Cognitive Behavioural Theory (CBT) is centred around the relationship between how we think, feel, and act. WhileCBT sessions spend a fair amount of time looking at how you can monitor and change your thoughts and thus help your mood, another part of CBT is looking at the behavioral aspect of your low moods – the way that things you do affect how you feel.
The idea is that by changing the actions you take in life, you can have a powerful impact on your thoughts, which then changes your emotions and mood.
A simple example of this is that when we actually manage to hit the gym we often then think “I had a productive day” and feel better about ourselves.
CBT calls this process, of using actions to intervene and affect thoughts and therefore how we feel,‘behavioral interventions’.Your CBT therapist, if focussing on behavioral interventions, would introduce techniques to help you to identify and then increase the activities that improve your mood, while at the same time lessening those activities that bring on negative moods.
But you can try out similar techniques for yourself. Here are five CBT-inspired ways to use actions to change your thoughts and moods for the better.
5 CBT-Inspired Ways to Take Actions Toward a Better Mood
1. Take Charge of Time
A common side effect of depression is to lose the desire to do the things you used to enjoy, or what a therapist might call ‘avoidance’. Of course doing less of what brings you happiness then increases your low moods. It becomes a vicious cycle of depression causing inactivity which then triggers more depression and thoughts like “I’m useless, I’m best left on my own”.
So really, the immobility that depression brings ends up not just a side effect, but unfortunately a cause of more depression.
Activity monitoring and scheduling, as this CBT behavioral intervention is called, is a technique to help low moods by breaking this cycle of immobility. Essentially, it’s a way to push yourself to do things even though you don’t ‘feel like it’. It does this by first helping you get a a clear picture of how you are actually managing to spend your time and how that is working for you, and then helping you make a plan to do activities that make you feel good.
The bonus of monitoring and scheduling your activities is that it also allows you to challenge the negative judgements about yourself depression can bring like ‘I don’t do anything with my time” or ‘this week has been useless and terrible’. Often such things aren’t even true and by tracking what you are doing you have the proof you need to stop such thoughts.
HOW TO USE THIS TECHNIQUE:
- Write down every single thing you do over the space of the next week. It’s best to make a chart with your week laid out in hours (or you can use a diary that has each day broken into hours if that’s easier).
- A timer or alarm clock set to go off every hour is the best idea – most phones have such a function nowadays.
- Don’t judge yourself for what you have or haven’t done, or try to do more than you would otherwise. The point is to just get a baseline of where you are now. Improvements can come later.
- At the end of the week, look over what you have done. Try to see pattens. Did you do more or less than you expected? Can you already start to see where certain activities led to worse mood and less activity for the rest of the day, whereas other things you did helped you feel better?
- Now make yourself a schedule for the next week, with all the things you have to do (work, school, etc) but also including things that make you feel good as well as confident. Go to the next step for how to do this…
2. Do Things You are Good at and Enjoy
As you might have noticed looking over your week, when you do things that make you feel good or make you feel a sense of accomplishment you tend to have a rise in your mood, which can then lead to more positive activity.
Or you might have alternately noticed that because of your low mood you didn’t do any of the things you like doing. What could happen to your mood if you somehow could get yourself to reintegrate the things that used to bring you joy?
CBT suggests we clearly identify the activities that bring joy and confidence and then carefully schedule them in to our week. This behavioural intervention is calledIncreasing Pleasure and Mastery.
The idea is that if you consistently do such actions your behaviours will increase your feel good factor until you might find your mood lifting more and more. It’s like the opposite pattern to the immobility one that we mentioned above – this one spirals you up, not down.
HOW TO USE THIS TECHNIQUE:
- First, go through all the activities your recorded in your week of time monitoring and next to all the activities you did that bought you pleasure, write a P. (Examples of pleasurable activities can include watching TV, being around friends, having a nice bath, and sitting out in the garden.)
- Then write a number between one and ten that rates how much pleasure the activity bought you.
- Now go back through your schedule and note all the things you did that made you feel accomplished- or just where you were taking care of yourself or others,. Often when depressed we never feel accomplished, but taking care of yourself is an accomplishment.
- These are ‘mastery’ activities, so write an M next to them, and again put a ranking from 1-10. (Examples of mastery activities include cooking yourself a healthy meal, doing your bills, getting the housework done, spending time journalling, or taking care of your kids.)
- It’s a good idea to then rewrite these things you’ve identified as ‘pleasure and mastery’ activities up into their own lists, and while you are at it add things that you would like to do that maybe you didn’t get to in the week you were monitoring your time. For example, you might want to add ‘go for a swim’ to your pleasure list and ‘get my hair cut’ to the mastery list.
- Now take at least 5 items from each list and schedule them in to your coming week. Not just in your head, but on paper, into your diary. Note that ideally, you only want to do one mastery activity a day as you don’t want to set yourself up for failure- (learn more on this front in the next section).
- Continue this scheduling, ideally, for eight weeks. Even if you start to feel more active and like your moods are lifting keep going with it so it becomes habit.
A tip is to schedule pleasurable activities after master activities, so that they can act like a kind of reward system to encourage you to get things like the housework done!
Do not talk yourself out of booking in any pleasurable activities as ‘you don’t have the time’. It’s important to remember that a weekly schedule of activities that make you feel better can help change your depression, which actually brings you energy and thus makes you able to do more with your time. So see it as a crucial intervention. Look at your week and cross out what isn’t essential and make room for pleasure and mastery.
And if you are balking at the idea of scheduling in something so ‘simple’ as doing the dishes, because in this moment if feels an obvious you will get it done, remember that if depression hits these things often get left. And also remember that if you write it down and achieve it, you’ve created a feel-good moment for yourself.
3. Take it Step-by-Step
Of course all the scheduling in the world will not help you feel better if you don’t manage to actually achieve any of it – in that case it could indeed make you feel worse! Part of planning activities is making sure they are realistic and you are not setting yourself up for failure.
Graded Task Assignment (GTA)is a CBT technique for turning overwhelming tasks into manageable achievements. In other words, see everything as step-by-step. This involves breaking a big goal into smaller goals that you put in the most logical, achievable order.
For example, applying to university would involve deciding what course you want to take, investigating the schools that offer the course, downloading the application, filling out the application, perhaps writing some essay questions, finding references, submitting the application, figuring out your finances, applying for loans… etc. It wouldn’t make sense to fill out applications for courses you have not decided are definitely for you, it would create stress and waste time that just creates more stress.
This behavioral intervention is also helpful when you have big difficult tasks coming up, or something that is going to require a substantial amount of time to finish.
HOW TO USE THIS TECHNIQUE:
- Choose an activity or goal to break down. Look at all the activities you have scheduled in for next week. Is there one that seems a bit big? If not, think of a goal you’d like to accomplish over the next month and practise on that.
- Write down your activity or goal, then break it down into all and every smaller step you can think of. For example, if you scheduled in ‘go to the gym’ you could break that down to have my gym outfit washed, have my bag packed, buy a bottle of water, find my membership card…
- Put the steps you’ve come up with into the most logical order. There is no point in packing your gym bag if you’ve lost you membership card.
- Schedule in your first step. If you chose an activity from your schedule, perhaps reschedule the various steps now so that you are definitely going to get the activity done. If you are working with a general goal, pick one task to get started on and either do it now if you have time or schedule it into your week.
- Match the task you choose to your present energy levels. Do not assume you can accomplish what you might have previously during a time when life was not as challenging. It’s better to choose a task that is too easy but you will accomplish then something you won’t.
Don’t forget to take time to note how it feels to get a step of your goal done, letting yourself feel good and honouring yourself with some positive praise, like your therapist would if you were in sessions.
For more help with setting achievable goals, see our guide to setting SMART goals.
4. Use Physical Activity
Exercise is not going to make the list of pleasure activities for many of us, and even it if we do manage to get it on to our mastery list, we might be tempted to not really ever schedule it in.
But research has shown that a reasonably high level of exercise (approximately 3 times per week for 45 minutes each go) has a considerable positive effect on depression. In other words, of all the activity choices that can elevate our moods, exercise is so far proven the most useful.
The secret is to take all you’ve learned above to make exercise more likely to happen for you.
HOW TO USE THIS TECHNIQUE:
- Schedule exercise before a pleasure activity so there is a reward waiting.
- Remember to break down your exercise goal into steps. Saying ‘I am going to start exercising’ won’t get you far but noting that the first step is deciding what sort of exercise you’ll try and where you can go to do it will.
- Consider ways exercise could somehow become a pleasure activity. It’s not impossible – things like dance and walking in nature with friends are both forms of exercise!
- Don’t overlook easier ways to achieve the goal. There is nothing wrong with dancing around your living room for 45 minutes to your favorite tunes or walking around the city for an hour if you can’t get out to the country.
- And to keep yourself exercising, remember to notice how you feel after exercising. You might even want to keep a record of pleasure rankings in your diary each time you exercise, again using that 1-10 scale, which can act as a kind of proof to your mind that exercise is indeed worth it.
5. Relax Into It
Often when depressed we replace enjoyable activities with sitting around feeling anxious and stressful, which further immobilises us and stops us from doing anything. So relaxation exercises can be an activity your CBT therapist might introduce to your sessions or encourage you to do at home when your anxiety and panic arises.
Therapists might use one or a combination of muscle relaxation, deep breathing, guided imagery or the increasingly popular mindfulness meditation.
Relaxation might sound overwhelming, but once you get the hang of it, it can be so enjoyable it might end up on your list of pleasurable activities to choose from.
HOW TO USE THIS TECHNIQUE:
- Experiment with different relaxation techniques that suit you. This doesn’t have to be yoga! Try our guide to progressive muscle relaxationor treat yourself to a two-minute mindfulness break.
- Create a supportive environment when using relaxation techniques. Try for a quiet, safe and comfortable place where you have privacy. You might want to wear comfortable clothes and dim the lights.
- If you really feel to busy and need something more adaptable that can be done anywhere, try deep breathing. This means that whenever you feel stressed, tired, or overwhelmed, you take a moment to consciously take at least three long, slow breaths, just for a moment forgetting about everything but the sound and feel of your breath coming in and out. To make sure you are breathing deeply, try placing your hand on your abdomen and ensure that it rises and falls slightly with each breath.
CBT is proven effective short-term therapy that gives you useful tools to manage your stress and low moods that you can then continue to use over your lifetime to stay well. If you have found the behavioral interventions above effective, remember that they are only a small part of what CBT Therapy involves. Also, working through such techniques with a qualified therapist usually ends in even better results as they can help you troubleshoot, guide you to stick to plan, and encourage you to notice your improvement.
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Homework in psychotherapy is sometimes assigned to patients as part of their treatment. In this context, homework assignments are introduced to practice skills taught in therapy, encourage patients to apply the skills they learned in therapy to real life situations, and to improve on specific problems encountered in treatment. For example, a patient with deficits in social skills may learn and rehearse proper social skills in one treatment session, then be asked to complete homework assignments before the next session that apply those newly learned skills (e.g., going to a social engagement or greeting five people each day).
Homework is most often used in cognitive behavioral therapy (CBT) for the treatment of mood and anxiety disorders, although other theoretical frameworks may also incorporate homework. Some of the types of homework used in CBT include thought records and behavioral experiments. Patients using thought records are instructed to write down negative cognitions on the thought record form and weigh the evidence both for and against the negative thoughts, with the goal being to come up with new, balanced thoughts in the process. Behavioral experiments are used as homework to help patients test out thoughts and beliefs directly. Studies have shown that homework completion and accuracy predict favorable outcomes in psychotherapy and may help patients stay in remission. However, some therapists are concerned that assigning homework makes therapy too formal and reduces the impact of the individual sessions.
Most of the literature published on homework in psychotherapy to date focuses on homework use during CBT, which involves changing patients' thoughts and behaviors to reduce the symptoms of the mental disorders from which they are suffering. A variety of homework assignments exist in CBT. These tasks can range from scheduling a daily exercise routine to practicing progressive muscle relaxation five times a day to monitoring and recording one's negative automatic thoughts throughout the day. In practice, these homework assignments are meant to help patients lift their mood, practice and master skills they developed in therapy, and progressively improve between treatment sessions. Research has found that homework compliance positively predicts successful outcomes in therapy, and therapists are now looking for better ways to implement homework, so that more individuals may receive its benefits.
CBT is not the only type of therapy to incorporate homework. Although each therapist makes his or her own choices regarding homework assignments, some of the other therapies that may assign homework include exposure therapy, psychodynamic therapy, and problem solving therapy. Homework can also be assigned even if therapists are not physically present with the patients being treated. Such cases include therapy delivered over the phone, over video, or over the Internet. Treatment of some disorders, such as major depression, may also be done without therapists at all. Although the efficacy of this self-help-like treatment is still under scrutiny, preliminary data suggest that completion of homework is one factor predicting positive treatment outcomes for patients who receive treatment over the Internet.
Thought records (or thought diaries) are among the most commonly used cognitive assignments in CBT. They allow patients in various situations to closely examine "hot thoughts" and cognitive distortions and, after having done so, arrive at a newly synthesized alternative thought that more closely fits the situation. Many thought records accomplish this task by having patients list out in order: the situation they are in; the emotions they are feeling and with what intensity those emotions are felt; what thoughts they are having and what the "hot thought" is; evidence for the hot thought; evidence against the "hot thought"; balanced alternative thoughts; and the emotions they feel after having completed the thought record and the intensity of those emotions.
Jane has social anxiety disorder and was just told at work that she would be giving a presentation in front of an audience of 200 people the following week. This produces a large amount of anxiety for Jane, and she starts filling out a thought record to try to calm herself down. To begin, she fills in the column about the situation she is in with: "I was told that I am going to give a speech in front of a large audience next week." In the next column, Jane writes what emotions she is feeling and with what intensity she is feeling them: "Anxious – 100. Afraid – 90. Sad – 40." She then starts identifying some thoughts that immediately ran through her head when she heard that she would be giving the presentation: "Oh no, I'm going to mess up and choke. Everyone will laugh at me. My boss will fire me. I will never be able to hold a job at this rate. I'm worthless and a failure." Jane identifies "I'm worthless and a failure" as the hot thought, the thought that invokes the greatest amount of negative emotion in her situation.
After that, Jane starts writing in the next column the pieces of evidence that support the hot thought: "I've done terribly on presentations in the past. I remember one time in high school when I had to give a speech in front of my class and I ended up crying in front of everyone instead. I got a C on that speech and barely scraped by in the class. My high school friends and I don't talk as much anymore. They must be starting to get sick of me too. My co-workers don't try to talk to me either." Jane jots down in the next column pieces of evidence against her hot thought: "I think my boss might have meant well when he gave me this presentation assignment. I did one of these presentations on a smaller scale last week and I think I did just fine. Almost everyone who was there even came up to me and told me so afterwards. I think that those audience members do care about me and would be willing to support me if I asked. Also, I'm filling out this thought record just like my therapist told me to. I think that's what she would have wanted from me."
In the next column, Jane writes down her alternative thought: "The presentation ahead may be scary and making me feel anxious, but I think I can handle it as long as I know that there are people who support me." After that, Jane writes the emotions she is now feeling and their intensities: "Anxious – 50. Afraid – 40. Sad – 10. Relieved – 50."
Both the quality and quantity of thought records completed during therapy have been found to be predictive of treatment outcomes for patients with depression and/or an anxiety disorder. Furthermore, Rees, McEvoy, & Nathan (2005) found that accuracy ratings of patients' thought records mid-treatment was positively correlated with post-treatment outcomes, and that doing homework in CBT was overall preferable to not doing homework in CBT. Completing thought records accurately may also be indicative of overall skill gain in treatment; Neimeyer and Feixas (1990) found that patients with depression who completed thought records accurately were less likely to relapse six months after treatment termination. The researchers hypothesized that this was because the patients who completed thought records accurately had acquired the skills taught in CBT, and that these skills served as valuable coping strategies when the patients were faced with future stressors and needed to act as their own therapists.
Behavioral experiments are collaborative endeavors in which therapists and patients work together to identify a potentially negative or harmful belief, then to either confirm or disprove it by designing an experiment that tests the belief. Like thought records, they are most often used in CBT.
Patients with panic disorder tend to interpret normal bodily sensations as signs of impending catastrophe. An individual with panic disorder may then believe that hyperventilation is a sign of an upcoming heart attack. A therapist who identifies this maladaptive thought can then work with the patient to test the belief with a behavioral experiment. To begin, the therapist and the patient would agree on a thought to test. In this case, it might be something like, "When I start hyperventilating, I will have a heart attack."
Then, the therapist may start giving suggestions on how to test the belief. She may suggest, "Why don't you try hyperventilating into this plastic bag? If you show signs of having a heart attack, I have training in CPR and I'll be able to help you while waiting for the authorities." After some initial apprehension, the patient may agree with the experiment and start breathing into a plastic bag while the therapist watches. Since the patient with panic disorder most likely will not have a heart attack while hyperventilating, he will be less likely to believe in the original thought, even though he may have been scared of testing the belief at first.
Relative to thought records, behavioral experiments are thought to be better at changing an individual's beliefs and behaviors. To test this hypothesis, researchers conducted an experiment comparing the degree of belief and behavioral change in participants who were given either a thought record or a behavioral experiment intervention. Specifically, this study tested participants who endorsed the commonly held belief, "If I don't wash my hands after going to the restroom, I'll get sick." Participants in the thought record condition were given a "normal" thought record not unlike the one described in the "Thought Record" section of this article and asked to come up with evidence for and against the following belief: "Not washing your hands after going to the toilet will make you ill." After this, they were asked to reflect on their own experiences of washing or not washing their hands after going to the toilet and to come up with a balanced alternative belief.
In the behavioral experiment condition, participants worked with the experimenter to come up with a study to test the validity of the same belief used in the thought record condition. For example, one study could involve having the participant void without washing her hands afterwards to see if she would become ill. The participant was encouraged to concretely define how she would tell whether she became ill or not (e.g., check for fever, coughing, aches, or other common symptoms of illness) and to test her belief as thoroughly as possible (e.g., if the participant believed she was more likely to get ill after touching the toilet seat and not washing her hands, she was encouraged to test this hypothesis as well).
The researchers found that, compared to a no-treatment control, both thought records and behavioral experiments were effective in reducing the belief that not washing one's hands after going to the toilet would make oneself ill. However, behavioral experiments were found to be able to change the individuals' beliefs immediately following the intervention, while thought records demonstrated this ability to change belief only at follow-up one week after the intervention. On the other hand, the researchers found that neither thought records nor behavioral experiments were effective at reducing how often individuals actually washed their hands after using the toilet, even if they no longer believed that they would become ill for not washing their hands. Since the sample being studied was drawn from a normal population (as opposed to the population of individuals seeking treatment for psychological disorders), this lack of an effect on behavior may be due to the possibility that the people being studied were not under any motivation to actually change their behavior.
Problems and uncertainties
Homework is generally associated with improved patient outcomes, but it is still uncertain what other factors may moderate or mediate the effects that homework has on how much patients improve. That is, some researchers have hypothesized that patients who are more motivated to complete homework are also more likely to improve; other researchers have suggested that only individuals with less severe psychopathologies are even capable of completing homework, so it would be effective only for a subset of individuals. To test these possibilities, Burns and Spengler (2000) used structural equation modeling to estimate the causal relations between homework compliance and depressive symptomatology before and after psychotherapy. These researchers found that "the data were consistent with the hypothesis that HW compliance had a causal effect on changes in depression, and the magnitude of this effect was large" (p. 46). Still, there may exist factors that improve homework compliance during therapy, such as general therapist competency and therapists' reviewing homework completed since the previous session.
The types of homework used in psychotherapy are not limited to thought records and behavioral experiments, which tend to be relatively structured in their implementation. In fact, even though researchers have found that psychotherapy with homework is generally more effective than psychotherapy without homework, there have not been many efforts to research if specific types of homework are better at effecting positive treatment outcomes than others, or if certain environments help promote the positive effects of homework. For example, Helbig-Lang and colleagues found that, in an environment where systematic homework assignment procedures were rare but where overall homework compliance remained high, homework compliance was not positively related to treatment outcomes. Another group of researchers looked at patients with depression who were in remission and undergoing maintenance therapy and found that homework compliance did not correlate with treatment outcomes in this sample, either. More research can help elucidate the relations among the types of homework used in psychotherapy, the environments in which they are incorporated, and treatment outcomes for patients with the various disorders for which the homework is being assigned.
Both clinicians and patients encounter difficulties in incorporating and complying to homework procedures throughout a treatment. Factors that have been found to be associated with homework compliance during treatment include having the therapist set concrete goals for completing the homework and involving the patient in discussions surrounding the assigned homework. If homework compliance is as important to treatment outcomes as most research suggest, however, then there is room for improvement and future studies could focus on how to improve compliance more effectively.
Like the psychotherapies in which they are incorporated, homework may not be effective at helping all people with all different kinds of psychological disorders. It is thus important to research for which disorders and in which general situations homework would enhance a therapy. This would ostensibly help patients being treated for psychological disorders receive more individualized care and support, and hopefully improve overall treatment outcomes for all disorders.
An example of a specific situation in which homework may be helpful is the mitigation of safety-seeking behaviors with behavioral experiments. Safety seeking behaviors are undertaken by individuals to prevent anticipated future catastrophes, but may end up being more harmful for these individuals in the long run. For example, a patient with panic disorder may avoid exercising because he believes that breathing heavily will make him have a panic attack. Because of the apparently preventative function of safety seeking behaviors, people who carry out these behaviors are unlikely to test their actual effectiveness in preventing catastrophes. So, designing behavioral experiments in therapy to test these behaviors could potentially be a helpful means for reducing their occurrence.
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