17,57,-20,114,1,-58,60,51,-26,-59,65,8,6,38,-10,12,15,-52,3,10,-18,13,2,23,11,77,-53,50,16,-3,-24,-10,90,24,-3,57,13,-54,26,-4,35,-35,-39,-39,-33,18,-8,-11,29,3,7,-20,-30,-56,29,5,24,6,24,67,-54,16,34,-3,1,-7,-2,11,19,-31,6,45,-27,-21,-5,-72,22,-35,105,-34,3,-6,-22,42,-38,-12,-41,-10,-41,28,-51,-8,56,12,-55,24,25,33,-50,-30,11,38,50,44,-35,-3,50,8,-45,7,41,32,13,-59,-67,13,-43,43,41,69,-36,22,-36,31,8,26,-2,-27,-56,39,-29,-62,-32,-5,15,-64,-33,-63,-64,63,-14,12,-17,-42,-25,-31,13,-64,47,-18,10,-23,-30,26,6,3,19,-40,-33,-5,-13,-28,46,16,-21,-14,15,24,5,-36,8,-8,28,-53,-78,-5,20,45,23,-4,30,2,23,-4,44,39,7,-57,33,-4,5,33,16,11,24,16,33,26,-38]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.219","t":"Reviewing CBT Sessions This form may be used by the clinician either during or following a therapy session in order to determine if the essential elements of CBT are covered in the session. Specific cognitive and behavioral strategies are listed on the back of the form that correspond to Item 13. 1. Did a brief mood check occur? 2. Was the BDI scored and reviewed? Was the patient suicidal or hopeless? If so, was a suicide risk assessment conducted? Was there a significant change in the depression score? If so, was this put on the agenda? 3. Was a medication check conducted (if taking medication)? If so, were the changes in medication noted? If so, were the last and next appointments with provider noted? 4. Was an alcohol and substance abuse check conducted (if indicated)? If so, were any changes in amount of alcohol or substance abuse noted? If so, were the last and next appointment with substance abuse counselor noted? 5. Was a brief summary of the last session conducted? Did a brief review of treatment goals occur? Was the patient asked about the most important issue that was discussed during the last session? 6. Did the therapist review the homework assignment from the last session? 7. Was a collaborative agenda established? Was the agenda prioritized? 8. Did the therapist listen and empathize with the patient’s concerns? Did the therapist summarize the patient’s concerns throughout the session? 9. Did the therapist have good interpersonal skills (such as warmth, concern, confidence, genuineness, and professionalism)? 10. Was the session reasonably paced by limiting peripheral and unproductive discussion? 11. Did the therapist use guided discovery to help the patient draw his/her own conclusions? Did the therapist limit the use of debate, persuasion, or lecturing? 12. Did the therapist focus on key thoughts, beliefs, or behaviors that were most relevant to the problem? 13. Did the therapist select a CBT strategy that offered some promise in helping the patient? Could the CBT strategy be clearly identified? (See next page) Did the therapist ask for feedback to determine if the strategy was successful? 14. Did the therapist skillfully implement the CBT strategy? 15 Did the therapist develop a homework assignment that was custom tailored to the patient’s concerns? Was the homework written down? Did the therapist ask the patient if he/she understood the rationale for the homework? Did the therapist ask the patient how likely he/she would complete the homework assignment? 16. Was a final summary of the therapy session conducted? 17. Did the therapist ask the patient for feedback about the session? Was the patient asked about the most helpful issue that was discussed?","e":[37,-2,-111,-69,57,-28,78,-19,41,-25,-15,-16,47,22,-1,-95,1,-56,-36,11,-59,-44,-65,-13,13,67,-46,43,-42,-17,58,-6,25,-40,-78,-17,88,38,-59,-19,89,7,-16,-112,9,-23,123,2,-24,-5,36,-13,26,-33,124,2,-21,38,7,-46,101,-6,-50,36,42,-53,-29,45,-53,-2,51,21,63,43,-54,13,-16,-19,-26,13,39,-18,44,-55,47,1,-17,28,-5,64,-3,5,20,30,-70,35,-18,-50,-35,-38,-71,-18,-11,-8,34,50,-21,-17,-18,-11,-73,-6,-26,23,4,36,68,-36,25,73,13,0,-13,-13,40,47,-88,-29,6,6,-18,-10,-8,15,-14,51,12,-7,3,-27,59,-14,-22,34,34,-14,20,-25,-39,17,29,-24,39,12,44,-54,-22,16,41,54,30,28,-44,61,13,-31,14,13,75,56,-33,-65,-2,-6,54,49,78,-18,5,-30,54,-8,25,19,20,-13,38,-47,-15,-26,22,47,-53,-4,-64,-51,42,-34,11,-33,-36,65,-32,48,-76,65,-13,-5,-35,-45,37,-5,14,42,-63,44,9,-23,-44,24,9,-22,-7,-18,14,43,-36,4,18,16,-38,-67,11,-29,-18,28,-21,8,4,58,2,42,64,-1,-96,14,-22,-19,40,55,19,32,25,38,25,4]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.222","t":"3-COLUMN THOUGHT RECORD DIRECTIONS: When you notice your mood getting worse, ask yourself, “What’s going through my mind right now?” and as soon as possible jot down the thought or mental image in the Automatic Thoughts column. DATE/TIME SITUATION EMOTION(S) AUTOMATIC THOUGHTS 1. Describe what happened. What were you 1. What emotion(s) (sad, anxious, angry, etc.) 1. What thoughts(s) and/or image(s) went doing at the time? did you feel at the time? through your mind? 2. What (if any) distressing physical sensations 2. How intense (0-100%) was the emotion? did you have?","e":[48,-28,-169,-64,67,7,65,-33,-17,-35,5,49,71,54,23,-32,22,-45,-7,53,8,-38,-72,-3,25,63,-45,-8,-61,33,24,-9,-21,-51,-74,-67,48,-4,32,8,88,-21,41,-69,43,-6,37,5,32,-23,10,-22,1,-41,101,29,56,42,38,13,88,12,-18,30,58,-31,-37,55,-11,-28,66,8,13,19,-44,11,-18,-19,55,55,52,-25,85,-51,63,12,12,17,-10,81,-19,-2,28,20,-75,33,-53,32,-33,-21,-63,-40,-23,-28,28,9,-24,11,-13,11,-28,58,-12,-4,9,-2,64,-18,23,51,29,61,-7,57,42,27,-7,12,2,-22,-22,-39,-8,29,-4,63,-11,-16,-5,22,96,-15,-26,-9,-47,-43,16,-54,-43,11,10,-18,-3,-8,48,-27,-38,27,35,18,54,14,-48,56,4,-37,30,45,19,27,-45,-42,0,-15,42,44,67,-35,61,-36,36,-45,28,-25,7,-72,3,3,-52,4,12,15,-56,-35,-86,-56,14,-12,18,-9,12,9,-41,53,-45,79,10,-2,-12,-41,76,8,-17,7,-45,14,13,-9,3,22,-9,2,2,-11,12,-1,-30,6,-3,13,-39,-86,45,-5,19,10,-30,38,12,32,-3,46,31,25,-83,11,28,-37,24,41,6,22,4,-19,43,-27]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.224","t":"DATE/ TIME SITUATION AUTOMATIC THOUGHT(S) EMOTION(S) ALTERNATIVE RESPONSE OUTCOME 1. What event, 1. What thought(s) and/or image(s) went through your mind? 1. What emotion(s) (sad, 1. (optional) What cognitive distortion did you 1. How much do you daydream, or 2. How much did you believe each one at the time? anxious, angry, etc.) did make? (e.g., all-or-nothing thinking, mind- now believe each recollection led to the you feel at the time? reading, catastrophizing) automatic thought? unpleasant emotion? 2. How intense (0-100%) 2. Use questions at bottom to compose a 2. What emotion(s) do 2. What (if any) was the emotion? response to the automatic thought(s). you feel now? How distressing physical 3. How much do you believe each response? intense (0-100%) is sensations did you the emotion? have? 3. What will or did you do?","e":[47,1,-160,-67,43,46,45,-26,29,-16,2,36,87,73,18,-29,11,-41,-14,57,-15,-37,-58,-5,17,26,-42,-7,-82,13,19,-18,6,-61,-69,-49,44,12,44,-9,67,-11,52,-45,45,1,37,6,37,-43,38,-36,8,-25,109,43,34,49,48,-12,84,16,-5,27,64,-18,-32,77,-9,-38,48,-6,-6,14,-43,11,-17,-26,28,70,64,-37,83,-56,57,-7,-17,18,0,96,-14,20,43,15,-81,30,-43,47,-53,-21,-61,-27,-2,-29,28,17,-2,5,-11,7,-53,37,-35,-14,24,-22,62,-17,18,52,17,57,-8,55,9,19,-28,-5,11,-25,-5,-43,-1,35,-10,61,1,-30,-1,33,81,-23,-15,-8,-43,-21,9,-28,-59,27,24,11,3,17,53,-36,-50,20,22,26,60,9,-57,54,-2,-15,37,30,27,31,-41,-36,14,-12,58,26,67,-46,32,-29,46,-53,43,-15,8,-78,21,33,-34,2,29,15,-48,-41,-94,-60,34,10,40,-27,28,38,-52,37,-37,81,9,5,-10,-35,88,31,-17,32,-47,7,9,-17,-14,17,12,-17,-5,-6,19,6,-22,10,-7,18,-13,-100,31,7,19,35,-6,46,20,11,12,21,14,15,-72,-8,44,-21,2,28,-7,25,10,-9,46,-17]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.224","t":"Questions to help compose an alternative response: (1) What is the evidence that the automatic thought is true? Not true? (4) What’s the effect of my believing the automatic thought? (2) Is there an alternative explanation? What could be the effect of changing my thinking? (3) What’s the worst that could happen? Could I live through it? (5) What should I do about it? What’s the best that could happen? What’s the most realistic outcome? (6) If ______________ (friend’s name) was in the situation and had this thought, what would I tell him/her?","e":[34,20,-123,-43,99,26,33,7,34,7,-22,-2,53,111,-22,-22,26,-88,18,45,-27,-51,-71,12,41,9,-57,0,-64,-6,15,-25,16,-62,-87,-38,68,38,31,-21,16,28,37,-57,75,-12,88,10,69,-48,43,-29,13,-25,81,44,28,52,40,-19,73,41,-35,18,63,-34,-26,77,-29,-23,44,-4,-7,-6,-54,3,8,-5,8,47,50,-41,109,-29,33,4,-10,4,-1,87,6,-8,35,9,-74,15,-62,9,-69,-27,-60,-41,1,-11,28,19,13,20,-7,25,-60,1,-29,-26,10,-26,70,-30,51,46,-7,66,-16,36,9,16,-53,-8,20,-40,14,-31,-16,43,0,64,-8,-32,12,2,69,2,9,19,-27,-39,28,-13,-60,39,26,7,5,4,45,-35,-41,11,36,10,67,-14,-59,63,-36,-5,22,76,34,30,-45,-39,23,32,74,-17,49,-74,-13,2,39,-38,31,-10,22,-47,34,18,-41,-11,-4,-4,-32,-53,-68,-71,40,-3,44,-27,14,25,-49,18,-22,45,-10,-11,-7,-56,100,25,6,29,-10,33,27,8,-32,37,4,-13,-36,-12,9,14,-36,-23,-49,26,-15,-118,48,-12,26,13,-18,24,30,33,5,27,19,18,-56,6,36,-48,12,66,-4,67,-5,8,39,-21]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.226","t":"Date________ Session__ ID # _ _ _ _ - _ Working Alliance Inventory – Short Revised (WAI-SR) Instructions: Below is a list of statements and questions about experiences people might have with their therapy or therapist. Think about your experience in therapy, and decide which category best describes your own experience. Please circle your choice. IMPORTANT!!! Please take your time to consider each question carefully. 1. As a result of these sessions I am clearer as to how I might be able to change. \u0003 \u0004 \u0005 \u0006 \u0007 Seldom Sometimes Fairly Often Very Often Always 2. What I am doing in therapy gives me new ways of looking at my problem. \u0007 \u0006 \u0005 \u0004 \u0003 Always Very Often Fairly Often Sometimes Seldom","e":[-6,5,-184,-72,6,-17,60,-26,67,-27,-22,23,30,17,15,-21,32,-68,-44,11,-53,-31,-45,-23,44,60,-9,5,-31,5,44,-6,52,-23,-31,-77,62,21,6,-3,31,-5,47,-77,34,-53,73,-5,42,-18,15,-45,5,46,80,12,-14,53,-6,-21,61,21,-57,64,63,-17,-33,25,-8,-35,66,10,32,32,-45,9,-25,-40,-15,39,30,-28,69,-50,40,16,6,45,21,76,21,38,-12,51,-109,12,-14,-7,-62,-31,-59,8,31,-44,29,13,-22,2,-38,9,-45,54,-11,-29,24,-20,57,-54,31,46,-43,1,-18,49,38,-12,-58,8,22,-21,-5,-16,-44,31,-2,16,7,3,9,13,58,16,-28,-20,5,-51,23,-59,-39,0,-1,44,-30,24,-17,-60,-26,45,66,21,62,-16,-11,72,6,-31,17,67,46,35,-10,-82,17,-16,41,36,75,-32,9,-7,29,-50,37,-36,-15,-26,42,-36,-35,-33,-4,14,-54,-44,-93,-73,24,-10,-3,-55,-8,7,-74,43,-18,67,-37,-8,-34,-23,107,-38,-24,56,-40,4,4,-21,-33,11,50,-46,5,-22,6,4,-25,-5,10,12,-33,-90,38,9,27,-25,-19,64,18,34,39,7,36,11,-54,55,-5,-37,35,36,-3,31,12,-1,40,-16]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.226","t":"3. I believe my therapist likes me. \u0003 \u0004 \u0005 \u0006 \u0007 Seldom Sometimes Fairly Often Very Often Always 4. My therapist and I collaborate on setting goals for my therapy. \u0003 \u0004 \u0005 \u0006 \u0007 Seldom Sometimes Fairly Often Very Often Always 5. My therapist and I respect each other. \u0007 \u0006 \u0005 \u0004 \u0003 Always Very Often Fairly Often Sometimes Seldom 6. My therapist and I are working towards mutually agreed upon goals. \u0007 \u0006 \u0005 \u0004 \u0003 Always Very Often Fairly Often Sometimes Seldom 7. I feel that my therapist appreciates me. \u0003 \u0004 \u0005 \u0006 \u0007 Seldom Sometimes Fairly Often Very Often Always","e":[29,-16,-169,-41,10,9,15,-36,8,-25,-48,17,28,40,-22,-7,-4,-69,-2,87,-86,12,-12,-58,22,73,-13,-9,-30,-16,-2,-24,24,-28,-55,-54,42,10,3,15,14,19,-15,-34,53,-58,18,23,11,-27,-16,-48,17,16,98,32,17,26,-4,-29,75,3,-46,88,48,33,-47,36,-7,-46,45,-27,28,18,-42,29,-33,-8,-7,4,30,-2,66,-37,36,51,-13,61,-6,69,2,-9,31,32,-86,-23,-6,-16,-78,-73,-39,24,22,-6,53,40,-17,-10,5,3,-72,57,-31,-58,6,9,49,-70,60,82,-12,-5,-32,53,2,9,-20,-1,-17,3,51,-40,14,8,-28,58,3,-13,6,48,64,-20,1,-39,8,-34,-12,-54,-24,20,21,43,6,-5,-19,-73,-40,-3,37,2,44,-27,-20,71,10,-13,19,52,-16,28,-9,-61,15,-12,19,10,30,-21,-22,-3,36,-29,58,9,-33,-26,39,-15,-41,-13,16,34,-31,-17,-36,-45,12,-5,-8,-73,-47,19,-41,35,-31,73,-41,48,-35,5,62,-78,-55,42,-36,-14,-17,5,-51,36,39,-11,-16,-21,15,17,-18,-5,-12,37,-28,-84,49,14,-4,-10,-7,24,38,26,38,-19,34,6,-88,47,-10,-14,24,48,22,41,-3,-1,50,-18]},{"s":"VA CBT for Depression Therapist Manual (Wenzel, Brown & Karlin 2011), p.227","t":"8. My therapist and I agree on what is important for me to work on. \u0007 \u0006 \u0005 \u0004 \u0003 Always Very Often Fairly Often Sometimes Seldom 9. I feel my therapist cares about me even when I do things that he/she does not approve of. \u0003 \u0004 \u0005 \u0006 \u0007 Seldom Sometimes Fairly Often Very Often Always 10. I feel that the things I do in therapy will help me to accomplish the changes that I want. \u0007 \u0006 \u0005 \u0004 \u0003 Always Very Often Fairly Often Sometimes Seldom 11. My therapist and I have established a good understanding of the kind of changes that would be good for me. \u0007 \u0006 \u0005 \u0004 \u0003 Always Very Often Fairly Often Sometimes Seldom","e":[22,-6,-150,-46,18,7,33,-12,40,-30,-41,11,33,45,-21,3,0,-57,1,84,-67,1,-33,-49,21,76,-5,-25,-39,5,-1,-39,31,-39,-64,-73,43,33,32,6,22,4,13,-50,42,-54,30,4,-6,-32,-3,-78,3,28,107,32,9,45,-16,-40,80,11,-60,94,45,39,-45,28,-11,-34,41,-39,42,23,-35,23,-11,4,-2,11,36,-8,82,-44,40,42,-14,58,17,82,3,-7,13,49,-84,-29,1,-16,-54,-69,-45,17,9,0,49,26,-6,-9,-9,3,-56,43,-28,-68,21,5,68,-61,44,72,-16,-8,-27,48,4,19,-11,3,0,-6,20,-33,30,22,-21,83,3,-21,15,29,79,6,-9,-27,-11,-19,3,-72,-11,9,22,34,-7,-5,-16,-71,-38,15,41,18,47,0,-16,64,-9,-9,3,43,-19,24,-6,-61,33,-4,47,20,44,-18,-3,-21,21,-31,50,-21,-35,-12,40,-46,-51,-19,12,38,-13,-13,-61,-50,-12,-14,-8,-68,-50,14,-55,26,-41,75,-17,35,-43,-20,81,-69,-51,50,-35,-13,-19,-12,-38,50,50,-4,17,-21,8,8,-23,0,-3,32,-17,-85,35,34,8,-10,-10,34,54,17,50,-7,44,-2,-81,52,-4,-24,4,51,35,16,-3,18,40,-23]}]}