Therapist aid worksheets: Worksheets for therapists
Therapist aid worksheets on this free PDF download include information about beliefs, rules, and negative automatic thoughts.
Longitudinal CBT formulations
One of the most important therapist aid worksheets is a longitudinal formulation. Longitudinal formulations usually contain information about an individual’s childhood experiences, beliefs, rules and behaviours. It is often beneficial (although not essential) to include a longitudinal formulation in case studies as it gives examiners a feel for the client that you are writing about.
Information that is included within a longitudinal formulation can be identified using a variety of strategies. However, by far the most effective starting point is to identify what induces the most intense negative affect in your client. When your client is experiencing intense negative or aversive affect, there is an opportunity to access thoughts and behaviours that accompany the affect, leading to downward arrow exercises (covered in Chapter 4 of this book), which can result in identification of core beliefs. Once core beliefs are identified, rules can be uncovered by asking clients what they expect of themselves in order for their deepest fears not to be true. Protective behaviours or coping strategies can then be relatively easy to isolate, as you can simply ask: ‘What do you normally do to keep your rules in place?’ Bear in mind that clients can keep their rules in place by carrying out specific safety or compensatory behaviours or even more simply by completely avoiding situations where their rules may be violated
The attached therapist aid worksheets will be useful to offer clients as you work on a longitudinal formulation with them and will enhance the collaborative process.
Therapist aid worksheets – Longitudinal CBT formulations
A longitudinal formulation is a psychological explanation that sets out clearly what makes you think, feel and behave the way that you do. Longitudinal formulations usually contain information about your childhood experiences, beliefs, rules and behaviours. Longitudinal formulations are cyclical in nature, and give you an indication of how your behaviour may have a tendency to reinforce your deepest fears over the passage of time.
Longitudinal CBT formulations usually include limiting beliefs. In CBT literature, limiting beliefs are referred to as ‘beliefs’, ‘core beliefs’ or ‘maladaptive beliefs’. Limiting beliefs are very strongly held negative ideas connected to the self and/or others and tend to be learnt as children. Limiting beliefs often have specific themes and fall into four general domains. These domains are: responsibility (e.g., ‘I am bad’); self-defectiveness (e.g., ‘I am flawed’); power and control (e.g., ‘I am weak’); and safety (e.g., ‘I am not safe’, ‘Others cannot be trusted’). Limiting beliefs have the capacity to hold back self-growth and because of this are often identified early on in cognitive behaviour therapy.
Within CBT, beliefs are regarded as unconditional and inflexible. You are likely to hold a limiting belief if you experience a strong emotional reaction that is more intense than most people might expect for any given situation. Beliefs operate at a felt level (experiential level) rather than a logical level. Beliefs can feel factual no matter how much evidence you have to the contrary. For example, many people who believe they are bad, may not have done anything seriously wrong in their lives and may spend a lot of time thinking or caring about how others feel (which, of course, is an unusual characteristic for people who really are bad). Beliefs have a tendency to retain their perceived experiential validity (i.e., they still feel true) whatever you think, do or say and can be triggered over and over again with the same results. Beliefs are very difficult to challenge in CBT as they carry an intense emotional charge, and are often held with strong conviction (or in other words, we tend to believe them very strongly). Luckily, the rigidity and validity of beliefs can be loosened through the use of specific CBT experiential exercises that focus on challenging the ‘believability’ of beliefs.
Rules and conditional assumptions
Rules and conditional assumptions are ideas that we put in place knowingly or unknowingly to protect ourselves from our limiting beliefs. Unlike beliefs, which are unconditional (which means they are there whatever you think, feel say or do), rules are conditional. Conditional means that if you or others meet certain conditions then your rules can be met and you can decide that you are OK. Rules often trigger bargaining within the self and you may find yourself changing your behaviour to keep your rules intact or to accommodate your rules. An alternative method that people use to keep their rules intact is to avoid situations that challenge their rules. For example, if you hold a rule ‘If I am successful at all times, then I will be OK’ you could try harder to make sure that you are successful or alternatively you may completely avoid putting yourself in challenging situations, (where you might not be successful). Other examples of rules include, ‘If I am strong and in control at all times, then I will be OK’ or ‘If others are happy with me and I say ‘yes’ to requests at all times, then I will be OK’;‘If I appear normal then I will be OK’ and ‘If I appear competent at all times then I will be OK’. You can identify whether you have a rule by assessing whether you have a strong emotional reaction when you are unable, for whatever reason, to meet the conditions of your rule. Examining your emotional reactions to events is likely to be the main method that your CBT therapist will use to identify whether you have a rule in place.
Rules are slightly easier than beliefs to challenge using CBT. To challenge rules, you will need to learn adaptive coping strategies so that you can help regulate or soothe the strong emotions that are likely to arise as a result of not following your rules or breaking your rules. Rule violations can occur over extended periods of time – years in some cases. (A rule violation ostensibly means that a rule has been broken or is in the process of being broken.) The effect of rule violations may be low mood, depression and anxiety. Equally, rules can be broken for a short duration a few minutes – for example – with the most common emotions being anxiety, anger, guilt, shame, and disgust.
Avoidance and safety behaviours
The use of avoidance and safety behaviours (also known as maladaptive coping strategies in these therapist aid worksheets) are common among people who experience psychological distress. If we are experiencing avoidance, we may recognise that this is occurring if we feel inclined to deliberately stay away from situations where we feel uncomfortable emotions. Alternatively, we may be using safety behaviours when we approach situations that create fear. Examples of coping strategies include, focusing on yourself, distracting yourself, avoiding conflict, saying ‘Yes’ to all requests, worrying about how you might cope, distracting yourself, planning escape routes and such like. If you are using avoidance and/or safety behaviours these are likely to keep your problems in place; and, as time progresses, continued use of them can lead to a gradual loss of self-esteem and self-confidence.
Negative automatic thoughts
Negative automatic thoughts or NATs are the types of thoughts that run in the back of our minds when we are distressed and are often included in therapist aid worksheets. NATs are particularly likely to be in operation if we are experiencing depression or anxiety. NATs are important to identify because they can have a big impact on the way that we feel. NATs (unlike beliefs) are relatively easy to challenge using CBT. They tend to be situation specific and very biased. They are narrow and simplistic in their content. Examples of NAT’s may include: ‘People will find me boring’; ‘I’ve got nothing to offer; ‘People always treat me like this.’ NATs can often have different levels of feeling attached to them. Christine Padesky, author of the best-selling CBT book Mind Over Mood suggests that some of the best NATs to identify and work with are ‘hot cognitions.’ Hot cognitions are basically NATs that carry high degrees of distressing emotion with them. Hot cognitions are generally connected to core beliefs at some level.