Renew Your Mind

Rom 12:2  And be not conformed to this world: but be ye transformed by the renewing of your mind, that ye may prove what is that good, and acceptable, and perfect, will of God.

 

Overcomer’s Scriptures

Eph_4:23  And be renewed in the spirit of your mind;

Rom 12:2  And be not conformed to this world: but be ye transformed by the renewing of your mind, that ye may prove what is that good, and acceptable, and perfect, will of God. 

Kill the ANTS!

 Learn how to RENEW YOUR MIND and change your Automatic Negative Thought Patterns (ANTS).

How?

By deliberately CREATING different thought to REPLACE the ANTS, every time you notice them! Consider COGNITIVE THERAPY as a possible tool in renewing the mind.  However, I recommend using the HOLY BIBLE as THE reference tool for the SOURCE of truth for the most dynamic effect.

(According to the latest research in 2015 AD., you exponentially change your results by doing this at least 7 times a day for 21 days minimum. See Dr Caroline Leaf page for link to her website & research!)

 

Blank Thought Record

 Follow the hints at the bottom of each column in order to help you successfully reappraise your automatic thoughts and achieve a better balance in your thinking and emotions.

(According to the latest research in 2015 AD., you exponentially change your results by doing this at least 7 times a day for 21 days minimum. See Dr Caroline Leaf page for link to her website & research!)

 

Use Thought Stopping to Reduce Anxiety

By Sheryl Ankrom
Panic Disorder Expert

One effective and quick technique to help you with the intrusive negative thoughts and worry that often accompany panic disorder, anxiety and agoraphobia is called “thought stopping.” The basis of this technique is that you consciously issue the command, “Stop!” when you experience repeated negative, unnecessary or distorted thoughts. You then replace the negative thought with something more positive and realistic.
Difficulty: Easy
Time Required: 15 Minutes, Several Times Per day
Here’s How:

  1. Identify Your Stressful Thoughts.

    Start by monitoring your bothersome and unnecessary thoughts. Write down the thoughts that are causing you the most trouble and pick one that you would like to work on.

  2. Create Positive Thought Substitutions.

    Write down positive statements and affirmations next to your stressful thought. For example, you can replace the stressful thought, “I’m so anxious, I’ll probably start to panic and embarrass myself if I accept the invitation to go to the concert,” with:

    I’ve been in anxious situations before and have succeeded.
    I am confident that I can control my anxiety and panic by using the relaxation techniques I have learned.
    I know that my medications are working to prevent me from having a full-blown panic attack.
    I will go to the concert and have a great time!

  3. Repeat and Replace.

    Close your eyes and think about the stressful thought. Try to imagine yourself in a situation in which the thought may occur. Repeat it in your mind for about three minutes and shout “Stop!” (You’ll probably want to do this part in private.) Let your mind relax and go blank for about one minute. If the thought intrudes, shout, “Stop!” again. Say the positive substitution statements and affirmations you identified in step 2 above aloud. Repeat these substitutions for about three minutes. Try to visualize your success in the stressful situation as you repeat your thought substitutions.

  4. Important Considerations.

    In order for thought stopping to be effective, you will need to practice it throughout the day for several days. The unwanted thoughts are likely to continue to recur during the initial days of this exercise. They should, though, gradually diminish.

    Thought stopping may not work for everyone. If you find that your stressful thoughts are becoming more frequent or if the exercise is producing increased anxiety, discontinue and talk to your doctor or therapist.

Stopping Negative Thoughts

  1. Listen for your worried, self-critical, or hopeless thoughts.
  2. Decide that you want to stop them. (“Are these thoughts helping me?”)
  3. Reinforce your decision through supportive comments (“I can let go of these thoughts.”)
  4. Mentally yell “stop!” (Snap rubber band on wrist.)
  5. Begin Calming Counts.

Spirit-Mind-Body 40 Day Challenge! Another way to get to some hidden ANTS...

I personally had to lower my antidepressant dose within one month after doing this! The side-effects made me so dysfunctional that I had to go to the doctor! WOW!

How to Write a Thought Record

NOTE: This is a secular template.  I have added my insight/Christian template in parenthesis (GRS 2016)

There are 10 steps to a thought record.
The first six steps help you understand your negative thinking.
The next four steps help you develop healthier thinking and incorporate it into your life.

Write a thought record about any unpleasant experience that you would like to have handled differently. You can write about past or current experiences.
Start with easy ones at first, and wait until you are more practiced before dealing with more uncomfortable experiences. (It is best to stick to one “stronghold” at a time.)  If you have any doubts about what to write about, discuss your plans with your doctor or therapist. Write a thought record every day for a month and see how much better you think and feel. (After a month, continue with the first topic, and add a second “stronghold” or “toxic thought pattern”)

Example
1. The situation. 
Briefly describe the situation you would like to have handled better. This will help you remember it later if you want to review your notes.
I made a mistake at work. I felt anxious and was reminded of past failures.

2. Initial thought. 
What thought first popped into your mind? This was probably a subconscious or automatic thought that you have had before.
I feel like a failure. If people knew the real me, they wouldn’t like me.

3. Negative thinking. 
Identify the negative thinking behind your initial thought. Choose one or more from the list of common types of negative thinking.
This is self-labeling and disqualifying the positives. (This is rejection, fear of rejection & abandonment, fear of man, self-hatred, etc.) 

4. Source of negative belief. 
Can you trace your thinking back to a situation or person? Is there a deep belief or fear driving your thinking? Search your heart. (Doorpoints/Entry Ways/Traumas)
I can hear the voice of my parent saying that I’m a failure and that I’ll never amount to anything. (Separate the being of sin from the person manifesting that sin)

5. Challenge your thinking. 
Look at the evidence both for and against your thinking. Have you been in a similar situation before? What did you learn from it? What strengths do you bring to this situation? Make sure you see the whole picture. (Recognize what is manifesting within and without that lead to this toxicity.)
I’m hard on myself. I don’t always succeed, but I do sometimes. People have complimented me on my work. I feel overwhelmed when I try to be perfect.

6. Consider the consequences. 
What are the short-term and long-term consequences if you continue to think like this? Look at the physical, psychological, professional, and emotional consequences. (And above all….Spiritual.  Think about the rollover of your actions on your descendants; ie Iniquity in the Holy Bible.)
I’m damaging my self-esteem. If I continue to think like this, my negativity will affect my relationships and possibly my health. I’ll become exhausted.

7. Alternative thinking. 
The previous steps of the thought record helped you understand your thinking and lower your defenses. Now that you’ve considered the facts, write down a healthier way of thinking.  (I fall out of agreement with participating with this spiritual force of ____; fear of failure, fear of rejection, self-conflict, etc.I am NOT the sin that is dwelling within me.)
I don’t have to succeed at everything. I can learn from my mistakes. I’m not a failure. I want to get rid of this negative thinking. I’m being hard on myself.

8. Positive belief and affirmation. 
Write down a statement that reflects your healthier beliefs. Find something that you can repeat to yourself. (Insert Scripture. Wash your mind with the water of the Word, and actively change that thought each time.  Then that though settles into the background of your conscious thinking it WILL be changed, one way or another.  i.e. “I can do all things through Christ who gives me strength.”)
A mistake is not failure. I am successful in many ways.
The serenity affirmation – “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

9. Action plan. 
What action can you take to support your new thinking? (Renew, replace, resist!) 
The next time I make a mistake, I won’t dwell on the negatives. Instead I will focus on what I can learn from my mistake. I will remind myself of my past successes.

10. Improvement.
Do you feel slightly better or more optimistic? This step reinforces the idea that if you change your thinking, you will change your mood. Gradually over time, your thinking and life will begin to improve.
If you write a thought record every day for a few weeks, you will begin to change your thinking. You’ll spot your negative thinking quickly and let it go. You will come up with better alternatives. You will practice your healthier way of thinking and incorporate it into your life. (Reference: www.CognitiveTherapyGuide.org .)

(According to the latest research in 2015 AD., you exponentially change your results by doing this at least 7 times a day for 21 days minimum. See Dr Caroline Leaf page for link to her website & research!)

The Step Thought Record and the Process of Change
The step thought record illustrated above is designed to produce fast and long-lasting change because it is based on the steps of self-change.

  • Identify what you need to change
  • Let it go
  • Learn healthier coping skills and thinking
  • Incorporate these changes into your life

Steps 1-6 are about identifying what you need to change and letting it go.
Steps 7-10 are about developing healthier thinking and incorporating it into your life.
There are other ways to write a thought record, but they do not so closely follow the steps of self-change.

The Step Thought Record Compared to the Traditional Thought Record.  The traditional thought record, introduced by Dr. Beck, uses a column format. You write your thoughts on specially lined paper within the columns provided, and there are usually five or six columns per thought record. The disadvantages of this approach are that it doesn’t follow the steps of self-change, it is somewhat inflexible, and you need to use specially lined paper. You have to write your thoughts in the columns provided, which may not give you enough room to think.

The step thought record uses a journal format, where each step starts a new line. This may seem like a small change, but it has a number of advantages. You are not limited to five or six steps, which gives you the opportunity to analyze your thinking deeper. It also gives you more room to write and it follows the steps of self-change.

Immanuel Healing God With Us (Condensed from Share Immanuel)

 by E. James Wilder and Chris M. Coursey   Copyright ©2010

Starting a good connection Learn the practice of interacting with Immanuel (God with us) in a way that resolves painful life experiences. God is always present with us and always has been. Our life memories are incomplete when we lack the awareness of God’s presence. Without this awareness our interpretations of life are distorted, bring pain and rob our peace. We interact with God best from the memories of times we spent with God. From these memories we can better explore those times where we do not perceive God’s presence. The memories of times when we had a close relationship with God are like open windows for seeing God’s active presence again in the present.

Starting with a good connection produces: 
Less confusion, distortion and resistance. 
Less time in our pain because we do not begin our search for God’s presence while we are sitting on our pain.
Instead, we explore our pain while sitting comfortably close to God. 
*Guidance from the starting moment. 
*A spot to return quickly if we get lost. 
*A place to pause an incomplete process without staying in pain. 
*A shorter healing process.

Sitting with God
When the pain-processing pathway in the human brain cannot figure out how the painful event fits together, our mind will keep the painful memory active. Every time something similar happens, the unfinished memory gets mixed in with the current event. Trauma comes from events that leave us feeling alone. When we have God with us (Immanuel) we are no longer alone and discover how to recover.

Don’t sit waiting in pain memory thorns! Most healing methods ask people to start in their pain and look for meaning or God from there. We do not recommend trying to climb the hill of awareness by starting in pain. Start at the top of the hill with God. God offers us hospitality. Begin where our minds remember God best – in either our appreciation memories or interactive memories. From either of these comfortable seats we can share a state of mind with God and feel God peace. These two seats face opposite directions but are both comfortable places to sit and hear God. From the interactive memories seat we can look toward God and sense His responses toward us. The appreciation memories seat faces the other way and, while we cannot see God or be directly aware if the responses come from God, we can see and appreciate the signs that God cares about us. Both appreciation memories and interactive memories need to be real times and places in our lives.

The appreciation memories seat will help us warm up our brains when we actively seek and focus on appreciation memories. Appreciation comes from the “ah!” moments: a baby’s smile, a beautiful scene, kindness, special recognition and warm cozy moments –whether we give them or receive them. Most of the time our appreciation memories have no sense of God’s presence in them. This is fine. Even if the appreciation memories seat faces away from God, God can still communicate to us. Our minds will be appreciative. You should have at least three appreciation memories that bring you a sense of warmth you can feel inside before we continue.

The interactive memories seat is the best place to stay for Immanuel experiences. These memories from our lives take us back to times when we could sense God’s thoughts and feelings toward us. These times are filled with God peace. They will feel like we are relating to someone we know. We will have a sense that both God and I are there. We may not be clear about which thoughts were God’s thoughts and which were ours – that is fine. The important point is that God is still there when we go back and remember the moment. Now we can interact again.

Stay seated at the top of the hill. Our goal, when looking at pain memories, is to stay in our appreciation or interactive memories seat and return to appreciation as soon as possible if we “fall off” due to pain, distraction or a blockage of some sort. It is most important that we get our minds synchronized with God in either an appreciation memories seat or an interactive memories seat before we look at thorny pain memories.

Sharing minds
An ancient example of sharing minds with God comes from the prophet Elisha and his servant. A large army had been sent to capture them and the young servant was badly frightened. The prophet said, “Do not fear” and prayed that the servant would see that God was with them (Immanuel). Then the servant saw the mountains were filled with horses and chariots of fire. Seeing what was on the mountains allowed the servant’s mind to share what God’s mind saw.

Asking questions of God – No matter which of the two comfortable seats we are sitting in, we ask questions and then look in our minds for responses from God. Responses can be words, pictures, thoughts, feelings in our bodies, desires, memories, emotions and internal shifts. Not all the things that come to our minds are God sending us a message. Often God shows us something we need to notice. When we do get “a message from God,” so to speak, it will make things fit together in God peace. When something does not feel true, again we tell God, “This does not feel true. What do you want me to know about that?” These instructions are easier to follow when we have someone with us. We ask questions and examine the responses together. Sometimes these responses seem important but often they do not. If we notice a response that does not seem important we ask God out loud, “What do I need to know about that?” This is how we talk to God whether we can perceive God’s presence or not.

If we are comfortably in the interactive memories seat we can often start by asking directly, “Where are You, God in the painful memory?” Sometimes that is all it takes. If we are in the appreciation memories seat, “What keeps me from perceiving You are with me?” or “What do You, God want me to know?” are You, God in the painful memory?” Sometimes that is all it takes. If we are in the appreciation memories seat, “What keeps me from perceiving You are with me?” or “What do You, God want me to know?” are good questions to ask. We may want to ask, “What keeps me from seeing You in the painful memory?”

So here is how the rounds of questions and answers and responses go:
1. Ask what God wants us to know (about that.)
2. Notice: a. In the appreciation seat we notice our responses. b. In the interactive seat we notice God’s responses and our responses.
3. Tell God our reactions (this is the same in both seats.)
4. Check to see we are still in our seats.

5. If we do not have God peace we repeat. We need to watch and see if we fall out of our seats. We need to notice when we stop feeling appreciation or don’t feel God’s presence. Every time this happens we go back to our appreciation memory or interactive memory and get back in our seat before going on. We don’t want to fall down the hill and lay in the thorns.

When the pain memories are processed we feel peace. If we ask the question, “Does that peace like to be with me?” there is a delightful discovery to be made about God. In God peace, we know where God is and everything now fits for us even when we can neither explain nor describe all we know.

Speaking telling

By this point we are half way through Immanuel and feeling much better. Our bed of thorny pain memories is now a picture in our minds. If we go back and try to feel how upset we were, we can’t feel it. Our minds do not yet understand what happened enough to change the way we view the future. Speaking the story of what changed when we perceived God’s presence is what changes the way that our brain sees the future, giving us hope and joy instead of dread and despair. We do not get the same benefit from telling the story of life in the thorn patch BEFORE Immanuel. That story depresses others and us.

Speaking the Immanuel story takes observation and preparation.

1. What was the moment in our memory where we first became aware of God’s presence? We give that moment a phrase like, “I was sitting in the dark hallway.” Now speak your phrase out loud or write it down.

2. What did God do first? Give that activity a phrase like, “I sensed God’s concern for me.” Continue speaking or writing the phrases.

3. What reaction did we have? Give the reaction a phrase like, “I was surprised but my body still felt frozen.”

4. What process did God take us through? Give a “play by play” description like a sports reporter would tell about a game. Tell each thing God did and our reaction to it. Speak or write each phrase.

5. Make a simple list of what we felt and thought before and after interacting with God’s presence in our painful memory. Make a series of sentences like, “Before I knew God was with me I felt hopeless and stuck forever (next, what God did to make a change) but then Immanuel showed me that God was holding me next to His heart (last, a phrase about the result) now I realize it really is over and I have a future and I started to smile and relax.” Speak this out loud or write it down. If we are in a group, we have the group repeat the sentences back and see if they sound and feel true.

6. What would we call the kind of changes we experienced with Immanuel? We can say or write, “I have always been afraid to get close to men but now that I can sense God is with me I have compassion for men that feels true and peaceful. I have become more loving.” Speak or write about everything that changed and now feels true.

We can now tell the whole Immanuel story. First we tell our story to God. We start by describing how our seat on the hill with God felt to us. We do not tell what our thorns were like. Next we tell about discovering God was with us, what changed with that discovery, how God peace feels and what we appreciate. When we are done we stop and sense God’s response to hearing our story. After telling God we speak the story to anyone who was with us for our Immanuel experience. We speak the Immanuel story to three people before we go to bed tonight. We tell others our Immanuel story in a way that helps them find an appreciation seat for their Immanuel healing.

Solutions when things go wrong

​It is common to encounter problems while seeking interaction, avoiding falls into the thorny patches of pain or telling our Immanuel story.

I don’t think the answers I am getting are from God 
The lack of God peace is a good indicator that we should take a moment to investigate. Because Immanuel is a relational interaction it may bring up beliefs or fears about God that come from our previous interactions with people. All these feelings come from pain memories and, if we ask God about them, Immanuel will remove the fears one at a time. If we are not sure then we check with respected people who know Immanuel.

I can’t do this on my own – There are three common reasons why we cannot finish Immanuel on our own:
1) difficulty observing ourselves
2) our brain lacks necessary brain skills and
3) our joy capacity is too low.
Ask God to show you your next step and who can help you.

My story is hard to tell or people don’t like to hear it – If our story is hard to tell or we notice people do not like to hear it most likely we are telling a thorny pain story instead of a top of the hill story. Our goal is to speak the change that happens when we perceive Immanuel’s presence. What should I expect will happen? –

We should expect four things from God with us:
1) God will answer us.
2) God’s peace will be exquisite.
3) Telling our Immanuel story will help us become the person we would have been if we had not been traumatized.
4) All parts of Immanuel, from the seating to the stories, lead to appreciation opportunities.

After telling the Immanuel story without the thorns three times we begin feeling and thinking differently about ourselves, our minds are renewed and we become the persons we would have been without the trauma. In the future we will be looking for Immanuel again.

Sources for more Life Model Works www.lifemodelworks.org
or P.O. Box 2376 East Peoria, IL 61611
Immanuel Approach
www.kclehman.com
Live session videos. Teaching videos. Free articles.

Share Immanuel: The Healing Lifestyle by E. James Wilder and Chris M. Coursey can be found at the online store at www.lifemodelworks.org

Spirit-Mind-Body 40 Day Challenge! 3 different things a day to be grateful for...

I personally had to lower my antidepressant dose within one month after doing this! The side-effects made me so dysfunctional that I had to go to the doctor! WOW!

BIBLICAL CBT VS WORLDLY CBT

If you have ever been anywhere near a diagnosis for depression, and certain other mental health issues, you will have come across Cognitive Behavioural Therapy (CBT). The thrust of CBT is to try and check your thought life against what you know to be true. It is important for those who are depressed because whilst we are ill our feelings are not our friends, they frequently lie to us. The only way to make sure we are acting sensibly is to fact check our feelings – which are fleeting and mercurial – against solid, unmoveable facts that we know.

The idea is a good one. Unfortunately, when I first became ill with depression and CBT was suggested, the ‘facts’ that were suggested to me as my feelings lied to me proved not to be facts at all. They were really opinions, or ideas, dressed up as facts that were open to a fair degree of interpretation. It was only when a Christian psychiatrist decided that the Bible was a better, immovable and unchanging thing that I was less likely to quibble with, that CBT began to help. He also took the pressure off by assuring me that, whilst it may not make me feel any better, it would certainly help me to act better (or, rather, not act irrationally according to my faulty feelings).

With that in mind, let me share with you some of the lies my feelings told me, the world’s suggestions to address them and the Biblical truths that helped me:

Lie: I am worthless and valueless
World: You are worth it just because
Bible: ‘God created mankind in his own image’ (Gen 1:27); ‘Are not two sparrows sold for a penny? And not one of them will fall to the ground apart from your Father… Fear not, therefore; you are of more value than many sparrows.’ (Mat 10:29, 31)

Lie: Everybody would be better off without me
World: But you’ve got so much to offer
Bible: The eye cannot say to the hand, “I don’t need you!” And the head cannot say to the feet, “I don’t need you!” On the contrary, those parts of the body that seem to be weaker are indispensable… If one part suffers, every part suffers with it.’ (1Co 12:21f, 26b)

Lie: Everybody hates me
World: I’m sure that isn’t true. I like you.
Bible: ‘God shows his love for us in that while we were still sinners, Christ died for us’ (Rom 5:8); ‘See what kind of love the Father has given to us, that we should be called children of God; and so we are.’ (1Jo 3:1)

Lie: I can’t cope
World: You can do it!
Bible: ‘For it is God who works in you, both to will and to work for his good pleasure.’ (Php 2:13)

Lie: Happiness isn’t possible for me
World: Distract yourself; follow your dreams and you’ll be happy
Bible: ‘May the God of hope fill you with all joy and peace in believing, so that by the power of the Holy Spirit you may abound in hope.’ (Rom 15:13, my emphasis added)

Lie: You’re broken and unfixable
World: Accept yourself
Bible: He heals the brokenhearted and binds up their wounds.’ (Psa 147:3)

Lie: There’s no hope
World: Where there’s life, there’s hope
Bible: For our light and momentary troubles are achieving for us an eternal glory that far outweighs them all. So we fix our eyes not on what is seen, but on what is unseen, since what is seen is temporary, but what is unseen is eternal.’ (2Co 4:17f)

 

Philippians 4:8 - Cognitive Behavior Therapy in the Bible.

Philippians 4:8 (NIV) Finally, brothers, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable–if anything is excellent or praiseworthy–think about such things.

Think about such things Phil. 4:8: The word translated “think” here means to “continually focus your mind.” But more is implied than considering. We are to concentrate on expressing these qualities in our lives, so that as we dwell on them, they in turn dwell in us. * the true–meaning the truthful in thought as well as every aspect of life. * the noble–meaning that which wins respect; the honest, honorable, worthy. * the right–meaning that which fulfills all our obligation to God and to other men. * the pure–meaning that which fits us for fellowship with and service to God, including but more than freedom from bodily sins. * the lovely–meaning that which is attractive and winsome. * the admirable–meaning that which is kind and likely to win others. These were considered excellent and praiseworthy qualities in Greek culture as well as among Christians. The Christian is not to be the “odd” man in society, but the ideal man. [The 365-Day Devotional Commentary] Thinking on these things causes one to think of Jesus. [Elder Steve House]

What you think about in your unguarded moments reflects what your mind dwells upon. What you speak about when your guard is down is a good gauge of what is in your heart (Mt 12:34). Your mind needs exercise just as your physical body does. To keep your body healthy, you must be careful what you put into it, and you must exercise regularly. To keep your thoughts pure, you must guard what goes into your mind. To exercise your mind, you must contemplate things that are noble and truths that stretch your mind. Some Christians allow the world to fill their minds with ungodly thinking. Some people seem drawn to concentrate on the negative, choosing to be pessimistic about everything. Some remain satisfied with thinking of the mundane. Others fail to intentionally place Scripture in their thoughts, choosing instead to adopt human reasoning.

Others, however, choose to expose their minds to the truths of God–to that which is true, noble, just, pure, lovely, and good. The things you allow your mind to dwell on will be revealed by the way you live. If you focus on negative things, you will inevitably be a negative person. If you allow unholy thoughts to fill your mind, ungodliness will become common in your life. If you fill your mind with thoughts of Christ, you will become Christlike. What you fill your mind with is a matter of choice. Choose to concentrate on the magnificent truths of God, and they will create in you a noble character that brings glory to God. [Experiencing God Day by Day by Henry and Richard Blackaby re Phil. 4:8]

Garbage In, Garbage Out: What we put into our minds determines what comes out in our words and actions. Paul tells us to program our minds with thoughts that are true, noble, right, pure, lovely, commendable, virtuous, and praiseworthy. Do you have problems with impure thoughts and daydreams? Examine what you are putting into your mind through television, books, music, conversations, movies, and magazines. Replace harmful input with wholesome material. Above all, read God’s Word and pray. Ask God to help you focus your mind on what is good and pure. It takes practice, but it can be done. (Life Application Commentary Series)

One evening an old Cherokee told his grandson about a battle that goes on inside people. He said, “My son, the battle is between 2 wolves. One is Evil. It is anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego. The other is Good. It is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion and faith.” The grandson thought about it for a minute and then asked his grandfather, “Which wolf wins? “The old Cherokee simply replied, “The one you feed.” [source unknown]

Religiously Integrated Cognitive Behavioral Therapy: A New Method of Treatment for Major Depression in Patients With Chronic Medical Illness

Abstract

Intervention studies have found that psychotherapeutic interventions that explicitly integrate clients’ spiritual and religious beliefs in therapy are as effective, if not more so, in reducing depression than those that do not for religious clients. However, few empirical studies have examined the effectiveness of religiously (vs. spiritually) integrated psychotherapy, and no manualized mental health intervention had been developed for the medically ill with religious beliefs. To address this gap, we developed and implemented a novel religiously integrated adaptation of cognitive–behavioral therapy (CBT) for the treatment of depression in individuals with chronic medical illness. This article describes the development and implementation of the intervention. First, we provide a brief overview of CBT. Next, we describe how religious beliefs and behaviors can be integrated into a CBT framework. Finally, we describe Religiously Integrated Cognitive Behavioral Therapy (RCBT), a manualized therapeutic approach designed to assist depressed individuals to develop depression-reducing thoughts and behaviors informed by their own religious beliefs, practices, and resources. This treatment approach has been developed for 5 major world religions (Christianity, Judaism, Islam, Buddhism, and Hinduism), increasing its potential to aid the depressed medically ill from a variety of religious backgrounds.

Keywords: depression, religion, spirituality, medical illness, psychotherapy

Depression is a significant public health problem and is one of the major causes of disability worldwide (). Depression is associated with higher rates of morbidity, mortality, and medical costs, especially among those with a medical illness, whose risk of mortality is up to twice that of the general population (; ; ; ; ). Medications used to treat depression are effective for only about 60% of individuals (Gartlehner et al., 2007) and appear to be minimally effective for those with mild to moderate depression (). Response rates drop further in those with comorbid medical illness (; ).

Two resources that are widely used by people suffering from mental and physical illness are psychotherapy and religion/spirituality. One of the most evidenced based forms of psychotherapy is cognitive–behavioral therapy (CBT; ). Randomized controlled trials (RCTs) generally indicate that CBT is an effective treatment for depression in the setting of medical comorbidity (e.g., ; ), although a systematic review of 23 RCTs concluded that the quality of many of these studies was questionable (). CBT may have disorder-specific effects, such that depression associated with some medical conditions (e.g., cancer) may respond better than depression associated with other medical conditions (e.g., HIV/AIDS; ). Those with medical illness also frequently report turning to religion to find strength and comfort and derive meaning (; ). Numerous empirical studies have revealed inverse relationships between religious beliefs and practices and depression (see ).

A number of theoretical and empirical articles emphasize the need to integrate religion/spirituality into treatment (see ; ; ; ; ; ; ). Several spirituality-based therapies have also been developed. These include Spiritual Self-Schema therapy for treatment of addiction and HIV risk behavior (); mindfulness, an integration of Buddhist and Western psychological principles and practices used for the amelioration of psychological problems (e.g., ; ); mindfulness-based cognitive therapy for depression (); and spiritual coping groups for those with HIV (), sexual abuse (), and cancer (). Spiritual interventions have been used for the treatment of generalized anxiety (; ) and posttraumatic stress disorder (; ).

Intervention studies have found that integrating religious clients’ spiritual and religious beliefs in therapy is at least as effective in reducing depression than secular treatments (; ; ; ; ; ; ; ; ; ; ; ; ; ).  meta-analytic review of 46 spiritual intervention studies concluded that patients with spiritual beliefs in spiritually integrated psychotherapies showed greater improvement than patients treated with other psychotherapies. When compared with the same type of therapy in secular form, spiritually integrated therapies showed greater improvement on spiritual outcomes and similar improvement on psychological outcomes. Furthermore, 77% to 83% of patients over age 55 wish to have their religious beliefs integrated into therapy ().

Spirituality-based interventions, however, may or may not include religious elements. In contrast, religious psychotherapy focuses specifically on including and using patients’ religious resources. Religious psychotherapy, specifically religiously integrated CBT, which uses the religious resources of patients in the treatment of depression, may boost the effects of conventional CBT in religious patients with medical illness (; ). Several studies have examined the effectiveness of Christian CBT among college students and clinical samples (e.g., ; ; ; ; ) and Muslim CBT-like approaches (; ; ) for the treatment of depression and anxiety. As with the other spiritually integrated therapies, these religiously integrated therapies were found to be as or more effective than conventional or control treatments for depression. However, many of these studies were small and of debatable quality. There are also few “religiously”-based manual-guided interventions available.

What remains to be determined is the effectiveness of religiously integrated CBT for the treatment of depression in the medically ill. To explore this important question, we designed and implemented a multisite, randomized controlled trial of religiously integrated CBT compared with conventional CBT for the treatment of depression in individuals with a chronic medical illness (). The randomized controlled trial of this intervention is now drawing to a close with patient follow-up to end December 2013; results will be reported soon thereafter.

The goal of the present article is to describe the development and implementation of the manualized intervention used in the above trial. First, we provide a brief overview of CBT. Next, we describe how clients’ religious beliefs and behaviors can be integrated into a CBT framework. Finally, we describe Religiously Integrated Cognitive Behavioral Therapy (RCBT), a manualized therapeutic approach designed to assist depressed individuals to develop depression-reducing thoughts and behaviors informed by their religious beliefs and resources.

One of the major challenges of designing and implementing a religiously integrated treatment is how to be both specific to a religious tradition, but also broad enough to be applicable to a number of world religions, as well as to the diversity of beliefs within one religious tradition. Our RCBT intervention was developed for five of the major world religions: Christianity, Judaism, Islam, Buddhism, and Hinduism. The challenges we encountered with integrating each of these religious traditions in treatment will be discussed.

Brief CBT Review

CBT is a psychotherapeutic approach that integrates behavioral and cognitive principles and research with behavioral therapy, cognitive therapy (based on the work of Aaron and Judy Beck), and rational emotive therapy (based on the work of Albert Ellis). The central premise of CBT is that thought patterns and beliefs, emotional state, and behavior are all interconnected. When a person suffers an emotional state such as depression, CBT emphasizes two effective ways to modify emotions. First is to identify, challenge, and change cognitive processes (i.e., how one views a situation), and second is to change behavior. How individuals perceive a situation and interpret it often determines how they feel and what they do. Research has shown that the perceptions and interpretations of depressed persons are usually not accurate (; ) and can initiate a vicious cycle. Those who are depressed have a greater tendency to engage in “cognitive errors,” such as jumping to conclusions, using a negative mental filter, all-or-nothing thinking, or catastrophizing. CBT teaches individuals to identify, challenge, and replace maladaptive thoughts and distorted thinking styles with healthy thoughts and behaviors. CBT is characterized by a collaborative therapeutic style, agenda-setting, frequent eliciting and responding to client feedback, empathic communication, Socratic questioning, guided discovery, homework assignments, and attention to difficulties in the therapeutic relationship.

Integrating Religious Beliefs Into CBT

Religiously integrated CBT adheres to the same principles and style of conventional CBT and uses many of the same tools. What is unique to religiously integrated CBT is the explicit use of the client’s own religious tradition as a major foundation to identify and replace unhelpful thoughts and behaviors to reduce depressive symptoms. When a client discusses symptoms and reactions to symptoms, therapists frame this material in terms of traditional CBT models and listen with a “third ear” for how this material can also be framed within a religiously integrative CBT model. The following section will review some of the major tools of RCBT (Table 1).

Table 1

The Major Tools of RCBT

Renewing of the mind
Scripture memorization
Contemplative prayer
Challenging thoughts using one’s religious resources
Religious practices (e.g., gratitude, altruism, forgiveness)
Religious/Spiritual resources
Involvement in religious community

Renewing of the Mind

The idea that our thoughts and interpretations play an important role in influencing our emotions and our behaviors is common to many world religions. For example, in the Jewish tradition, King Solomon wrote “ … for as he thinks in his heart, so is he” (Proverbs 23:7). In the Christian tradition, “metanoia” literally means “change your mind” or “change how you think,” which the Bible translated as “repent” (Matthew 4:17). Islam teaches this notion as well: “Surely Allah does not change the condition of a people until they change their own condition” (Qur’an 13:11). Religious individuals’ worldviews and value systems are often founded on their sacred scriptures. For these individuals, sacred scriptures can be used to help form more adaptive and accurate thinking, inconsistent with depression. In RCBT, clients are taught to use their religious teachings to replace negative and inaccurate thoughts with positive principles found in scripture that promote mental health.

Scripture Memorization and Contemplative Prayer

In RCBT, therapists provide clients with a passage from scripture that is relevant to a particular session’s topic. For example, the third session focuses on meditation for the purpose of managing feelings of distress. In our Hindu CBT manual, clients are asked to memorize the following passage: “Let him a (wise man) sit intent on Me (God) …” (Bhagavad Gita ch 2, v 61). Similarly in the Buddhist CBT manual, clients memorize this passage “Meditation brings wisdom; lack of meditation leaves ignorance. Know well what leads you forward and what holds you back, and choose the path that leads to wisdom” (Dhammapada 282). Clients are asked to memorize the passage and therapists suggest that the more positive teachings of their religious tradition they have stored away in their memories, the easier it will be to challenge and help them change their negative thinking. Clients can also be taught to meditate on these passages, called Contemplative Prayer, which helps them to remember and apply this type of thinking (Table 2).

Table 2

Contemplative Prayer Instructions

  1. Choose a scripture. Begin with your memory passage for the week.

  2. Sit comfortably, but not too comfortably, back straight, chest open so the breath is free and open.

  3. Read the passage slowly. Savor each phrase. What word phrase or idea speaks to you?

  4. Read the passage again. Where does this passage touch your life? What do you see, hear, touch, or remember?

  5. Read the passage a third time. Listen quietly.

  6. Note insights, reflections, and personal response to the reading in your journal.

  7. Follow the steps in order or go back and forth between them as you feel moved.

  8. Finish by waiting for a few moments in silence.

Challenging Thoughts Using One’s Religious Resources

A common strategy for identifying and challenging negative thinking, and the central approach used in RCBT, is the ABCDE method developed by Albert Ellis (). We add step R for religious beliefs and resources (Table 3). This is a practical approach to help clients see how their thoughts, feelings, and behaviors are linked. Clients are instructed on how to be scientists, examining their thoughts carefully and objectively, before automatically accepting them as truth.

Table 3

ABCDE Method for Challenging Thoughts

Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead to? Rate each feeling using a scale of 1–10, where 10 is very painful. What behavior did these beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or expectations are not totally accurate or true? Describe the contrary evidence. Specify the unhelpful thought category that best describes the error in the belief. Even if the situation can’t change, what evidence do you have that you could manage it (based on your talents, past experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation? How did your feelings change after you looked at the situation differently? Rate each feeling using a scale of 1–10, where 10 is very painful.

The first step, “A,” stands for the Activating event and is used to describe the situation that occurred around the time the negative emotions began. The second step, “B,” stands for Beliefs, and involves identifying the thoughts that went through the clients’ minds as a result of the activating event. The third step, “C,” stands for Consequences, of which there are two types: emotional and behavioral. This ABC process is the basic premise of conventional CBT. Several additions are made at this point to integrate the client’s religious beliefs and practices to help them challenge dysfunctional beliefs and thinking patterns. First, clients are introduced to categories of unhelpful thinking styles, such as magnification, all-or-nothing thinking, and should statements (Table 4). What makes this different from conventional CBT is that a theological reflection for each style of thinking is provided and discussed. The theological reflections ground this exercise in the client’s religious tradition, which is different from conventional CBT. It also helps clients to focus their minds on the truths taught by their religious tradition. Contrasting the maladaptive thinking style with their religious teaching provides another source of motivation to change negative thoughts. This method can also address distorted religious beliefs, such as a distorted view of a punishing God.

Table 4

Theological Reflections on an Unhelpful Thinking Style

Should Statements: You try to motivate yourself with shoulds and shouldn’ts, as if you had to be whipped and punished before you could be expected to do anything. “Musts” and “oughts” are also offenders. The emotional consequence is guilt. When you direct should statements toward others, you feel anger, frustration, and resentment. One example is the depressed housewife who says to herself, “I should keep my house cleaner, and I shouldn’t complain,” or, “I should be able to get my work done during the day.”
Theological Reflection from Christianity
One of the central themes of the New Testament is that Christ has given us a spirit of freedom and accepted us, and we should not condemn ourselves by getting upset at ourselves if we do not perform the way we think we should perform (Romans 8: 31), or the way others think we should. Saying, “I shouldn’t do that,” leads to a spirit of condemnation. Even if we do not do any “shoulds,” God still loves us (Romans 5:8). We are made OK with God simply by grace, not by our pressured determination to keep all the “shoulds” in one’s life. (Romans 5:1–2).
Theological Reflection from Islam
Several verses in Holy Koran emphasize the concept that, Allah does not impose upon any soul a duty but to the extent of its ability (2:286, 2:233,
6:152, 23:62, and 7:42). “Should statements” on the contrary, often expect us or other people to do or feel what they cannot do or feel under those circumstances. Therefore, they cause resentment and despair and are dysfunctional. For example, when you are depressed, if you tell yourself, “I shouldn’t be so weak, I shouldn’t feel sad like that,” you usually feel bad about yourself, and this can lead to more sadness, weakness, and depression. Even prophet Muhammad is also encouraged in the Koran not to be so hard on himself: as God says to him, we have not sent down the Koran to you for you to be distressed (20:2); so we could be taught that being hard on ourselves can sometimes be dysfunctional.
Theological Reflection from Buddhism
When we use the word “should,” there is generally little room for self-acceptance or flexibility. The Buddha taught that guidelines for our own behavior can be important, but that these need to come from a place of caring and love for others, and from a place of higher wisdom and caring for ourselves. Such wisdom may reflect the recognition that situations are often complex and that a single mode of action or behavior is not even desirable or useful.

After the client identifies the unhelpful thinking style involved in their thought process, they are ready to implement steps “D” and “E” of the ABCDE approach to change negative beliefs. These steps explicitly call upon the client’s religious beliefs and practices as resources to help confront and change dysfunctional beliefs. Step “D” stands for Disputing and is used to challenge unhelpful and negative thinking. An essential part of step D is having clients examine their religious beliefs and resources to see how these might help them dispute their negative thoughts. For example, clients can turn to the way they believe the world works from a religious viewpoint, their sacred scriptures and religious writings, spiritual wisdom, and other sources for evidence to challenge their negative beliefs. Clients are asked questions like the following: “When you look at your original belief, expectation, or your way of thinking about the situation, are there any beliefs or attitudes from your religious tradition that strike you as helping to generate an alternative viewpoint?” The answers clients derive from these disputing questions, such as supporting or negating evidence, will result in step “E,” which is an Effective new belief and new Emotional and behavioral consequences.

Religious Practices

RCBT not only addresses cognitions that contribute to depression, but also behaviors. In terms of the behavioral arm of RCBT, like traditional CBT, religious beliefs can be effective motivators that may support clients in their striving to build positive behavioral patterns to combat depression. For example, most world religions encourage forgiveness, gratitude, generosity, and altruism, each of which is addressed in RCBT. Other behavioral practices in RCBT include praying for self and others, regular social contact with members of their religious community, writing a gratitude letter, and engaging in hope-promoting, stress-reducing activities based on the spiritual concept of “walking by faith” and not by feelings. For example in the Jewish tradition, the notion that a person can use freewill to engage in positive behaviors despite conflicting emotions is reinforced in the Torah. The Talmud writes: “one who seeks to improve, the way is opened for him.”

Clients are instructed to engage in several specific religious practices daily, namely contemplative prayer, scripture memorization, and prayer for others. These daily practices have the potential to impact psychological skill agility and spiritual growth where spiritual growth represents an understanding of one’s self that empowers the person to overcome depression. One of the strengths of RCBT is that it integrates CBT skills into the structure of daily spiritual activities, daily devotional practice, and daily ritual. In religious traditions, daily practices are typically regarded as important ingredients of spiritual growth (e.g., prayer, keeping scripture at the forefront of one’s mind). In RCBT, they are used to support the development of psychological skill agility (e.g., ability to readily access learned emotional regulation, thought challenging, support seeking skills).

Religious/Spiritual Resources

RCBT encourages clients to make use of the many religious/spiritual resources they have available to them. These may include meditation, social support from members of their house of worship, conversations with religious leaders, participating in religious study groups, reading religious literature, watching religious programming, engaging in charity, and attending religious services or activities sponsored by religious groups, such as Swadhyaya (Hinduism) activities or activities in mosques (Islam), or meditation retreats/sessions (Buddhism).

Involvement in Religious Community

RCBT encourages involvement in the religious community and identification of someone whom the patient can support; for example, someone whom they can spend time with and pray for. This is different than simply seeking support from others within the religious community, as religious traditions typically encourage their adherents to live out their religion by supporting and caring for others. This community engagement is likely to lead to both increased social support () and increased altruistic activities that help to neutralize negative emotions (; ; ).

Development and Implementation of RCBT

In this section, we discuss the study’s development and implementation of RCBT, including a description of the content and format of the 10 sessions, use of the workbook, therapy delivery methods, training and supervision of RCBT therapists, and challenges involving the application to five world religions. The RCBT we developed is a variant of the treatment protocol originally designed by  and is based on theory and empirical research on the important role that religious beliefs play in the lives of religious clients in psychotherapy. We adapted the intervention to apply to individuals who are depressed in the setting of chronic medical illness. This design is present across the five manuals corresponding to the religious traditions of the major five world religions.

We use the following scriptures in the five religiously integrated treatments: In the Jewish treatment manual, the Torah and Talmud are used as the main sacred scriptures; in the Christian manual, the Holy Bible; in the Hindu manual, the Bhagavad Gita (containing the essence of all four Vedas that were revealed through Brahman); in the Buddhist manual, the Dhammapada (a collection of several hundred short wise sayings or verses attributed to the Buddha); and in the Muslim manual, the Holy Qur’an.

Session Length

We chose a 10-session protocol for a number of reasons. First, many insurance companies allow only a limited number of sessions for psychotherapy, requiring that this therapy be relatively brief. Second, our patients were those who had situational depression related to their medical condition and disability. They were not psychiatric patients with long-standing mental disorders. Finally, a systematic review indicates that depression can be treated efficaciously by psychotherapy, particularly CBT, with >10 session (). Therefore, we followed protocols designed for either Internet- () or telephone-based CBT (; ) used previously in primary care patients. We acknowledge that in clinical practice some patients may need >10 sessions and/or may need more time spent on specific sessions, such as the session on spiritual struggles. Long-term follow-up may also be necessary, depending on how deep seated the patient’s problems are.

Session Content

Each session was 50 to 60 min in length and followed a similar format.

Session 1: Assessment and Introduction to RCBT

In the first session, clients are introduced to the basic format of treatment and the therapist begins to establish rapport by allowing the client to discuss his or her emotional and medical problems, life circumstances, and religious beliefs. The rationale for the treatment is presented, and the nature of religiously integrated CBT is described in detail. Clients are then taught how to monitor their activities and mood during the upcoming week using an activity monitor. Scripture/sacred writing memorization is introduced. Clients are taught that a key way to begin to change their thoughts and perspectives is by replacing negative thoughts with what is said in their sacred scriptures. For example, in the Christian manual, patients learn that the Bible is self-described as “alive and powerful” and that as they meditate on scripture, God’s words become alive in them and change them from the inside out. Christian patients are then assigned the following verse to memorize that week: “Finally, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things” (Philippians 4:8). In all sessions across all manuals, a verse from scripture relevant to the session material is given to memorize and meditate on for the following week (see Table 5 for examples).

Table 5

Scripture Memorization Examples Across Religious Traditions

Session 1
Christianity
 “Finally, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things.” (Philippians 4:8)
Judaism
 “Think Good and it will be good.” (Tzemach Tzedek)
Islam
 “Allah sets forth a parable that a goodly word is like a goodly tree, whose root is firmly fixed, and its branches are in the heaven, giving its fruit at all times by permission of its lord.” (14 (Ibrahim: 24,25)
Hindu
 “Those whose mind and intellect are wholly merged in Him, who remain constantly established in identity with Him, finally become one with Him. Their sins are wiped out by wisdom. They reach the supreme goal from where there is no return.” Bhagavad Gita Ch 2, V 17
Buddhism
 “Light the lamp within; strive hard to attain wisdom. Become pure and innocent, and live in the world of light.” (Dhammapada 236)

Session 2: Behavioral Activation

In the second session, therapists reinforce clients’ basic understanding of the treatment rationale and further refine their ability to self-monitor their mood and activities. Clients are taught the importance of participating in pleasant activities for improving their moods and are asked to schedule several pleasant activities for that week. For clients who are monotheistic in their belief, therapists emphasize that there are many things God asks people to do that they don’t necessarily feel like doing. People do these things because they believe that a loving God would only ask them to do things that are ultimately for their benefit. In the same way, clients may not feel like engaging in activities, but they can draw upon this principle to do so and have faith that their feelings will change. In the Jewish manual this concept is explained as follows: An effective way to change our mood is to engage in pleasant activities. One of the first steps in changing our perceptions and negative thoughts is to begin to see the good things in our environment and to make some of them a part of our daily activity. This idea is consistent with Torah thought. The 13th Century work “Sefer HaChinuch” writes, “Know that a man is influenced in accordance with his actions. His heart and thoughts follow after his deeds in which he is occupied  Therefore, look carefully at what you do, for after your actions your heart will be drawn.” We cannot always remove the source of the negative events—in your case, for example, your medical condition—but things can be improved by increasing the number of positive events. Finally, clients are asked to identify a supportive person from their religious community with whom they can interact, support, and pray for during the coming weeks. The goal is not only to increase their social support, but to provide them with ways to care for others, increase a sense of purpose, and evoke gratitude for what is going well in their lives.

Session 3: Identifying Unhelpful Thoughts

In the third session, cognitive processing is introduced. Clients are taught to identify their mood and the thoughts accompanying changes in mood. Categories of distorted thinking styles are introduced and discussed. For each category, theological reasons are presented for why these types of thinking are unhelpful and unscriptural (Table 4). The ABC method of challenging beliefs that lead to negative emotions is taught and practiced (Table 3). Finally, clients are introduced to contemplative prayer (Table 2). Contemplative prayer involves meditating on a passage of scripture, repeating it silently to oneself, saying it as a prayer, and focusing one’s attention on the words. This leads to a contemplative, prayerful state and also helps clients to memorize key passages of scripture that can be used to challenge negative thoughts.

Session 4: Challenging Unhelpful Thoughts

In the fourth session, therapists help clients to reinforce and refine their ability to monitor thoughts and to clarify their understanding of the thought distortion categories. They are introduced to how one’s interpretation of an event leads to a change in mood. Finally, they are taught how to dispute negative automatic thoughts and develop alternative ways of responding to negative beliefs and expectations based on their personal value systems and goals (steps D and E of the ABCDE method). Therapists emphasize that clients’ religious beliefs can help them formulate more effective ways of looking at a situation and that religious practices can aid them in generating coping responses to negative events. In the Muslim manual, clients are instructed as follows: As a Muslim, you are not just challenging unhelpful thoughts and replacing them with more positive thoughts. You also have the added power of being able to replace your negative thoughts with the true words of God, which, according to the Holy Koran, “guides to the straightest way” (17:9).

Session 5: Dealing With Loss

In session five, clients identify the losses they are suffering as a result of physical illness and depression. They also identify sacred losses, which in clients who are monotheistic are defined as losses that are related to their religious orientation and relationship with God, such as the loss of relationships with members of their religious community, feeling abandoned by God, and the loss of specific religious beliefs (e.g., A good God doesn’t let his children suffer). The difference between control and active surrender is explained, and active surrender is offered as one potentially effective tool for dealing with loss. Active surrender involves a conscious decision to release or let go of those things that one does not have the power to change. Clients are taught that when people surrender to God they demonstrate their faith that God will take care of things in God’s own way. Paradoxically, people often report feeling more in control after surrendering. The Buddhist manual instructs clients in a similar manner: Surrendering the need to have things be a certain way helps us begin the process of letting go. It is important to remember that active surrender is different from giving up. Notably, surrender is paradoxical—the Buddha said that much dukkha or stress has to do our need for things to happen in a certain way. In Buddhist terms, “surrender” is not surrendering the “will” to God, but rather surrendering or letting go of identity with the core of the ego, or the identification of the self with a source of pain or a source of desire. Therapists also emphasize the use of religious resources to understand and giving meaning to their losses.

Session 6: Coping With Spiritual Struggles and Negative Emotions

In the sixth session, clients discuss various spiritual struggles as a result of their depression and/or medical illness. Therapists help clients to explore core experiences that may have contributed to a change in the client’s religious beliefs, such as feeling abandoned or punished by God (if monotheistic). Clients are given time and permission to voice their hurts, doubts, and questions. Therapist and client discuss the meaning of forgiveness and repentance and explore how these tools can help to cope with spiritual struggles and negative emotions. Research on the relationship between negative emotions and physical/mental health is shared with the client. The ABCDE method is used to help the client see the situation from the offender’s perspective, aiding in the development of empathy and the alignment of feelings with the decision to forgive. In the Christian manual, if clients desire to forgive themselves or someone else, they are given the option of praying the following prayer or one similar to this: Heavenly Father, I purpose and choose to forgive ___ (the person) for ___ (the action). I release him/her and cancel their debt to me completely. I will no longer hold any accusation against them. Even now I release them from this sin. I ask that you would forgive them for this sin and separate the sin from them forever. Please forgive me for the unforgiveness/bitterness (or other feelings against this person) that I have stored in my heart. I give you all my feelings of ____ and ask that You would cause my feelings to line up with my decision to forgive ___ (the person). I also purpose and choose to forgive myself. Thank you for forgiving me and making me righteous in your sight. Holy Spirit, please heal my heart and tell me your truth about the situation.

Session 7: Gratitude

Clients are first introduced to the benefits of gratitude. Therapists help clients explore what it means to be a grateful person and how their feelings of gratitude may have been reduced or even destroyed by experiences with illness. Cognitive restructuring is then practiced from a gratitude framework. Special focus is given to religious gratitude, including the importance of gratitude in the client’s religious tradition and being grateful to God and the things, people, and experiences God has provided (again, if monotheistic). The concept of giving thanks in all situations is explored. In the Jewish manual, therapists share the following: The Torah has a lot to say about being thankful. In fact, it’s hard to find a section of the Torah or even a single Psalm that does not mention gratitude, praise, or thankfulness. We are instructed in Psalms to thank God for the fact that He is good and that His goodness extends to the entire world without ceasing. God wants us to be thankful at all times. Indeed, many times the word “thanksgiving” is paired with the words “sacrifice” and “offering.” This suggests that giving thanks to God is seen as a pleasing sacrifice of our wills and desires to God. Clients across all religious traditions are led in an exercise of identifying the things they are grateful for in their lives. They are also directed to engage in grateful behavior by writing a thank you letter to someone significant.

Session 8: Altruism and Generosity

Here the client is introduced to the notion of expressing religious gratitude by being generous and engaging in altruistic acts. A religious motivation is provided for helping others (e.g., the great commandment of doing unto others as you would have them do unto you). In the Hindu manual, therapists share the following religious rationale for altruism: Research tells us that if we pay even a little attention to giving to others that, over time, we end up feeling better ourselves. We also know that no behavioral feature characterizes Hinduism more than its focus on doing your duty, caring for and loving other people. Compassion toward the less fortunate, giving alms to the needy, building temples for prayers, and giving a certain portion of one’s wealth is a highly desired virtue. Clients are led in an exercise to plan several altruistic acts they can perform that week.

Session 9: Stress-Related and Spiritual Growth

The concept of stress-related growth, particularly from a spiritual perspective, is discussed. Clients explore ways they may have experienced positive growth through their illness experience, including positive changes in their personal relationships, character, and abilities. A series of exercises are completed in which clients look for the positives in their lives in the midst of the current challenges. Clients are encouraged to look to their religion to help them find meaning and purpose in their suffering. Therapists revisit the importance of one’s interpretation of life events as a means to achieve stress-related and spiritual growth through discussing several stories in scripture illustrating this point. In the Muslim manual, therapists share the following with clients to show how a prophet found meaning and purpose in his suffering: A Koranic example is prophet Yusuf, who was thrown into the well and spent many years innocent in the jail, but these unfortunate events led him to become a high authority in the land and to be an example of morality among the people. So as is said in Surah Yusuf: “certainly those who keep from evil and are patient, Allah does not let the wage of the good doers go to waste” (12:90).

Session 10: Hope and Relapse Prevention

In the final session, hope is introduced as a positive state of being that results from using religious cognitive and behavioral strategies. When discussing hope with Buddhist clients, therapists state the following: According to the words of the Buddha: “Insight into change teaches us to embrace our experiences without clinging to them—to get the most out of them in the present moment by fully appreciating their intensity, in full knowledge that we will soon have to let them go to embrace whatever comes next. Insight into change teaches us hope. Because change is built into the nature of things, nothing is inherently fixed, not even our own identity. No matter how bad the situation, anything is possible (Thanissaru Bhikkhu). Clients discuss their dreams and goals, their spiritual resources, and what they have learned over the course of therapy. Therapist and client review the key skills the client learned over the 10 weeks of therapy and explore how to maintain the gains achieved, such as continued involvement in their religious community (receiving and giving support), monitoring and challenging thoughts, and making use of spiritual resources.

Despite the differences across the five major world religions, the religious themes included in treatment were those that were similar across all five religious traditions. There were, however, a few themes or concepts that differed between religions and these are noted in the manuals. For example, a fundamental difference in theology between Buddhism and monotheistic religions is that the Buddha was not considered a manifestation of a transcendent God. There is no concept of being “saved” by God, or of intercessory action by a god. At the same time, there are many Buddhist stories that depict Buddha as a god and that refer to miraculous powers, reincarnation, a heavenly like paradise, a hell populated by demons. Asian Buddhists are more likely to relate to such images, but they are unlikely to hold the same meaning they would for a Christian. Therefore, in relation to the emphasis and purpose of the Buddhist manual, the focus is brought back over and over to the core teachings of Buddhism: that the power to heal suffering lies within, and relief from suffering lies in using the teachings of the Buddha in a way that he intended.

Workbook and Home Practice Activities

A 10-session patient workbook and corresponding therapist workbook were created to complement the treatment manual. Clients are provided with a copy of the workbook before treatment begins. Each section of the workbook begins with a home practice activities instruction page, which summarizes the assignments the client will complete on their own during the week following the therapy session. At the end of a session, therapists review these assignments with clients. Clients are expected to complete all of the home practice activities, with the expectation that the more effort they put into treatment, the more they will get out of it. At the same time, it is important for therapists to remember that they are working with depressed people, who are limited to some degree by their medical illness and the fatigue caused by their depression. As such, when clients do not complete home practice activities, therapists are instructed to praise clients for what they did accomplish and focus on identifying barriers and engaging in problem solving.

Training and Supervision

Therapists who want to provide RCBT to their clients need first to be well versed in conventional CBT. They then need to learn how to integrate clients’ religious beliefs and practices effectively, sensitively, and ethically into the CBT model. Our manuals provide detailed instructions on how to do this; however, additional training and supervision may be necessary for those who do not have prior experience integrating religion into psychotherapy. This is a form of cultural competence and is a lifelong learning and refining process. All therapists who participated in our randomized controlled trial of RCBT received two days of onsite training followed by regular supervision sessions conducted by telephone throughout the trial.

After a brief refresher course on CBT for depression, including specific examples and modeling, therapists will need specific training in RCBT, including the basic principles of RCBT, how to use the manual and workbook, and ample time to role play each session with a colleague. After the training, it is recommended that therapists participate in regular supervision until they are comfortable delivering the therapy. When treating patients from a religious tradition outside the therapist’s familiarity, it is advisable to seek a supervisor within that religious tradition for guidance. In our RCBT clinical trial, supervisors experienced in CBT from each of the religious traditions who developed the manuals helped to supervise therapists. We acknowledge that access to supervisors from other religious traditions may be limited for some clinicians. To address this need, our team is exploring ways to provide therapists with online training, consultation, and supervision. The treatment manuals will be available on the Duke Center for Spirituality, Theology, and Health Web site in early 2014.

Challenges

We have encountered numerous challenges to implementing RCBT during the clinical trial, some of which are common to administering a manualized treatment (e.g., fidelity to the manual, uniformity of therapist abilities) and others that pertained to the religious nature of the treatment. This section will address those challenges and the lessons learned. One such challenge was the unfamiliarity of therapists with religions traditions outside of their own. When there was a discrepancy in religious orientation between therapist and client, therapists discussed this with their clients during the first session. To assist with this challenge, the manuals include ample dialogue script for the therapists to use, as well as notes and instructions to the therapists regarding religious concepts and resources discussed in the treatment manual. Developers of each of the five religious manuals answered questions posed by either the therapists or their clients pertaining to the particular religious tradition and advised on how best to integrate the patient’s religious beliefs and practices into treatment. This approach for working with patients outside of the therapist’s religious tradition worked well and has been suggested by others in the field as a way to develop competence in providing religiously/spiritually integrated therapy.

A second challenge was providing treatment for clients who considered themselves spiritual, but not religious. When first recruiting for the study, we enrolled individuals for whom religion or spirituality was at least somewhat important. When participants indicated this and were from a Christian religious tradition, they were assigned the Christian manualized treatment. During the initial session, clients who were spiritual but not religious often objected to the liberal use of scripture and a clear focus on Christian teachings and practices. They stated that they considered themselves to be nominal Christians, meaning that while they were raised Christian, they did not follow the teachings of the Bible and were not interested in a treatment that was based on that model. We recognized that continuing in this manner was at odds with the goal of RCBT, which is to integrate the client’s religious beliefs and practices into treatment. For those who do not have an active religious tradition, it is not ethical to try to integrate Christian or any other religious beliefs and practices into treatment. To rectify the problem, we changed the recruitment criteria such that interested participants needed to be practicing within a religious tradition rather than only considering themselves to be spiritual but not religious. Therefore, if clients are spiritual, but not religious, this RCBT treatment would not be a good or ethical choice for therapy.

A third challenge was intrareligious differences. Specifically, each of the religions represented in the RCBT manuals have many different subgroups and sets of beliefs and practices. Take Hinduism, for example. Within Hinduism there are a number of subgroups and belief systems. Based on the theory that God is “Avatar” (rebirth), the Hindu diety is recognized by different names based on the time and era they were born on this earth. There is a misperception among non-Hindus that Hinduism has many gods. In reality, there is one God (Brahman) who is recognized by many different names and forms, such as Rama, Krishna, Ganesh, Buddha, Mahavira (Maha-Vira), Hanuman (Hanuman), and others. In addition, there are a number of gurus or religious leaders who give presentations based on Hindu scriptures. Therefore, when working with a Hindu client, it is important to identify if he or she has chosen a name for God to worship and if he or she listens to presentations given by religious leaders.

Judaism has several major groups, including reconstructionist, reform, conservative, orthodox, and ultraorthodox. For each subgroup, the integration of Judaism into treatment will be different. The same is true for practitioners of Islam: there are major differences between Sunni, Shia, and Sufi subgroups. Significant differences exist among Vipassana, Tibetan, and Zen Buddhist practitioners. Christianity also has many different denominations with varying beliefs and practices. The manuals for each religion would have been much too long and far too complicated to address all the various beliefs and practices within each religion. To meet this challenge, therapists were instructed to learn relevant details from the client about his or her own religious beliefs and practices and were reminded to use the manual as a guide not a prescription. The emphasis was always placed on working with the material provided by the client in terms of their own religious beliefs and practices.

Conclusion

Much has been written about the need for empirically validated, theory-driven spiritually and religiously integrated psychotherapy. Intervention studies have found that integrating clients’ spiritual and religious beliefs in therapy is as or more effective in reducing depression than secular treatments for religious clients. However, few empirical studies have examined the effectiveness of religiously (vs. spiritually) integrated psychotherapy, and no manualized mental health intervention until now has been developed for the medically ill with religious beliefs. We offer RCBT as an approach for treating depressed medically ill individuals with religious beliefs. We believe this is a novel strategy for reducing depressive thoughts and behaviors. The goal of RCBT is to use explicitly a patient’s own religious tradition as a foundation to identify and replace depression-maintaining thoughts and to emphasize that religious beliefs and practices can be used as resources to reduce depressive symptoms and facilitate positive emotions. Some of the major tools of RCBT include scripture memorization to renew one’s mind, contemplative prayer, challenging thoughts using religious teachings, engaging in religious practices (e.g., gratitude, altruism, forgiveness), and involvement in a religious community. Helping clients to integrate their own religious beliefs, behaviors, and resources in skillful and appropriate ways is the heart and soul of religiously integrative CBT. Depression in those with medical illness knows no cultural or religious bounds. Accordingly, this treatment approach has been developed for five major world religions (Christianity, Judaism, Islam, Buddhism, and Hinduism), increasing its potential to aid the depressed medically ill from a variety of religious backgrounds. RCBT is sensitive to the challenge of being specific to a religious tradition, but also broad enough to be applicable to a number of world religions, as well as to the diversity of beliefs within each religious tradition.

Acknowledgments

We would like to acknowledge the contributions of our study therapists who skillfully administered the intervention and the contributions of those on our team who helped develop the five religious versions of the manual.

Contributor Information

Michelle J. Pearce, University of Maryland and Duke University Medical Center.

Harold G. Koenig, Duke University Medical Center and King Abdulaziz University.

Clive J. Robins, Duke University Medical Center.

Bruce Nelson, Innovative Healthcare Research Consortium, Glendale, California.

Sally F. Shaw, Innovative Healthcare Research Consortium, Glendale, California.

Harvey J. Cohen, Duke University Medical Center.

Michael B. King, University College.

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The Original CBT Manual (a faith-based approach to CBT)

by Steven Gledhill for FREEdom from MEdom Project

FREEdom from MEdom Project (FFMP) is a unique opportunity to merge together the best of evidenced-based cognitive-behavioral therapy (CBT) approaches with faith-driven Christ-centered 12-Step power for a transformative new life experience. This online resource appreciates the scientific realities of how the brain functions. It recognizes that both excitatory and inhibitory biochemical activity are self-centered and therefore predisposed to untamed automatic thinking patterns that foster distortions (errors) and dysfunction from an irrational core belief of entitlement. This core belief of entitlement fuels an ongoing diagnosis of ill psychological health, with the prognosis being painful consequences that trigger more distortions and dysfunction. Add to that the spiritual reality of man’s selfish sin nature and you have… (?)

The Bible, recognized by Judaeo-Christian scholars and Evangelicals as the Word of God, should also be recognized as a vehicle for clinicians utilizing a cognitive-behavioral therapeutic (CBT) approach to spark behavioral change into rational recovery. The parallels between CBT principles and Scripture are profound and seemingly endless when studied in this context. As you read article after article throughout FFMP, you will discover these obvious parallels again and again. This is meant to be a reference particularly for Christian counselors to map out these relevant parallels to benefit clients seeking to make sense of faith-driven Bible-based principles for thinking and behaving differently, while also remaining clinically sound.

The following two paragraphs are taken from the Beck Institute for Cognitive-Behavioral Therapy:

Developed by Dr. Aaron T. Beck, Cognitive Therapy (CT), or Cognitive Behavior Therapy (CBT), is a form of psychotherapy in which the therapist and the client work together as a team to identify and solve problems. Therapists use the Cognitive Model to help clients overcome their difficulties by changing their thinking, behavior, and emotional responses. Cognitive behavior therapy is one of the few forms of psychotherapy that has been scientifically tested and found to be effective in hundreds of clinical trials for many different disorders. In contrast to other forms of psychotherapy, cognitive therapy is usually more focused on the present, more time-limited, and more problem-solving oriented. In addition, patients learn specific skills that they can use for the rest of their lives. These skills involve identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.

Cognitive behavior therapy is based on the cognitive model: the way we perceive situations influences how we feel emotionally. When people are in distress, they often do not think clearly and their thoughts are distorted in some way. Cognitive behavior therapy helps people identify their distressing thoughts and evaluate how realistic the thoughts are. Then they learn to change their distorted thinking. When they think more realistically, they feel better. The emphasis is also consistently on solving problems and initiating behavioral change.

1st Century CBT

The primary focus of CBT is to change behavior from something unhealthy into something healthy. If the cognitive-behavioral emphasis is to change behavior then it goes without saying that there must be a change in how a person thinks; coming to believe that such behavioral change makes complete sense. CBT strategies involve targeting irrational beliefs (conclusions) that distort values and motivations according to what the irrational mind thinks and believes it wants.

CBT/REBT

Albert Ellis in the middle of the twentieth century hypothesized that we respond to events in our lives that activate beliefs from the way the events are interpreted; the beliefs give way to behaviors that result in consequential outcomes. His process of human thinking and emotion driving behavior is referred to as Rational Emotive Behavioral Therapy (REBT). Dr. Ellis suggested that A (Activating event) plus B (Belief about the event) equals C (Consequence from behavior fueled by irrational beliefs or conclusions drawn from the activating event).

The truth about how one interprets life experiences (activating events), drawing conclusions about experiences, is that beliefs are shaped by desire and expectations set up according to desire. We desire satisfaction and contentment. We desire to love and to be loved. We desire nourishment. Desire evolves into selfish ambition, lust, and jealousy—coveting the things that we want that we do not yet possess. The science of it is that there are chemicals in the brain that respond and react to desire while at the same time feed into human desire. The spiritual reality is that we have a selfish sin nature at the core of human desire that is unhealthy from the outset of our human existence.

Each one is tempted when he is drawn away by his own desires and enticed. Then, when desire has conceived, it gives birth to sin; and sin, when it is full-grown, brings forth death. James 1:14-15 (NKJV)

What is recognized today as revelation and fundamental to twenty-first century CBT therapists was not lost on the New Testament writers of the first century. Let’s break down this passage from James 1 from Dr. Ellis’ point of view.

Each one is tempted… This is the natural response to the (A) Activating event that evokes an interpretation of the occurrence (stimulus); it is the action that calls for a reaction; the cause that precipitates an effect. What is temptation? It is a natural interpretation that through the lens of selfish entitlement breeds expectation. The expectation enhances inherent desire, according to cognitive impulses from the interpretation of the event.

When he is drawn away by his own desires and enticed… Here lies the antecedent to one’s interpretation of the (A) Activating event. Inherent desire, from a core value of entitlement, is on its own wild and free. Untamed and stimulated, desire is off to the races wanting what it wants when it wants. Desire is motivated to dominate; getting its way. The Limbic System of the brain is where dopamine thrives for the purpose of pleasure, reward, and relief. Dopamine and serotonin levels can spike when stimulated. The brain’s thinking center—reasoning, judgment, emotion, memory, language—are also influenced and motivated by selfish intentions. The inhibitory process intended to protect us you could say is under the influence. As excitatory “GO” or “DRIVE” systems of the brain are in full acceleration mode, trending typically to override inhibitory “STOP” or “BRAKE” systems, we are “dragged away by desire and enticed”.

Then, when desire has conceived… We are driven toward a (B) Belief about the (A) Activating event inspired by desire and the obsession to gratify it. Considering that our reasoning is impaired by selfish desire, we are prone to irrational beliefs that we justify in our self-centered thinking to make enough sense that we are willing to risk losing what we intellectually, emotionally, and spiritually hold dear, even sacred. Desire extends itself as far, as high, and as low as it takes to be gratified, inconsiderate of the cost to the things held most sacred.

You have traveled far, even into the world of the dead, to find new gods to love. You grew weary in your search, but you never gave up. Desire gave you renewed strength, and you did not grow weary. Isaiah 57:9-10 (NLT)

It (human desire) gives birth to sin… S.I.N. is the Bible’s three-letter word for Self-Inflicted N-sanity, meaning that the harder we try to achieve satisfaction left to our own selfish devises, independent of God’s will and plan, settling for instant but fleeting gratification, the deeper we dig our way into the pit of dissatisfaction, decline, and destruction. It is here that our (B) Belief of entitlement is deeply rooted and firmly established. It is here that desire for satisfaction is translated into ambition and greed, lust and covetousness, jealousy and resentment, self-pity and shame, failure and fear. When we believe in the lies of unmet expectations we fall prey to the traps set in our minds about our livelihood, the world, and our place in it. As we buy into our Self-Inflicted N-sanity, we fall victim to moral sabotage caught in the deceitful web of irrational thinking and belief. Of course, by this time we have given in to these automatic thinking patterns and obsessions, then into compulsive (addictive) behaviors. The GO system of our brain remains in perpetual drive mode, the brakes don’t work very well, making it very difficult to STOP in time, and as previously stated, we are off to the races.

Sin, when it is full-grown… Most CBT/REBT models suggest that from the (A) Activating event to (B) Belief about the event, there is a time of thinking that is affected by the automatic processes within the brain that, when healthy, can lead to rational conclusions and healthy decisions. When unhealthy, this time of thinking is infected by the automatic processes within the brain leading to irrational conclusions—irrational beliefs—paving the way for irrational decisions resulting in unhealthy irrational behavior.

Ambivalence is being attracted to and desiring things equally that are opposite of each other—a conflict in the mind between good and evil, if you will. Ambivalence during this time of reasoning, when infected by irrational thinking, weakens the ability for sensible reason. Borne out of that irrational belief state is compulsive and addictive behavior. Common sensibility is replaced by Self Induced N-sanity, and behavior reflects this sick reality. Despite adverse consequences, the addictive behavior continues.

Brings forth death… There is a plethora of (C) Consequences throughout this rational-emotive-behavioral cycle. Scripture here is identifying the negative outcomes of irrational reasoning and addictive behavior. Dissatisfaction, decline, and destruction result in the ultimate outcome: death.

Insanity is often described as doing the same thing over and over again expecting a different result. The different result would be finally achieving fulfilling satisfaction instead of ongoing and perpetuating empty dissatisfaction. The deception lies in the temporary gratification that arrives through addictive behavior. If there was not some temporary gain from the behavior, the behavior would extinguish. Of course there is gain realized in addictive behavior. You are angry so you yell at someone or hit something. The anger-stress hormone cortisol is released and the gain is, at the very least, relief (a form of gratification). But the gain is temporary. That someone you yelled at yells back at you with stinging words, or perhaps you broke your hand had you hit something. Now you are angry again, or worse, your spirit is crushed.

Stress, shame, resentment, and fear seem to fade away when thoughts and feelings are medicated. Yet, for some reason, our irrational-minded beliefs continue to fuel and drive addictive behavior until all of the setbacks are too much to recover from until we finally succumb to the ultimate dissatisfaction: death. Death can be physical death: to the body, and/or psychological death: to the mind (cognitive-rational), and/or behavioral (addiction)/social (relationships) death: to the heart (emotive); and/or spiritual death: to the soul (will).

Stages of Change

The Stages of Change Model was originally developed in the late 1970’s and early 1980’s by James Prochaska and Carlo DiClemente at the University of Rhode Island when they were studying how smokers were able to give up their habits or addiction. This model has been applied to a broad range of behaviors including weight loss, injury prevention, and overcoming alcohol and drug problems among others. The idea here is that behavioral change does not happen in one step. Rather, we tend to progress through different stages on our way to successful change in recovery.

Assuming you are likely a clinician reading this, here is the in-a-nutshell recap of stages of change as you know them. In the Precontemplation stage we are not yet acknowledging that there is a problem behavior that needs to be changed. In the Contemplation stage we are acknowledging that there is a problem but we’re ambivalent, not sure we are wanting or willing to make a change, though we might begin to make inquiries into what needs to change. In the Preparation stage, also called Determination stage we’re getting ready to change, wondering perhaps what changing will require—what will it take? In the Action stage we are changing behavior perhaps with the attitude of doing whatever it takes to change. In the Maintenance stage it is just that: maintaining the behavioral change. And in the Reoccurance stage (otherwise known as relapse) we are returning to older behaviors, giving in to tempting triggers rejecting and abandoning the new changes.

Precontemplation & Contemplation

The Bible, the original CBT manual, takes its readers through the stages of change in recovery from sin, Self-Inflicted N-sanity. Even Jesus, Counselor, Prince of Peace, recognized those perhaps not ready to get well. He identified the ones lost in the pain of their mess and asked the question, “Do you want to be well?”

Crowds of sick people—blind, lame, or paralyzed—lay on the porches. One of the men lying there had been sick for thirty-eight years. When Jesus saw him and knew he had been ill for a long time, he asked him, “Would you like to get well?” “I can’t, sir,” the sick man said. John 5:4-7 (NLT)

We learn in the story that the man was paralyzed, obviously aware that he had a problem, but over the better part of four decades had become oblivious to it; it having been such a familiar reality in his life. According to the story, he had the opportunity weekly to be the first one placed in the pool of Bethesda for healing as the waters stirred. In 38 years there would be nearly 2000 chances for his healing. You would think that someone or group would have made it a point to get this man in the pool.

I do counseling work in a prison and have used this example of pre-contemplation and suggested that Jesus asking this man if he wanted to be well would be like asking the inmate, “Do you want to be set free?” It sounds silly but it is a legitimate question for the inmate who, while he treasures freedom, takes freedom for granted. He had the very thing he claims to hold sacred until he sacrificed his freedom for temporary gratification in a manner connected to prison. The inmates I work with do not like this truth because the truth really hurts. They do, however, appreciate it and want desperately their next shot at freedom.

As one vacillates between the precontemplation and contemplation stages in recovery there is a tendency to take on a kind of victim disposition. A Scripture passage that depicts this “the world is out to get me”, or worse, “God has set out to punish me”, for my choices and behavior is from King David. David often times talked the talk while struggling to walk the walk. As King of Israel, David was wealthy and powerful enough to take on more than one wife and did so, contrary to the will of God. And he didn’t stop there. He had ongoing sexual relationships with the young servants of his multiple wives; all after he’d confessed and repented to God for his adultery with Bathsheba and conspirator role in the murder of her husband. Any chance David had issues with addictive thinking and behavior? Consequences of his choices and behavior rippled through his family for years. One son raped his half-sister. Another son arranged the murder of his brother that had raped his sister. Then the son who had his brother killed and then plotted to kill his father, the king, was killed by David’s security force. David became so depressed and despondent that he nearly lost his kingdom in the process of it all.

Look at David’s words in the midst of the aftermath after his addiction wrought tragic consequences:

O Lord, don’t rebuke me in your anger or discipline me in your rage! Your arrows have struck deep, and your blows are crushing me. Because of your anger, my whole body is sick; my health is broken because of my sins. My guilt overwhelms me—it is a burden too heavy to bear. My wounds fester and stink because of my foolish sins. I am bent over and racked with pain. All day long I walk around filled with grief. A raging fever burns within me, and my health is broken. I am exhausted and completely crushed. My groans come from an anguished heart. 9 You know what I long for, Lord; you hear my every sigh. 10 My heart beats wildly, my strength fails, and I am going blind. 11 My loved ones and friends stay away, fearing my disease. Even my own family stands at a distance. Psalm 38:1-11 (NLT)

Prior to David’s relapse into his addictive chaos, he had come to his senses regarding his adultery with Bathsheba and the hit he’d put out on her husband. David had taken responsibility for his actions and had this moment of repentant prayer with God, seemingly determined and prepared to begin a commitment to a changed life. We cannot know, though, if David committed to recovery more than a minute or two into the action stage of change. What would active change into authentic recovery even look like for this king? Anyway, below is the confession at the time that David realized how low he had sunk into his addiction (Self-Inflicted N-sanity). Addiction to what… power… sex… love… wealth…? How about entitlement? Let’s go with that.

Contemplation and Preparation/Determination

Have mercy on me, O God, because of your unfailing love. Because of your great compassion, blot out the stain of my sins. Wash me clean from my guilt. Purify me from my sin. For I recognize my rebellion; it haunts me day and night.

Purify me from my sins, and I will be clean; wash me, and I will be whiter than snow. Oh, give me back my joy again; you have broken me—now let me rejoice. Don’t keep looking at my sins. Remove the stain of my guilt. 10 Create in me a clean heart, O God. Renew a loyal spirit within me. 11 Do not banish me from your presence, and don’t take your Holy Spirit from me. 12 Restore to me the joy of your salvation, and make me willing to obey you.

17 The sacrifice you desire is a broken spirit. You will not reject a broken and repentant heart, O God. from Psalm 51 (NLT)

There appears to be a clear difference between David’s Psalm 38 plea for mercy and his Psalm 51 desire for change. In Psalm 38, David feels like a victim of the consequences of his shameful behavior, expecting to be punished by a vengeful God. In Psalm 51, David talks to God as his Higher Power, understanding that he deserves to experience the full consequential weight of his action, but expectant of God’s forgiveness because of His gracious compassionate mercy. In Psalm 38, David seems to vacillate between precontemplation and contemplation in terms of his readiness for real substantive change. In Psalm 51, David is still in a contemplative place and appears to be trending toward preparation for recovery. There is determination in his words anticipating reconciliation and salvation, where in his Psalm 38 confession, the tenor of his words is self-pity in failure, rejection, and defeat.

While David was described as a man after God’s own heart, perhaps because his repentance was authentic from a relationship with his God of love, peace, and joy; his recovery experience was a bit schizophrenic. It was on the one hand victorious, even glorious; and on the other hand it was tragic, as David lamented in the desperate cycle of contemplation to preparation, and maybe action stages of change now and then, but free falling into relapse to the point that he almost lost everything after he seemingly lost everything once before.

It should be noted that David’s desperate plea in Psalm 38, chronologically was written a number of years after his beautiful prayer of repentance in Psalm 51. Toward the end of David’s life, he said the things that are reassuring about where he was in his recovery journey while, at the same time, curious.

“The Lord is my rock, my fortress, and my savior; my God is my rock, in whom I find protection. He is my shield, the power that saves me, and my place of safety. He is my refuge, my savior, the one who saves me from violence. I called on the Lord, who is worthy of praise, and he saved me from my enemies.“The waves of death overwhelmed me; floods of destruction swept over me. The grave wrapped its ropes around me; death laid a trap in my path. But in my distress I cried out to the Lord; yes, I cried to my God for help. He heard me from his sanctuary; my cry reached his ears. 2 Samuel 22:2-7

He led me to a place of safety; he rescued me because he delights in me. The Lord rewarded me for doing right; he restored me because of my innocence. For I have kept the ways of the Lord; I have not turned from my God to follow evil. I have followed all his regulations; I have never abandoned his decrees. I am blameless before God; I have kept myself from sin. The Lord rewarded me for doing right. He has seen my innocence. 2 Samuel 22:20-25

What is curious is that David would appear to a recovery clinician to be in denial about his behavior and the consequences of it. Or, I suppose you might say that he had overcome his shame in recovery and set free from it; and that God when He looks at the life of David, sees a man whose slate is wiped clean, declared innocent through repentance. It is clear looking back at his life that David was a pawn in his ambivalence between what he wanted in the moment and what was good and right and truly satisfying.

Ambivalence/Cognitive Dissonance: Resistant or Motivating?

When I want and am motivation for more than one thing equally, and those things I desire are opposite of each other—meaning to gain the one things means to lose the other—I am experiencing ambivalence. My ambivalence presents cognitive dissonance (means internal conflict or disagreement), which means that I am experiencing conflict between continuing in my problem behavior and embracing, or at least considering, healthier behavior choices in recovery. This inner conflict in my thinking can be resistant to recovery or motivation for recovery, or both. If I am in a precontemplative stage of change (not in recovery), cognitive dissonance can create a conflict in my thinking about my negative behavior when I had no conflict about using in the worst of my addiction. It could be that something severe enough to really catch my attention has motivated me to contemplate that I might have a problem requiring behavioral change to solve it. But if I am contemplating change, determined and preparing for change, or acting on change, cognitive dissonance can argue against rational sensibilities that had proven effective for awhile.

Once again, there is some 2000 year old literature that speaks to this condition from a man named Paul. Apostle Paul understood the problem of ambivalence for the person who wants to do the right thing while also craving to do the opposite. Paul describes the problem of ambivalence as conflict between two natures; that which is flesh and that which is spiritual.

So I say, let the Holy Spirit guide your lives. Then you won’t be doing what your sinful nature craves. The sinful nature wants to do evil, which is just the opposite of what the Spirit wants. And the Spirit gives us desires that are the opposite of what the sinful nature desires. These two forces are constantly fighting each other, so you are not free to carry out your good intentions. Galatians 5:16-17 (NLT)

The trouble is with me, for I am all too human, a slave to sin. I don’t really understand myself, for I want to do what is right, but I don’t do it. Instead, I do what I hate. But if I know that what I am doing is wrong, this shows that I agree that the law is good. So I am not the one doing wrong; it is sin living in me that does it.

And I know that nothing good lives in me, that is, in my sinful nature. I want to do what is right, but I can’t. I want to do what is good, but I don’t. I don’t want to do what is wrong, but I do it anyway. But if I do what I don’t want to do, I am not really the one doing wrong; it is sin living in me that does it.

I have discovered this principle of life—that when I want to do what is right, I inevitably do what is wrong. I love God’s law with all my heart. But there is another power within me that is at war with my mind. This power makes me a slave to the sin that is still within me. Oh, what a miserable person I am! Who will free me from this life that is dominated by sin and death? Romans 7:14-24 (NLT)

Ambivalence—cognitive dissonance—can be resistant to addiction, and motivation to advance to the next stage of recovery, or it can be resistant to effective recovery. Which would you say is true in the context of this passage from Romans 7? In this case, the writer is indicating that his ambivalence is resistant to recovery. We can recognize this since he is in recovery wanting to surrender his will over to his higher power for recovery. It is what he wants to do. But then he encounters resistance in the form of triggers to relapse, something that he does not want to do. He has indicated that he is a slave to the addiction that compels him and that when he lapses back into his mess he is miserable in his mess. Why would he give in to his triggers if he does not want to be an addict, which he recognizes he is? Because the deception of the temporary gains, that instant gratification, which appears in the moment to be worth it. Even aware of the risk of loss, which can be most severe, it seemingly is worth the risk. From an action stage of change there are temptations that can trigger addictive thinking into relapse behavior when a person’s recovery becomes undisciplined with divided loyalties.

But don’t just listen to God’s word. You must do what it says. Otherwise, you are only fooling yourselves. For if you listen to the word and don’t obey, it is like glancing at your face in a mirror You see yourself, walk away, and forget what you look like… If you need wisdom, ask our generous God, and he will give it to you. He will not rebuke you for asking. But when you ask him, be sure that your faith is in God alone. Do not waver, for a person with divided loyalty is as unsettled as a wave of the sea that is blown and tossed by the wind. Such people should not expect to receive anything from the Lord. Their loyalty is divided between God and the world, and they are unstable in everything they do. James 1:22-24, 5-8 (NLT)

Ambivalence in Scripture is described as being double-minded. No matter how much we genuinely love God committed to a surrendered relationship with Jesus Christ, even empowered by His Spirit as we work steps, we remain in our selfishness. While free from the eternal consequences of sin, having been justified by faith, we can become comfortable until we’re complacent. Then we get lazy and are again dragged away by selfish human desire and enticed into behaving like we did in our addiction. That is how our loyalties become divided. That is when we take our will back, deceiving ourselves that we are in control—recovered perhaps, surrendering to our selfish desires instead of surrendering all (body, mind, heart, and soul) to the perfect plan of our Higher Power, Jesus Christ.

Do not merely listen to the word, and so deceive yourselves. Do what it says. Anyone who listens to the word but does not do what it says is like someone who looks at his face in a mirror and, after looking at himself, goes away and immediately forgets what he looks like… If any of you lacks wisdom, you should ask God, who gives generously to all without finding fault, and it will be given to you. But when you ask, you must believe and not doubt, because the one who doubts is like a wave of the sea, blown and tossed by the wind. That person should not expect to receive anything from the Lord. Such a person is double-minded and unstable in all they do. James 1:22-24, 5-8 (NIV)

Action Stage of Change

The Bible is direct when it comes to its cognitive-behavioral focus and emphasis about recovery. The writer of James purposefully stated the need to resolve ambivalence by doing the work of recovery laid out in Scripture. There is a distinct relationship between deciding (determining/preparing) to live out recovery God’s way, and acting on that decision. When in doubt, DO! Do what the Word of God says.

Therefore, I urge you, brothers and sisters, in view of God’s mercy, to offer your bodies as a living sacrifice, holy and pleasing to God—this is your true and proper worship. Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will. Romans 12:1-2 (NLV)

Here is where our plan of action begins in recovery as we progress into the action stage of change. The behavioral change is in offering the specific members of our body into our action stage of recovery. ‘Offer’ is an action verb that is all about doing. It is about what we do. It’s about what we do with our eyes. What are we looking at and looking for? Will I surrender my eyes as a sacrificial act of worship unto God in my recovery? (Wow, that just spoke to me as I wrote it just now.) Will I surrender my ears and what I listen to unto God in my recovery? Will I surrender my arms and hands, legs and feet—what I actively pursue—unto God in my recovery? Will I surrender my physical brain as a sacrificial act of worship unto God in my recovery? Only then, acting according to His plan of surrender for me, will I willfully act on my decision to no longer conform to the obsessive and addictive patterns of the place and time in which I live. Only then will I experience the transformative power of a new life experience as God of all gods renews my mind, changing how I think; from irrational to rational—confused to sensible. When we read “Be transformed by the renewing of your mind”, ‘Be’ is a passive verb since it is about change. Except that this change God does in me as I act out change in what I do behaviorally. In the action stage of change through recovery God’s way I can have assurance in the midst of my doubt. I can have confidence that the way I think and process in my daily experience is new and right and good.

This assurance from Romans 12:1-2 is the cognitive-behavioral pay-off. It involves me changing my behavior and it involves God changing how I think. This transformation suggests that God has the power to rearrange the automatic thinking mechanisms in my brain as I offer myself to Him each and every moment of each and every day. It sounds impossible to make that kind of commitment, right? That is why Paul wrote that it’s about being a living sacrifice. So the question that Jesus asked the paralytic still stands: “Do you want to be made well?” Or I suppose the question could be asked, how much or how badly do you want to be made well? What is it worth to you? What is it worth to me?

Rational Thinking and Belief

When an (A) Activating event occurs, my (B) Belief about the event is through a renewed lens. As my behavior in active recovery reflects my transformed belief system, founded no longer in lies and irrational expectations, but in the truth of God’s word revealed spiritually to my mind. Then (C) Consequences will trend toward positive outcomes and blessing. This is huge! Of course, there will be struggles along the way. There will be heartbreak and pain. There will be disappointment, failures, and loss that will be a challenge to productive healthy recovery. But if I stay focused with my daily emphasis on maintaining (the next change stage in recovery) my disciplined daily walk on the journey, the most likely scenario for my life in recovery is the promise of blessing in my life. I now possess the God-given tools to do this recovery thing the right way.

Maintenance Stage of Change

Essential to maintaining disciplined recovery is a disciplined healthy thought-life. To experience confidence in the midst of doubt is to bring even my thoughts into submission to win the argument against spiritual Christ-centered intentions. Situations, circumstances, and people will challenge my faith in God to restore my unmanageable life to sanity. It will be tempting along the way to seek remedies in the midst of working to solve problems; remedies to ease anxiety and stress, anger and resentment, injury, discouragement, and fear. Central to continuing to rationally challenge thoughts of doubt that seek to justify relapse is to daily surrender my mind sacrificially as unto the Lord, Jesus Christ, the rational authority in my life.

We are human, but we don’t wage war as humans do. We use God’s mighty weapons, not worldly weapons, to knock down the strongholds of human reasoning and to destroy false arguments. We destroy every proud obstacle that keeps people from knowing God. We capture their rebellious thoughts and teach them to obey Christ. 2 Corinthians 10:3-5 (NLT)

What powerful words to rationally challenge the human reasoning that appeals to my prideful thinking. Add to that that I live among people in my family, my community, and throughout society that are set before me who will spew their sick irrational justifications into the mix and I am in jeopardy every day of my life. So again, to minimize and not be overrun by the ambivalent cognitive dissonance that is natural to my selfish mind, I must go to my Higher Power throughout each day and call on Him to receive my thoughts and to help me to bring each thought into obedience. It is in this discipline that I can and will maintain recovery cognitively and behaviorally.

Reoccurrence Stage of Change

Relapse is a stage of change. Something occurs in the life of the recovering addict that evokes ambivalence about how to respond to the occurrence. There is once again internal disagreement about how to manage conflict within the automatic thinking process. We can forget that we are still selfish during what feels so good and right in recovery. We are praying daily, perhaps attending recovery meetings or fellowship gatherings on a consistent basis that promote recovery principles, avoiding high-risk situations and associations that could jeopardize our health.

Then, BANG! We are hit with something unexpected that drops us to our knees; though, not necessarily to pray. We get knocked down. We need relief as soon as possible. Or, BANG! We are hit with an unexpected temptation that appeals to every impulse we have to “act out”. It could be a relationship, an event, a place, a smell, a dream… anything nostalgic that brings us face to face again with thought and feeling triggers that can and likely will challenge the rational sensibilities of recovery. Remember the passage from Romans 7 that says, “I do the things I don’t want to do and don’t do the things I want to do.” As we lose discipline in our recovery in the face of “justifiable” relapse triggers, what were obvious sensibilities regarding the principles to live by become less palpable. We can become less conflicted about “using” behavior. In weighing our ambivalence, we adopt the belief again that whatever we risk losing for instant gratification is worth it.

But afterward Jesus found him in the Temple and told him, “Now you are well; so stop sinning, or something even worse may happen to you.” John 5:14 (NLT)

Remember the story of the lame man who had been paralyzed nearly 40 years until he was healed by Jesus? Well, Jesus saw the man again. The man was walking around in the temple courtyard. This was an area that men went seeking out women, perhaps for hire. The healed man likely had not been intimate with a woman all that time. For all we know the man may have contracted a sexually transmitted disease that rendered him paralyzed. Whether or not that was the case, the healed man was engaging in undisciplined behavior; maybe returning to the very behavior that was his undoing in the past. He was starving for “relationship”. This is a strong case for the Bible identifying the matter of relapse.

Relapse Prevention

The CBT strategy for relapse prevention emphasizes, of course, cognitive awareness of high-risk situations that can trigger thoughts that rationalize using, that feeds cravings and fuels urges to use, and that trigger beliefs to justify using as a sensible acceptable option for managing the situation at hand. This could also involve a 4th, 5th, 6th, and 7th step in the process of being aware and alert to formidable obstacles along the recovery path. CBT considers the full spectrum of circumstances that precipitate relapse and seeks to keep the consequences of addictive behavior in the cognitive forefront to hopefully allow people in recovery to avoid the kind of dissonance that can sabotage the miracle of sobriety and avoid the destructive outcomes connected to relapse.

A wise person thinks a lot about death (destructive outcomes), while a fool thinks only about having a good time. Ecclesiastes 7:4 (NLT)

For by the grace given me I say to every one of you: Do not think of yourself more highly than you ought, but rather think of yourself with sober judgment, in accordance with the faith God has portioned to each of you. Romans 12:3 (NIV – modified)

There is so much Scripture that goes right to the heart of our relapse triggers that can prove to be effective intervention for the body, mind, heart, and soul. Below is a list of stressors that can trigger cognitive dissonance that given the opportunity to steer us in the wrong direction can be harmful to the best of our recovery.

Anxiety and Stress –

Rejoice in the Lord always. I will say it again: Rejoice! Let your gentleness be evident to all. The Lord is near. Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus. Philippians 4:4-7 (NIV)

Humble yourselves, therefore, under God’s mighty hand, that he may lift you up in due time. Cast all your anxiety on him because he cares for you. 1 Peter 5:6-7 (NLT)

Always be full of joy in the Lord. I say it again—rejoice! Let everyone see that you are considerate in all you do. Remember, the Lord is coming soon. Don’t worry about anything; instead, pray about everything. Tell God what you need, and thank him for all he has done. Then you will experience God’s peace, which exceeds anything we can understand. His peace will guard your hearts and minds as you live in Christ Jesus. Philippians 4:4-7 (NLT)

Don’t fret or worry. Instead of worrying, pray. Let petitions and praises shape your worries into prayers, letting God know your concerns. Before you know it, a sense of God’s wholeness, everything coming together for good, will come and settle you down. It’s wonderful what happens when Christ displaces worry at the center of your life. Philippians 4:6-7 (The Message)

Anger and Resentment –

And “don’t sin by letting anger control you.” Don’t let the sun go down while you are still angry, for anger gives a foothold to the devil. Ephesians 4:26-27 (NLT)

Surely resentment destroys the fool, and jealousy kills the simple. Job 5:2 (NLT)

Let some one else praise you, not your own mouth—a stranger, not your own lips. A stone is heavy and sand is weighty, but the resentment caused by a fool is even heavier. Anger is cruel, and wrath is like a flood, but jealousy is even more dangerous. An open rebuke is better than hidden love! Proverbs 27:2-6 (NLT)

An angry person starts fights; a hot-tempered person commits all kinds of sin (Self-Induced N-sanity). Proverbs 29:22 (NLT)

People with understanding control their anger; a hot temper shows great foolishness. Proverbs 14:29 (NLT)

Pride –

Those who belong to Christ Jesus have nailed the passions and desires of their sinful nature to his cross and crucified them there. Since we are living by the Spirit, let us follow the Spirit’s leading in every part of our lives. Let us not become conceited, or provoke one another, or be jealous of one another. Galatians 5:24-26 (NLT)

Sin whispers to the wicked, deep within their hearts. They have no fear of God at all. In their blind conceit, they cannot see how wicked they really are. Psalm 36:1-2 (NLT)

Don’t be selfish; don’t try to impress others. Be humble, thinking of others as better than yourselves. Don’t look out only for your own interests, but take an interest in others, too. Philippians 2:3-4 (NLT)

Pride ends in humiliation, while humility brings honor. Proverbs 29:23 (NLT)

Jealousy –

If you are wise and understand God’s ways, prove it by living an honorable life, doing good works with the humility that comes from wisdom. But if you are bitterly jealous and there is selfish ambition in your heart, don’t cover up the truth with boasting and lying. For jealousy and selfishness are not God’s kind of wisdom. Such things are earthly, unspiritual, and demonic. For wherever there is jealousy and selfish ambition, there you will find disorder and evil of every kind. James 3:13-16 (NLT)

Anger is cruel, and wrath is like a flood, but jealousy is even more dangerous. Proverbs 27:4 (NLT)

A peaceful heart leads to a healthy body; jealousy is like cancer in the bones. Proverbs 14:30 (NLT)

“I can see that you are full of bitter jealousy and are held captive by sin.” Acts 8:23 (NLT)

Guilt and Shame –

Even if we feel guilty, God is greater than our feelings, and he knows everything. Dear friends, if we don’t feel guilty, we can come to God with bold confidence. And we will receive from him whatever we ask because we obey him and do the things that please him. 1 John 3:20-22 (NLT)

Finally, I confessed all my sins to you and stopped trying to hide my guilt. I said to myself, “I will confess my rebellion to the LORD.” And you forgave me! All my guilt is gone. Psalm 32:5 (NLT)

“Fear not; you will no longer live in shame. Don’t be afraid; there is no more disgrace for you. You will no longer remember the shame of your youth.” Psalm 54:4 (NLT)

“Have I tried to hide my sins like other people do, concealing my guilt in my heart? Job 31:33 (NLT)

Those who look to him for help will be radiant with joy; no shadow of shame will darken their faces. Psalm 34:5 (NLT)

For the kind of sorrow God wants us to experience leads us away from sin and results in salvation. There’s no regret for that kind of sorrow. But worldly sorrow, which lacks repentance, results in spiritual death. 2 Corinthians 7:10 (NLT)

Suffering –

In his kindness God called you to share in his eternal glory by means of Christ Jesus. So after you have suffered a little while, he will restore, support, and strengthen you, and he will place you on a firm foundation. 1 Peter 5:10 (NLT)

Doubt –

I cried out, “I am slipping!” but your unfailing love, O Lord, supported me. When doubts filled my mind, your comfort gave me renewed hope and cheer. Psalm 94:18-19 (NLT)

Then Jesus said to the disciples, “Have faith in God. I tell you the truth, you can say to this mountain, ‘May you be lifted up and thrown into the sea,’ and it will happen. But you must really believe it will happen and have no doubt in your heart. I tell you, you can pray for anything, and if you believe that you’ve received it, it will be yours. Mark 11:22-24 (NLT)

Now all glory to God, who is able, through his mighty power at work within us, to accomplish infinitely more than we might ask or think. Ephesians 3:20 (NLT)

Fear –

And as we live in God, our love grows more perfect. So we will not be afraid on the day of judgment, but we can face him with confidence because we live like Jesus here in this world. Such love has no fear, because perfect love expels all fear. If we are afraid, it is for fear of punishment, and this shows that we have not fully experienced his perfect love. 1 John 4:17-18 (NLT)

Then Jesus got into the boat and started across the lake with his disciples. Suddenly, a fierce storm struck the lake, with waves breaking into the boat. But Jesus was sleeping. The disciples went and woke him up, shouting, “Lord, save us! We’re going to drown!” Jesus responded, “Why are you afraid? You have so little faith!” Then he got up and rebuked the wind and waves, and suddenly there was a great calm. The disciples were amazed. “Who is this man?” they asked. “Even the winds and waves obey him!” Matthew 8:23-27 (NLT)

Fatigue –

Then Jesus said, “Come to me, all of you who are weary and carry heavy burdens, and I will give you rest. Take my yoke upon you. Let me teach you, because I am humble and gentle at heart, and you will find rest for your souls. Matthew 11:28-29 (NLT)

I would like to encourage clinicians to leave a comment below concerning the relevance this Biblical approach to cognitive-behavioral therapy might have to your practice. This is the result of several years of researching what the writers of the Bible had to say about the cognitive-behavioral approach to change in recovery from MEdom—my addiction to me. God is so great. He is loving, gracious, and kind. And He has given us a way out by letting us in on all of it. Praise God!

Religious Cognitive Behavioral Therapy (Christian Version) 10-Session Treatment Manual for Depression in Clients with Chronic Physical Illness

Religious Cognitive Behavioral Therapy
(Christian Version)
10-Session Treatment Manual for Depression
in Clients with Chronic Physical Illness
Joseph W. Ciarrocchi, Ph.D.
Debbie Schechter
Michelle J. Pearce, Ph.D.
Harold G. Koenig, M.D.
With contributions by Rebecca Propst, Ph.D.
This workbook is a variant of the treatment protocol
originally designed by A. T. Beck, M.D.
2014
Christian version developed largely
by Michelle J. Pearce, Ph.D.
*Please cite appropriately*
Contact Information:
Michelle Pearce, Ph.D.
Department of Family and Community Medicine
Center for Integrative Medicine
University of Maryland School of Medicine
520 W. Lombard Street, East Hall
Baltimore, MD 21201
Office: (410) 706-6164
mpearce@som.umaryland.edu
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TABLE OF CONTENTS
PART I
Therapist Training Overview
PART II
Session 1 – Assessment and Introduction to RCBT
Session 2 – Behavioral Activation: Walking by Faith
Session 3 – Identifying Unhelpful Thoughts: The Battlefield of the Mind
Session 4 – Challenging Unhelpful Thoughts: Bringing All Thoughts Captive
Session 5 – Dealing with Loss
Session 6 – Coping with Spiritual Struggles and Negative Emotions
Session 7 – Gratitude
Session 8 – Altruism and Generosity
Session 9 – Stress-Related and Spiritual Growth
Session 10 – Hope and Relapse Prevention
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PART I: THERAPIST TRAINING
Session Length and Time
Each session is 50 minutes long. You may find that you run 5-10 minutes longer on the
first session depending on how long it takes to gather the assessment information. I have
indicated how long you should spend on each section in the session. If you stay within
these guidelines your session should be 50 minutes long. That said, there is a lot of
information in the manual and at times, depending on what the client brings to the
session, you may find that you are unable to cover all of the material in the allotted time
for the session. You can add a few minutes to the session, if necessary, and if you have
time. But please to not add more than 10 minutes. The material that is not covered in one
session should be covered after the homework review in the following session.
Session Format
Each session follows the same format:
1. Goals of session
2. To do before the session begins
3. Materials needed in client workbook
4. Set the agenda
5. Review of Home Practice Activities
6. Introduction to topic(s) for that session
7. Exercises to be completed in session
8. Home Practice Activities
9. Terminate session
Scheduling Sessions
It will be easiest for the client if you are able to choose the same meeting time each week.
Please emphasize in the first session (and throughout treatment, if necessary) how
important it is that the client complete all ten sessions. Discuss with the client how he can
contact you should he be unable to make one of the sessions. If this happens, please
reschedule the session as soon as possible.
Client Information
You can decide on the best way to keep track of the information you collect from your
clients as you progress through treatment. It will be helpful for you to have detailed notes
for each session that you can refer back to in later sessions. This is what the Therapist
Workbook for each client is for. This way you can track exactly what the client is
following and completing. Suggest a separate Therapist Workbook for each client.
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Differences from CBT intervention
As early as possible in treatment, the goal is to socialize clients into the treatment model
in order to facilitate communication between counselor and client. In general,
socialization is a dance between conventional cognitive behavior therapy (CBT) and
religiously integrative cognitive behavior therapy (RCBT). The framing of each aspect
of treatment reinforces both traditional CBT and religiously integrative CBT. To use a
metaphor to capture what is intended, think of a two-dimensional drawing of a square
placed into a three-dimensional cube. Everything within the square is contained in the
cube, yet the cube contains so much more. In the same way conventional CBT is like the
square that fits into religiously integrative CBT. When a client discusses symptoms and
reactions to symptoms, counselors will want to frame this material in terms of traditional
CBT models. Counselors also listen with a “third ear” for how this material can also be
framed within a religiously integrative CBT model. Many examples will be given
throughout the manual, the worksheets, and training.
Workbook/Home Practice Activities
Your clients should be given a copy of the Participant Workbook that has been written to
complement this manual. Please familiarize yourself with the Therapist Workbook, which
is an almost identical copy of the Participant Workbook. For each of the ten sessions,
there is a home practice activities instruction page. This is the same as the Home Practice
Activities section in your manual. You will review the assignments with your client at the
end of each session. Have them follow along in their workbook as you review the
assignments for that week. The pages that follow the instruction sheet in the Workbook
will be completed by the client during the week. For example, in the earlier sessions,
clients will complete a daily thought log. Sometimes you will complete a worksheet, or
part of a worksheet, with your client in session. This will be clearly indicated in the
manual.
The home practice activities are critical for the effectiveness of the treatment. (Note: we
are calling them home practice activities because that is a more inviting term to clients
than is homework, although in the manual the word ‘homework’ may be used. Please try
to refer to this as home practice activities when you are speaking with your client). It is
very important that clients understand from day one that they are expected to complete
the Home Practice Activities. The more they put into treatment, the more they will get
out of it. At the same time, we need to remember that we are working with a depressed
population who will also be limited in some degree by their medical illness. Therefore,
when clients do not complete their homework, praise them for what they did do (e.g.,
think about the assignment) so that they do not become discouraged. Focus the
conversation on what barriers they faced and problem solve with them so that they will
be more likely to complete the homework that week. It is much better for you to take
responsibility for the incomplete assignment (i.e., not explaining it well enough or
helping the client to anticipate barriers) rather than to let the client feel discouraged about
their inability to do yet another thing in their life. We don’t want them to feel like they
failed!
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It is also very important that clients have their completed home practice activities with
them when they meet with you (i.e., they need their workbook with them during each
session, as do you). Be sure to emphasize this point at the end of each session.
Adherence to the Manual
It is important that you closely adhere to the manual throughout treatment. Sessions will
vary between clients based on the specific problems, beliefs, and behaviors of the
individual clients. However, the information you teach, the order in which you teach it,
and the way in which you teach it should be similar across clients.
Suggested counselor dialogue in the Manual is provided in italics throughout. Counselors
do not have to use the exact wording given; however, it is important that the same
information is conveyed to the client. The manual specifically includes much of the
counselor dialogue so as to make the delivery of treatment as easy and efficient as
possible for the counselors. If you are using the telephone, you can read the dialogue
(without sounding like you are reading!). If you are using Skype, you can have the
manual with you and refer to it frequently as you deliver the treatment.
Handling a crisis
Patients should be given emergency contact numbers before they begin treatment. If an
emergency situation arises, you should take the necessary measures to stabilize the
patient and to ensure the safety of those in danger.
Training
All therapists should receive initial baseline training. We will be developing this training
in days to come depending on financial support that we can raise. We are hoping to
develop an online training program for this purpose.
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Part II: Individual Sessions RCBT Manual
SESSION 1: Assessment and Introduction to RCBT
Goals of Session:
There is a lot packed into this session. You will likely need 60 minutes instead of 50
minutes. You need to allow time for subject to respond; this is critical, even if time runs
out and session goes over 60 min (just record how much time it takes in Therapist
Workbook). Be careful that this session does not turn into a lecture by the therapist.
1) To introduce clients to the basic format of the program
2) To begin to establish rapport by allowing the client to discuss his/her basic problem,
life circumstances and religious beliefs with the therapist
3) To present the basic rationale for the treatment
4) To teach clients how to monitor their activities and mood.
Notes:
• Key sections and suggested counselor dialogue are highlighted in yellow.
• Some of the material in the Manual is repeated in the Workbook. We have
highlighted in blue some of this overlap. Note that there may be other sections
that are the same in both, including the Home Practice Activities that are not
highlighted.
• Suggested counselor dialogue in this Manual will be provided in italics
throughout. Counselors can adapt according to their own needs.
• Use the Therapist Workbook to keep track of your client’s responses and
comments for each of the ten sessions. It will be helpful for you to have detailed
notes for each session that you can refer back to in later sessions. It is essential to
keep therapist workbook for each client in a locked cabinet.
• The use of he/his and she/her are alternated throughout the Manual.
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• Thinking and Depression Overview
• Activity and Mood Monitor
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Rapport Building and Introduction of Basic Format (10 mins)
1. Counselors introduce themselves and invite the client to do the same.
**Remind the client that they have been assigned to the CBT treatment group that will
utilize their spiritual and religious resources in treatment]
Before we get into the program itself, I want to take some time for us to get to know each
other briefly. I will start by saying a few things about myself.
Introduce yourself and provide the client with your professional credentials and perhaps
share where you received your training. Also state that you are coming from a Christian
belief system:
I also consider myself a Christian and believe that one’s Christian faith can help one to
deal with one’s problems. I will help you make use of your faith in these sessions to deal
with your problems as it seems appropriate and you feel comfortable with it.
2. Counselors review with client the purpose of the study, its intentions, and its goals.
As you know, this treatment is designed to help people who are suffering from depression
and who are also dealing with a medical illness or disability. Having a medical illness or
disability is challenging and can be very stressful. We also know that your challenges go
far beyond just your physical body. Many people facing a medical illness notice changes
in their mood, thoughts, and relationships. Some question their identity and the meaning
and purpose of their illness. Many struggle with issues related to their faith and
relationship with God.
3. Reassure clients again that we will do everything possible to ensure that all
information will be confidential and will only be seen by the therapists and researchers
who are part of this study. Ask for questions
4. Counselors inquire about the client’s expectations and hopes regarding the treatment.
5. Counselors invite clients to ask any questions they have about treatment, and clarify
any misunderstandings that may have cropped up when asking about client expectations.
6. The completion of *all* ten sessions is very important. Clients should be informed
that each of the ten sessions offers different information. They should also be told that
while the treatment is effective for depression it can only help them if they make an
active commitment to participate fully in therapy. Emphasize that this is a partnership. If
they cannot make a session, they should contact you, the therapist, as soon as they know
that they will not be able to make the session and schedule an alternative time for that
session.
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Introduce Mood Rating Scale (2 mins)
**This should be BRIEF each week. Only allot 2-3 minutes at the most each week for
this check in.
Each week we will ask you before we begin to rate what your mood was during the week.
Using a scale ranging from 0 to 10, where 0 is the worst that you’ve ever felt in your life
and 10 is the best you’ve ever felt, what was your mood like on average this week?
*Note: At times you may then ask what made their week negative or positive. This is not
necessary this week because you will be assessing the reasons for their participation in
treatment in a few minutes
Initial Assessment Questions in Spiritual/Religious Domains (10 mins)
The questions below (partially taken from Ciarrocchi, 2002) provide one way to explore
clients’ spiritual and religious experience. They should be used flexibly and do not
necessarily have to be asked in this order, although there is a certain logic in the way they
are currently arranged. Regardless of where you are personally coming from, be very
accepting of the client’s expression of their faith.
1. What role, would you say, spirituality or religion plays in your life?
2. Do you attend religious services? How frequently?
3. Do you pray? How often?
4. Do you enjoy reading religious or spiritual literature, such as the Bible?
5. What effect, if any, does . . . [the issue that brings the person into treatment]
have on your spirituality?
The reason for gathering this information is to obtain a solid understanding of the
clients’ faith tradition, religious beliefs, language and sacred symbols used to
express their faith, so that this can be integrated into therapy in a client-centered
way. Of critical importance is that therapists begin where clients are in terms of
their spirituality, utilizing whatever spiritual resources clients may have. Therapists
should avoid arguing with patients about spiritual or religious matters, and instead
go with wherever patients feels comfortable with (at least to start), while gently
introducing more explicitly religious material to them over time as they are able to
receive it.
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Assessment of Problems (5 mins)
After the initial introductions, ask the client what problems led them to decide to
participate in the current treatment program. It will be helpful for you to have already
read through the client’s assessment materials so that you are somewhat familiar with the
reason he is seeking treatment and his medical issue(s). Ask the client to say in a sentence
or two why they are seeking treatment. These prompts will help to keep this section brief.
Paraphrase back to the client to make sure that you understand him. Do not spend more
than 5 minutes on this assessment.
Try to empathize at least once with each problem that is presented. For example, “It
sounds like you are feeling ___________________ ?”
To gain rapport with the client, summarize through reflective listening the major
struggles you have heard and any personal or environmental strengths/resources you have
noticed.
It is also not too early to ask the client to identify which aspects of their emotional
distress and environmental problems they might like to work on during the treatment:
Of all the different things you’ve mentioned, which ones stand out for you as creating the
most difficulty, and which you want to work on together during the sessions?
Presentation of Rationale for Treatment (8 mins)
As early as possible in treatment, the goal is to socialize clients into the treatment model
in order to facilitate communication between counselor and client. In general,
socialization is a dance between conventional cognitive behavior therapy (CBT) and
religiously integrative cognitive behavior therapy (RCBT). The framing of each aspect
of treatment reinforces both traditional CBT and religiously integrative CBT. To use a
metaphor to capture what is intended, think of a two-dimensional drawing of a square
placed into a three-dimensional cube. Everything within the square is contained in the
cube, yet the cube contains so much more. In the same way conventional CBT is like the
square that fits into religiously integrative CBT. When a client discusses symptoms and
reactions to symptoms, counselors will want to frame this material in terms of traditional
CBT models. Counselors also listen with a “third ear” for how this material can also be
framed within a religiously integrative CBT model. Many examples will be given
throughout the manual, the worksheets, and training.
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CBT Model Overview
Our goal is to provide the most up-to-date treatment available to help you with your
difficulties with depression and your medical condition. Recent research has identified a
number of treatments that are called “evidence-based”. This means that a sufficient
amount of research has determined that a specific treatment is effective in reducing
certain symptoms. We have selected one of the most well researched evidence-based
treatments for depression known as cognitive behavior therapy (or CBT). This treatment
is based on the idea that emotional distress is in many ways associated with how we view
a situation, and that we can obtain emotional relief by changing our views about the
events in our life.
The most effective way of employing the model is to use material the client has given
you from this early assessment. Ideally, pick some emotional reaction that appears
connected to how the client is viewing the situation. Potentially good examples include
getting angry at those who do not anticipate their needs, getting depressed because they
imagine people are viewing them in certain negative ways, giving up on activities
because they don’t believe they have sufficient support or the proper skills, etc. The idea
here is not to prove anything to the client, but simply show how things tend to go
together. Never argue with the client. Remember the adage, “Win an argument and lose
a client”.
If you do not get any material from the client you can share a commonly used example:
Let me share an example from the workbook that can help illustrate my point. Please feel
free to follow along with me. It says: “Imagine that you have a flat tire on a deserted
highway and do not have anything to change the tire with, including a car jack. As you
are standing there stranded, your next-door neighbor drives by and looks up briefly but
keeps going. How would you feel about the fact that your neighbor kept driving? What
would you most likely be telling yourself about the situation?
Now let’s imagine, further, that you see your neighbor the next day and he comes over to
you and apologizes for driving by you. “I’m so sorry I couldn’t stop; my son fell and was
bleeding from his head and I was rushing him to the emergency room.” How might you
be feeling now? What changed? What are you now telling yourself about the situation
that is different from when you were standing on the road?
NOTE: When sharing material from the workbook, it is helpful to find out whether the
patient has already read the material. If the sections have already been read, the therapist
or patient can summarize and discuss the illustration. If the section hasn’t been read, a
helpful alternative may be to ask the patient to read the section and share reflections.
Having some discussion around this idea will get across what you will be looking for in
treatment. (You can have the patient turn to page 2 in the Workbook: “Thinking and
Depression” for a description and pictorial model),
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The main point is how we view a situation and interpret it often drives how we end up
feeling and what we do. Research has shown that the perceptions and interpretations of
depressed individuals are usually not accurate. They have a greater tendency to jump to
conclusions and see only the negative side of an issue. The way you look at a situation in
turn will influence your behaviors, and thus a vicious cycle is set up. Together you and I
will attempt to identify the ways of looking at situations that make negative emotions
worse, with the idea of changing the situation or the way it is being interpreted.
Again at this point it is important to pause so as to ascertain the extent to which the client
has understood and agrees with these points. At this point, complete agreement with this
framework by the client is not necessary. However, this process should have been
initiated. Ask for questions.
Also underline the fact that these points will be emphasized again and again in the
remaining therapy sessions. In addition, an explanation and diagram of this model is
provided for clients in their workbook. You can tell clients about this resource and have
them read it on their own this week. In other words, if this session feels like a lot of
information at once, it is! As such, a summary of this information in the session is
provided in the workbook so that they can refer back to it during the week.
Religiously Integrative CBT Model Overview. (10 mins)
Extend and emphasize the rationale by giving a theological basis for it. If the client asks
about the specifics of your own faith, you can return the focus to the client by reminding
her that the purpose of the treatment is to integrate her faith into treatment. As such, you
will want to learn about what she believes and practices, as this is what is important for
the success of treatment and helping her to feel better. The following can be included.
Please use prompts and questions about clarity of the material to break up lengthy
therapist dialogue as you see fit, both here and throughout the entire manual.
What is innovative about this treatment is that we want to use as many of the important
resources available to people to combat their depression and to make their lives more
effective. As we discussed earlier, one of the most overlooked resources people have is
their religious faith.
Call attention, as appropriate, to your referencing of the following workbook material:
The idea that our thoughts and assumptions play an important role in influencing our
emotions and our behaviors is a very common idea in both the Old and New Testaments.
Indeed, for Christians the cognitive behavior model is 2000 years old! Let me give you
some examples from the Bible:
The first words of both John the Baptist and Jesus in their public ministries were,
“Metanoia” literally meaning “Change your mind” or “Change how you think”, which
the Bible translated as “Repent”. To repent means to change your attitude, change your
mind, change how you think (Matthew 4:17).
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The apostle Paul told the Roman Christians, “Do not be conformed to this world, but be
transformed by the renewing of your minds, so that you may discern what is the will of
God — what is good and acceptable and perfect” (Romans: 12:2). In other words, Paul
is saying that transformation comes about by renewing your mind.
I’ll be providing many more examples from the Bible as we go through this treatment
together.
Introduction to role of behavior to change mood
One of the ways we can change our thinking is by changing what we are doing. Some
activities or behaviors give us a sense of reward, satisfaction, or pleasure. These positive
activities produce positive or good moods. For example, if you talk to a friend or did a
job well, you will feel good. However, if you failed at something or got a parking ticket,
you will tend to feel in a bad mood. Therefore, in this treatment we will focus not only
upon changing our thoughts and perspectives but also upon changing some of our
behaviors and activities so that we will feel better about that aspect of our lives as well.
Introduce Concept of Renewing Your Mind (5 mins)
*It is very important that you spend adequate time on this section and provide a thorough
explanation for why memory verses will be given each week. This section provides the
“buy-in” for the client for this critical part of treatment.
One of the ways we will begin to change our thoughts and perspectives is by replacing
negative and unhelpful thoughts with the Word of God. The Bible also states that the
Word of God is alive and very powerful. As we meditate on scripture, God’s words
become alive in us and change us from the inside out. Think about what happens when
you plant a seed. The kind of crop you grow depends on the kind of seed you put in the
ground. If you plant a tomato seed, don’t expect to grow cucumbers! The same is true for
the “seeds” you plant in your heart. If you plant positive seeds of truth in your heart,
God’s words and promises, you will begin to think in the way that God thinks and will
reap the good things He says about your life.
[elicit feedback from client]
Each week I will give you a verse that is relevant to the topic we are studying. Part of
your homework assignment each week will be to memorize this verse. The more of God’s
Word you have hidden in your heart, the easier it will be to challenge and change your
negative thinking, a skill we will learn in a few weeks. At the beginning of next session, I
will ask you to say the memory verse to me, as a way to review what we learned in our
previous session. I’ll also teach you an effective way of meditating on these verses, called
contemplative prayer that will help you remember and apply God’s way of thinking in
your life. Do you have any questions about this part of the treatment?
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Homework Assignments (10 mins)
Please open your Workbook to Session 1, page 1.
We are just about out of time for today. The last thing we will do in each session is go
over your homework assignments, which are found in your workbook. Each session after
this one will begin by reviewing your homework assignments. It’s very important that you
complete all of your assignments. This treatment will only be effective if you are spending
the week putting what you learned in your session into practice. I only have you for 50-60
minutes each week. Therefore, most of the change you will experience in your life will
occur outside of these sessions. The more you put into this treatment over the next ten
weeks, the more you will get out of it!
1. Memory Verse
This week your memory verse is the following:
“Finally, whatever is true, whatever is noble, whatever is right, whatever is pure,
whatever is lovely, whatever is admirable—if anything is excellent or
praiseworthy—think about such things.” (Philippians 4:8)
Write the verse down and post it somewhere you will see it often, perhaps on a sticky
note placed on your mirror or fridge. You may want to make several copies and post
them in places you will see it throughout the day.
Make sure clients understand why they are being given this assignment and the
importance of taking the time to commit the verse to memory.
2. Activity and Mood Monitor
Explain to the client that part of the active nature of the treatment is to try out
different approaches between sessions to see what works best.
The goal of the first session’s homework assignment is begin developing skills in selfmonitoring negative emotions. The goal at this stage is not to change any regular
habits. Rather, clients are merely to complete the self-monitoring log as follows:
The second part of your first homework assignment will be to record your daily
activities and mood. Please turn to page 4 in your Workbook. The self-monitoring
logs in your workbook have a place to record your activities and mood every two
hours. Please complete this log daily. It may be easiest to fill out the activity log
twice during the day. For example, you could record all of your morning activities
when you eat lunch and all of your afternoon and evening activities just before you go
to bed. I would like you to do this until our next appointment.
This record will give us some information as to which activities may lead to better
moods and which activities may lead to worsened moods. I will show you how to do it
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by helping you fill in the spaces for the present time period. For example, right now
the time is______________. What types of activities have you been doing the last two
hours, especially the last half hour or so?________________ Finally, what is your
mood right now?___________________ Generally, you should record your mood
and activity as they exist at the end of the time period.
[Or, you can the client fill in her activities and mood so far that day, rather than just
the last two hours.]
The following principles should be communicated to the client regarding selfmonitoring. These instructions are included in the client’s workbook.
[Ask the client to turn to the first page of her workbook and have her follow along
with you as you review these principles.]
a. Keep the self-monitoring log with you throughout the day and record your
activities as close as possible to the end of the time periods.
b. Record the activity in a very few words. For example, you could record “went out
to dinner” or “washed my clothes” or “read a book” or even “watched TV.”
c. Immediately after recording your activities, record your mood.
d. Purchase a notebook to put the logs in, so that you will have a record of your
activities. We will make use of them later.
e. Make sure you have your logs with you during each session. They are necessary for
the rest of the program
f. Be sure and include even trivial events on your chart, such as missed the bus or
read the newspaper.
3. Solicit feedback on how the session went today.
Terminate the Session
1. End the session by making sure you are both clear on your next meeting time, as well
as the homework assignments.
2. Be sure that the client understands that he needs to have his completed homework
assignment worksheets readily accessible next week so you can review them together.
3. Thank the client again for the courage he has demonstrated through his willingness to
work on these difficult issues.
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SESSION 2: Behavioral Activation: Walking by Faith
Goals of Session:
1) To reinforce the client’s basic understanding of the treatment rationale;
2) To further refine the client’s ability to self-monitor mood and activities;
3) To contract with the client to add more positive activities to their daily schedule.
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• Pleasant Activities to Consider
• Planning Pleasant Activities Instructions
• Planning Pleasant Activities Worksheet
• Unhelpful Thinking Styles and Theological Reflections
Set the Agenda
Our session today is called “Behavioral Activation: Walking by Faith.” We will be
examining how our behavior directly impacts our mood and ways we can engage in more
positive behaviors to improve our moods. At the end, I will give you a homework
assignment based on what we sent over today and another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your mood this week and homework assignments.
Complete Mood Rating Scale (2 mins)
a. Using a scale ranging from 0 to 10, where 0 is the worst that you’ve ever felt in
your life and 10 is the best you’ve ever felt, what was your mood like on average
this week?
To keep this section brief, you may find it best to only ask what the client’s mood
was like on average, but not why. You can then cover the ‘why’ aspect as you
review the thought logs.
b. Indicate that today you will be discussing alternative ways of coping that may be
more effective.
Review of Home Practices Activities (10 mins)
It is important to begin each session with a review of the previous week’s homework
assignments, as this reinforces their efforts and feeds their motivation to complete future
assignments. It also represents an ongoing socialization of the CBT model.
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1. Memory Verse Review: Ask the client to say last week’s verse to you from
memory. If they can’t remember the verse, have her read it out loud from her
Workbook (follow this protocol each week). Ask the client to tell you how this
verse ties in with the topic of the first session last week.
Finally, whatever is true, whatever is noble, whatever is right, whatever is pure,
whatever is lovely, whatever is admirable—if anything is excellent or
praiseworthy—think about such things. (Philippians 4:8)
2. Go over the home practice activities log with the client, correcting any errors and
suggesting that she either write more or less when describing activities, if
necessary. Be brief!
3. It is important to give the client positive reinforcement for completing the
homework at least two or three times during the discussion.
4. Review with the client any negative emotional experience, which they tracked by
writing it down, or, if they didn’t write it down, what they can recall from
memory.
Tips and Problem-Shooting
Remember for some depressed individuals it is often difficult to do any activity. If the
client collected no data at all, complete the log for one or two events with them.
Clients frequently do not get the hang of this the first time, so it is useful to praise
anything that they accomplished and fix things that were not completed correctly in a
nonjudgmental manner. The main point of the exercise is to see if they understand the
mood-behavior-sequence or saw a pattern emerging.
The counselor uses information from the client’s experiences during the week to further
socialize the client into the CBT model. The counselor points out how our beliefs,
expectations, or thoughts are closely connected to the way we end up feeling and to what
we end up doing.
Practice: Alternative Ways to View Situations from the Week
Briefly, you can invite clients to consider alternative ways they could have viewed one
situation. Clients are then invited to consider other ways they may have ended up feeling
and what other behaviors they might have tried had they viewed the situation in this
different way. When client and counselor together work their way through one simple
example, the counselor can point out that, in essence, this is the heart of what they will be
attempting to do over the course of treatment. Even though they will need to develop
skills in doing this “on the spot” so-to-speak, the main point of the therapy is really not
more complicated than what they have just accomplished.
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Incorporate Religious Faith in Developing Alternative Viewpoint
As they develop the alternative viewpoint counselors can now ask the following:
When you look at your original belief, expectation, or your way of thinking about the
situation, are there any beliefs or attitudes from your Christian faith that strike you as
helping to generate an alternative viewpoint?
Behavioral Activation: Positive Activities and Walking by Faith (15 mins)
Point out from the client’s chart how it is indeed that certain activities lead him to have a
more negative mood (this may be a reiteration of above). Indicate also, if this is the case,
(which it usually is) that there do not seem to be too many positive activities in his daily
schedule. As such, one of the first things we want to do is change that. Introduce the
exercises with the following rationale. You can break up this lengthy dialogue by asking
questions or providing other prompts.
Our main idea today is quite simple: one of the most effective ways to change our mood
is to engage in pleasant activities. One of the first steps in changing our perceptions and
negative thoughts is to begin to see the good things in our environment and to make some
of them a part of our daily activity.
In 2nd Corinthians 5:7 it says that “the righteous live by faith and not by sight”. This can
also be read as ‘the righteous live by faith and not by feelings.’ In other words, many
times we don’t feel like doing something, but we are asked to do it anyway. Jesus didn’t
feel like dying a painful death on the cross, but He did it anyway: “for the joy set before
Him, He endured the cross” (Hebrews 12:2). Notice that the joy in this verse is in the
future. Jesus was not feeling joyful about being accused, beaten, and put to death on the
cross, but He was able to look at His difficult circumstance from the perspective of what
the result of His sacrifice would be—victory over sin and death so that He could have an
eternal relationship with us. In the same way, God asks us to do things that we may not
feel like doing for our own good. He asks us to walk by faith and act in a certain way or
engage in a certain behavior and trust that our feelings will follow the decision we make
with our wills. We have to trust that our feelings and desire will follow our attention and
our actions.
We cannot always remove the source of the negative events — in your case, for example,
your medical condition — but things can be improved by increasing the number of
positive events. .
Can you recall any time that you have been feeling badly but forced yourself to attend
some pleasant social or physical event and it picked up your mood?
[Review with the client any examples given and analyze in detail what precisely the
client did, what was going on at the time, and how, in the client’s opinion, this picked up
his or her mood].
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Later we will see how inactivity is often a form of avoidance. Avoidance has a snowball
effect. We’re tired and don’t go out. By staying home it seems like we get even more tired,
and now we want to go out even less. So on and so on until we barely can do anything to
help ourselves.
To break this vicious cycle we need to —
• Identify the link between doing nothing and bad moods and feelings.
• Identify activities that are likely to pick us up.
• Plan which activities can happen at what time in our schedule.
• Identify and obtain commitments from others who will be part of these plans.
To help with this work we have a simple Record sheet to identify which events give us a
sense of enjoyment and accomplishment as well as a Planning Worksheet* to help us
follow through on fun activities.
Choose Pleasant Activities for Homework Assignment (10 mins)
Ask the client to turn to page 10 in the Workbook (“Planning Pleasant Activities
Instructions”) to follow along as you describe this next activity. Assist the client in
identifying both mundane events (doing dishes, making beds, cleaning the garage, driving
a child to school, a special project at work, etc.), as well as less common ones that might
be considered recreational (taking visitors out to dinner, a visit to a museum, going to the
movies, etc.). Turn to page 9 in the Workbook: “Pleasant Activities List” for a list of
potential activities.
Ask her to decide on two activities that she would like to do between now and the next
appointment. Stress that the activities need only be small activities and often it is the
small things that make a difference in their lives. These activities should be ones that take
more than 10 to 15 minutes to perform yet that can be accomplished in one day.
After she has made a decision on two activities, refer her to the Planning Pleasant
Activities Worksheet* on Pages 11 and 12 and complete *both* pages (items #1 to #3)
with her. The following rules are important:
1. The activity should be specified exactly. For example, if it is to browse in a
bookstore, have her specify the bookstore that they will visit. Likewise if she is to
visit some setting she should exactly specify that and how she will get there. This
is important to insure that the activity will be carried out.
2. All information regarding date and time should also be noted.
3. The chart should be completed before the end of the session. Indicate she can note
on the chart when she has completed the activity.
She should also be careful to note on her logs when the activity is carried out, also being
careful to note her mood.
**Note: Both activities should be planned & written down before the end of the session.
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The Power of People for Improving Mood (5 mins)
For most people, associating with others gives our reward and pleasure centers a big
boost. When considering Pleasant Activities* keep in mind activities that involve being
with others. People are usually great distractions from our own troubles. Similarly
people will generally be empathic about our struggles and we naturally shift topics to
more pleasant conversation over time.
A great way to engage in more than one pleasant event at once is to identify supportive
persons from your faith community. Such people not only can be there for you as others
are, but even without speaking about religious topics there is a deep bonding that takes
place because of your common faith. It also helps to choose someone who is suffering,
too. That way you can get your mind off of your problems by listening to and caring for
them, and it helps you to be grateful for what is going well in your life.
Therefore, we can use today and the coming week to try to identify such persons if they
already exist, and if not, figure out how we might discover them in your community. Once
this is accomplished the next task is to make contact with them and find out whether they
could be ongoing contact persons and supportive resources in the future. Are there such
persons in your life now? How often are you able to be with them?
*Note: The person needs to be local and ideally not a family member. If they do not
belong to a faith community, you can help them think of someone else in their
community.
This leads to a problem solving discussion of how to identify and make contact with such
persons. The homework assignment will be to at least identify several possible faith
companions, and to begin to make contact, if not during the week, after discussion with
you after the next session.
Homework Assignment (8 mins)
Ask the client to turn to page 7 in her Workbook to follow along with you as you describe
her Home Practice Activities.
1. Memory Verse
“We walk by faith and not by sight.” 2nd Corinthians 5:7
As you did last week, write the verse down and put it in a place, or ideally more than
one place, where you will see it many times a day. The more you meditate on these
verses the more your mind is renewed and the greater improvement you will begin to
see in your mood.
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2. Plan Pleasant Events
• Keep track of your accomplishments (mastery) and pleasant events on the
record sheet. This will provide us a lot of information to help plot the future
in terms of activities for improving your mood.
• Select two pleasant events to accomplish between now and next session. Fill
out a Planning Pleasant Activities Worksheet for both activities. Remember to
complete the worksheet after you finish the activities.
3. Identify and Contact Member of Faith Community
When you reach out to people, especially those who are in a worse situation than
yourself, it helps to get your mind off of your problems, helps you realize that things
could be worse, and helps you to feel grateful for what you do have. It also gives you
a sense of purpose and meaning that will result in eternal rewards as a service to God
by caring for another.
This week, identify several possible faith companions and make contact with at least
one of them. You might say something like this to the person you reach out to: “I’m
having a pretty difficult time now and I’m wondering if you would agree to pray for
and with me during this period. Maybe we could talk on the phone or go out for
coffee once a week or every other week.”
4. Reading
*Emphasize: Please read the pages in your workbook titled, “The Categories of
Unhelpful Thinking” to prepare for next week’s session. This is somewhat lengthy
and to make the most of the limited time in session it very important that you have
already reviewed this material.
*There are seven pages in this reading; you can suggest that she read one page a day
to make it seem less overwhelming.
Review with the client any questions about the assignments, and brainstorm any potential
problems that could get in the way of carrying them out: e.g., the client is going on
vacation this week.
5. Solicit feedback on how the session went today.
Terminate Session
Terminate the session, following the instructions listed in Session 1.
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SESSION 3: Identifying Unhelpful Thoughts: The Battlefield of the
Mind
Goals for Session:
1. Introduce cognitive processing: Teach client to identify mood and thoughts
accompanying changes in mood
2. Introduce categories of unhelpful thinking
3. Present theological reasons for why these types of thinking are unhelpful and
unbiblical
4. Introduce Contemplative Prayer
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• Unhelpful Thinking Styles
• Contemplative Prayer: Praying God’s Word
• ABC Method for Challenging Beliefs Leading to Negative Emotions
• Planning Pleasant Events
Set the Agenda
Our session today is called “Identifying unhelpful thoughts: The battlefield of the mind.”
We will learn how to identify the thoughts you have that lead to negative emotions. We’ll
examine a number of unhelpful thinking styles and theological reasons for why these
types of thinking styles are unhelpful. We will also discuss contemplative prayer. As
always, at the end, I will give you a homework assignment based on what we discuss
today and another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Review Homework Assignments (10 mins)
1. Review Memory Verse: Ask the client to say the verse from memory. If she is not
able to do so, have her read the verse from the Workbook instead.
“We walk by faith and not by sight.” 2nd Corinthians 5:7
2. Review with the client the Weekly Mood Scale to get an overall sense of the level of
depression recently.
a. Using a scale ranging from 0 to 10, where 0 is the worst that you’ve ever felt
in your life and 10 is the best you’ve ever felt, what was your mood like on
average this week?
b. Empathize with her response and state that you will review why this was the
case as you go through the session.
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3. Review the client’s success in making contact with a person from faith community
4. Review the client’s two Scheduled Pleasant Activities. Discuss with the client any
difficulties he may have had with the assignment. Do not spend too much time
attending to the problems and complaints.
• Praise the client for his efforts in carrying out the assignment, specifying what he
did well; even if the assignment was not completed.
• Note very carefully whether there was any change in mood while the activities
were being done.
• Reflect on whether or not this exercise brought home the idea that he might not be
paying attention to how ordinary aspects of daily living give him some sense of
control and pleasure.
o Did the sheets help him plan for more activities that bring him feelings of
control and pleasure?
o What immediate and long-term effects did planning and carrying out these
activities have on his mood?
Didactic: Identify Thoughts Accompanying Changes in Mood
If Mood Changed Following Activity:
If the individual’s mood was improved, the Therapist should reinforce the rationale,
pointing out:
Indeed, as had been discussed, changing one’s activities, leads to a change in mood.
This is because one is led to pay more attention to the positive aspects of one’s
environment and perhaps see more readily some of God’s gifts that were there all the
time.
If Mood Did Not Change Following Activity:
If the individual’s mood did not improve because of the increased positive activities, he
will most likely be puzzled and a bit discouraged. This puzzlement will present the
perfect opportunity to present him again with the cognitive model.
If changing your activities did not result in a more positive mood, it probably is because
you were not paying attention to the positive aspects of the situation and instead were
saying something negative to yourself about the situation. However, since I did not ask
you to monitor your thoughts, you do not know what those thoughts were. In a few
moments we will do that, but first I want to say a few things about the examination of our
thoughts.
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Thought Monitoring Rationale (5 mins)
As I said before, our thoughts are closely related to our emotions and the behaviors we
do. A decrease in a certain activity may result, for example, because we have told
ourselves that ‘I won’t be able to do it,’ or ‘if I do this I will only feel worse.’ Likewise, if
an individual tells herself that, ‘I am stupid,’ she is not likely to feel very good. These
thoughts, however, are not something that we are readily aware of. Often the depressed
individual has become so use to saying negative things to herself, that she is completely
unaware of them. The purpose of the program then is to teach you to become aware of
what you are saying to yourself. This will take some time and effort on your part.
Patterns that have become so deeply engrained over the years are hard to become aware
of and remove. For example, if you drive a car, you have ceased to become aware of all
the behaviors you do while driving a car. The same is true of thoughts. However, I will
work with you to make you aware of them.
[Here it might be good to ask the client what he / she thinks about this, before
proceeding]
The importance of being aware of our thoughts is, again, a very important notion in the
scriptures. For example, in the Old Testament, the psalmist says, ‘search me, oh God,
and know my thoughts’ (Psalm 139). David is asking to be made aware of what he is
thinking. As you proceed through these exercises, you may find it helpful to stop and
pray and ask God to reveal your thoughts to yourself as you wait quietly before Him.
Sometimes it may even help to talk to yourself. In Psalm 42, for example, the psalmist
says, ‘Why are you cast down, oh my soul?’ He is talking to himself and examining his
thoughts in an attempt to perhaps discover why he is feeling depressed.” Indeed, if we
are going to modify our thoughts and bring every thought captive to Christ or think in a
Christ-like manner (as 2 Corinthians 10.5 says), we must become aware of those aspects
of our thought which are incompatible with Christ’s.
Do you have any questions about this?
ABC Method of Identifying Thoughts (15 mins)
*This is the meat of the cognitive component of the intervention. Be sure the client has a
good understanding of this by the end of the session. We will continue this in Session 4,
adding the next steps for challenging their thoughts.
Now I’d like to teach you the ABC method to identify your thoughts. This method will
help you see how your thoughts, feelings, and behaviors are all linked. You will learn to
be like a scientist, examining your thoughts carefully and objectively, before
automatically accepting them as truth.
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The first step, “A,” stand for the Activating Event. When you notice that you are feeling a
negative emotion, I would like you to stop and ask yourself, what just happened? What
did I do? What did others do? This step is used to describe the situation. It can be helpful
to use the ‘who, what, where, when’ questions to complete Step A.
The second step, “B,” stands for Beliefs. You are going to identify the thoughts that went
through your mind as a result of the activating event. You will ask yourself questions such
as, What do I believe about the activating event? What just went through my mind? What
am I telling myself about this situation? What is my interpretation of what just happened?
The third step, “C,” stands for Consequences. There are two kinds of consequences I
want you to identify. The first is the emotional consequences. You will ask yourself, what
am I feeling right now as a result of the automatic thoughts I identified in Step B? (e.g.,
anger, depression, frustration, self-pity, etc.). You will then rate how intense those
feelings were using a scale from ‘0’ indicating the worst you have ever felt to ‘10’
indicating the best you have ever felt.
[Here it might be good to ask the client what he / she thinks about this, before
proceeding]
The second consequence is behavioral. You will ask yourself, What am I doing as a result
of believing these thoughts and having this interpretation of the activation event? Am I
behaving in a way that is unhelpful or destructive? (e.g., drinking, attacking, moping,
avoiding, etc.).
Note that usually the best way to know that we have just had some sort of negative
thought or interpretation is the negative emotion we are feeling. So, although emotional
consequence isn’t recorded until step 3 (Step C), you may find yourself using your
negative emotions as the first clue that you have been thinking negative or unhelpful
thoughts.
Does this ABC method for identifying your thoughts and their consequences make sense
to you? Do you have any questions?
[Encourage feedback here]
Next week will add another two steps to this method, but for this week we are going to
practice these first three steps.
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Put Steps into Practice
Let’s try this method together using the ABC Worksheet* in your workbook. Let’s choose
an example from this week and work through it together. I’d like you to write down your
answers on the worksheet as we go. This way you will have an example to refer back to
this week when you are completing this on your own this week
*Work with the client to come up with a suitable situation to work through together. It
may be something that came up earlier in the session or in previous session.
What is Step A, our activating event? What are we doing right now? Have the client write
this down on the worksheet.
What will you write down for Step B? What are you thinking about or have you been
thinking about as I’ve been explaining how to identify your thoughts?
Allow the client to answer and then sum up the answer with the following:
“It sounds like you are telling yourself___________________” (Have the client record
this on their worksheet in the appropriate row.)
Step C is the emotional and behavioral consequences. How depressed are you right
now? Now rate how intense those feelings were using a scale from ‘0’ indicating the
worst you have ever felt to ‘10’ indicating the best you have ever felt.
Provide feedback for the client about how they used the ABC method and be sure to
praise their efforts.
Introduce Categories of Unhelpful Thinking and Theological Reflections (10 mins)
Last week I asked you to read over the pages in your workbook on the Categories of
Unhelpful Thinking. Did you have a chance to do that to prepare for this week’s session?
Whether or not the client has read these sheets, review each category of thought with
them by sharing with them 1) the name of the category, 2) the definition, and 3) the
example. You can skip the section on why these thoughts are unhelpful.
After you have provided the client with these three pieces of information, have her read
the theological reflections to herself. One at a time, go through all ten categories in this
manner.
If she did not read these sheets last week, ask her to do so this week. You can have her
read one page a day, as there are seven pages, to make the task seem less overwhelming.
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We all have our “favorite” categories of unhelpful thinking, myself included. As you read
through all of the different types, which kinds of unhelpful thinking categories do you find
yourself using often?
After briefly discussing her “favorite” categories, ask the client if she has any questions
or thoughts about the theological reflections. It is important to highlight this aspect as you
want them to draw upon their faith and Biblical beliefs to challenge their unhelpful and
negative thoughts. The theological reflections ground this exercise in their faith, which is
different from secular CBT, and, we think, more effective. It also helps them to see
Christ’s perspective and shows them that this is more than just thinking positive thoughts.
It is about focusing their minds on Truth. Be sure to emphasize these points in this
session.
Complete ABC Thought Log
Now, return to the ABC log you filled out together earlier in this session and ask him to
categorize his beliefs, indicating the appropriate abbreviation on the log. Ask him why he
thinks each thought thus categorized belongs in the chosen category. This way, not only
are you applying the information, but you can also be teaching it as you go through each
thought on the thought log.
**Note: The following are included for the therapist’s convenience. They are also
provided in the client and therapist workbook.
1. All-or-Nothing Thinking (AN):
You see things in black-and-white categories. If your performance falls short of perfect,
you see yourself as a total failure.
Example: An example would be a straight-A student who received a B on an exam and
concluded, “Now I’m a total failure.”
A. Why is this thinking incorrect?
This type of thinking causes one to fear any mistake or imperfection because that is taken
as an indication of being worthless. This way of evaluating things is unrealistic because
life is rarely completely either one way or the other. For example, no one is absolutely
brilliant or totally stupid. Nothing on earth is totally one way or the other. Rarely, does
everyone always like us, or rarely do we always find the perfect solution.
B. Theological reflection
The idea that nothing on earth will ever be perfect, including people and their activities is
certainly a common theme in the New Testament. Romans 3:23, for example, says that
everyone has failed in some way, or to use the New Testament language, they have
sinned. However, Romans 3:24 goes on to say that even though we are not OK, that is
OK. In other words, we are accepted by God anyway, through His forgiveness. This
theme is expressed in Romans 8:1: “there is no condemnation for those who are in
Christ.” Romans 5:12 continues this theme and says that “we are justified by faith, and
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we therefore have peace with God.” In other words, we need merely to have faith in the
perspective that we are OK as far as God is concerned.
2. Overgeneralization (OG):
You see a single negative event as a never-ending pattern of defeat.
Example: An example of this type of thinking would occur when a shy young man, who
is self-conscious of his artificial leg, mustered up his courage to ask a woman for a date.
When she politely declined because of a previous engagement, he said to himself, “I’m
never going to get a date. No one wants to date a guy with only one leg.” He believed that
all women will turn him down just because one declined his offer. And, he erroneously
assumed it was because of his artificial leg. The pain of rejection is generated almost
entirely from overgeneralization.
A. Why is this thinking incorrect?
It is logically incorrect to conclude that one thing that happened to you once will occur
over and over again. It is also incorrect to assume that all situations are similar; or that all
individuals are similar.
B. Theological reflection
There are also several stories in the Bible that suggest that one failure does not therefore
mean that there will always be failure. Perhaps the most vivid story is that of Jesus and
Peter. In John 18: 15-17 we read that Peter denied that he even knew Jesus. This could
surely be considered a major affront. One might assume with some justification that Peter
had failed as a friend and could never again consider himself to be a worthy friend of
anyone, especially Jesus. However, later we see Jesus asking Peter if he loves Him and
Peter responding in a positive manner. We then see Jesus being willing to trust Peter with
something that is very important to Jesus. (John 21:15-19 describes this situation). It
certainly sounds as if one major catastrophe or mistake does not mean that the individual
will continue to make those mistakes.
3. Mental Filter (MF):
You pick out a single negative detail and dwell on it exclusively so that your vision of all
reality becomes darkened, like a drop of ink that discolors an entire beaker of water.
Example: A woman with severe arthritis failed to complete one task that she had hoped to
complete. She became more depressed and angry at herself for not completing that task.
She overlooked the fact that there had been many tasks that she had, in fact, completed.
A. Why is this thinking incorrect?
It is more sensib1e to clearly view one’s environment and be aware of the positive things
one has done in addition to negative occurrences. It is not adaptive to filter out anything
positive. It is irrational to say, “I should preoccupy myself with dangerous or negative
ideas.” Nothing is gained by dwelling on them.
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B. Theological reflections:
The Scriptures usually emphasize that one should reflect on the positive rather than the
negative. One should certainly reflect on what is true, and that includes seeing the
positive things you have accomplished. This theme is reflected in Philippians 4:8 which
says, “…. whatever is true, or lovely, or gracious … think on that. If there is any
excellence, if there is anything worthy of praise …think about that.” Whi1e the emphasis
here might be on values and ideas, it could also refer to one’s actions.
4. Disqualifying the Positive (DP):
You disqualify positive experiences by insisting they “don’t count” for some reason or
other. In this way you can maintain a negative belief that is contradicted by your
everyday experiences. You don’t just ignore positive experiences as in the Mental Filter,
but you clearly and swiftly turn them into their very opposite.
Example: An example would occur when someone praises your appearance or your work
and you automatically tell yourself, “They’re just being nice.”
A. Why is this thinking incorrect?
Again, it is maladaptive not to pay attention to feedback you get from your environment.
We should take that feedback at face value and incorporate it into our understanding of
ourselves. If we disbelieved everything everyone told us, we might still believe the world
was flat. An adjusted person is one who pays attention to everything in their environment.
B. Theological Reflections
We must not be like the Israelites in the wilderness who made a negative interpretation of
God’s actions towards them. (They also probably thought the worse about other people’s
actions towards them.) When God took them into the wilderness, they distorted the
situation and said, “God has brought us here to slay us.”
Similarly, in the New Testament, a constant theme is put forth that every individual has
some valuable important talents. This applies to even the individual who may think they
were sitting in the back row when talents were handed out. One place where such a theme
is discussed is in I Corinthians 12:4-31, especially verses 15-17 and 21-14. Those
seemingly less important individuals are actually very valuable people in the larger
scheme of things and have much to offer.
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5. Jumping to Conclusions (JC):
You make a negative interpretation even though there are no definite facts that
convincingly support your conclusions. There are two areas in which depressed
individuals jump to conclusions.
Mind Reading (MR):
This is one area in which depressed individuals jump to conclusions. You arbitrarily
conclude that someone is reacting negatively to you, and you do not bother to check this
out.
Example: Suppose a friend says she does not have time to have a conversation with you
on the telephone at a certain point. The depressed individual may conclude, “She is
ignoring me and does not want to talk with me, because she does not like me anymore.”
A. Why is this thinking incorrect?
One should never make an assumption about what someone is thinking without asking
them because it is usually impossible to know what another person is thinking, no matter
how sure we are we know. Jumping to conclusions about what the other is thinking is
also maladaptive because our negative reactions to their imagined thoughts may set up a
self-fulfilling prophecy. That is, we may react negatively to them when we suspect they
do not like us, when in fact they do. However, our negative reactions will soon turn them
off.
B. Theological reflections
In the New Testament, Jesus provides a perfect example of someone who chooses to
check out what people were actually thinking about him, rather than merely make
assumptions. A good example of this is in Mark 8:27, when He said, “who do men say
that I am?” It may be also that we begin to try to read other’s minds because we are
overly concerned about their perceptions of us, to the extent of basing our worth on their
perceptions of us. Jesus, however, presents an example of someone ‘who was not overly
concerned about others’ impression of Him, and indeed, surely did not have the favor of
most people. He even went so far as to contend that, “Blessed are you when men hate
you,” (Luke 6:22).
The Fortune Telling Error (FT):
The second way in which depressed individuals jump to conclusions is they anticipate
that things will turn out badly. They feel convinced that their predictions are an already
established fact.
Example: Depressed individuals will tell themselves that they are never going to recover,
“I will feel miserable forever.”
A. Why is this thinking incorrect?
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No one has ever successfully predicted the future; there are so many factors that could
have an impact upon the future. Furthermore, our predictions are likely to be even more
off base if we predict only negative events because probability suggests that both positive
and negative events will occur.
B. Theological Reflections
Often our jumping to conclusions regarding the future implies a fear about the future. The
New Testament certainly emphasizes the idea that God will give us a spirit of power and
love, the ability to control our fears rather than a spirit of timidity (2 Timothy 1:7). There
is also the theme of anxiety concerning the future in Matthew 6:25-34. Essentially, by
worrying and imaging a negative future we do not improve the situation. Our thoughts
should be on the present. (verse 34).
6. Magnification (Catastrophizing) or Minimization (MM):
You exaggerate the importance of things (such as your goof-up or someone else’s
achievement), or you inappropriately shrink things until they appear tiny (your own
desirable qualities or the other fellow’s imperfections). This is also called the “binocular
trick”.
Example: A depressed individual accidentally misfiled some papers while working at his
job. He concluded, “I made a mistake. How horrible! Everyone will think I am
incompetent.” An example of minimization would occur when the same employee was
told by one of his or her colleagues that he had done a good job on a report. His reaction
was to think, “0h well, doing the report was very simple and anyone could do a good job
on it.”
A. Why is this thinking incorrect?
It is important to have an accurate perception of ourselves and our performance. It is also
important to realize that everyone makes mistakes and that they are to be expected. It is
impossible for anyone to be perfect.
B. Theological reflections
Perhaps Christ’s temptation in the garden (recorded in Matthew 26:39, 42) was a
temptation not to drink the cup of humanness, not to identify with humanity in their
imperfections. Often the negative events that happen to us are merely part of that
humanness, and we do not wish to accept that. Becoming close to Christ, therefore, does
not mean perfection; but rather sharing in His poverty.
In the Old Testament, Psalm 88 goes even further in lessening the sting of negative
events. In that particular Psalm, the suggestion is made that perhaps the negative events
are precipitated by God, the implication being that God has a good purpose behind them.
Indeed, this was the theme of a Christian writer, Juliana of Norwich, writing in
Revelations of Divine Love she contends that the Lord rejoices at the tribulations of His
servants… and He lays on His beloved something that is no lack in His (God’s) sight but
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by which the person is lowered in the world. This He does to preserve the individual from
pomp, and to make them holy.
As far as the minimization of our positive aspects, we have only to recall again the New
Testament discussion of gifts. More specifically, every individual has something that is
valuable, and should consider it so (I Corinthians 12:4-31).
7. Emotional Reasoning (ER):
You assume that your negative emotions necessarily reflect the way things really are: “I
feel it, therefore, it must be true.”
Example: A depressed individual may tell himself, “I feel overwhelmed and hopeless,
therefore, my problems must be impossible to solve, or I’ll feel inadequate, therefore, I
must be a worthless person.
A. Why is this thinking incorrect?
One cannot assume that one’s emotions are a reflection of the true state of things. Our
emotions are a reflection of our thoughts and beliefs, which as we have seen are a product
of our past and may be distorted. Emotions may also be a reflection of our physiology
and how tired we are, but they are not necessarily a reflection of the true state of affairs.
B. Theological Reflections
Both the Old Testament and the New Testament speak much about negative emotions
and their role in our life.
a) John 1:12 suggests that our standing with God may be dependent upon our actions and
our belief, but it mentions nothing about it being dependent upon our feelings.
b) Christian writers have often commented that faith is only faith when there is darkness,
when the individual does not even feel God. As long as there is a feeling of God’s
presence, we do not have to go on blind faith. Juliana of Norwich has commented that
our prayers are most precious to God when we feel nothing because then we have
faith.
c) Often in our growth as a Christian, we must go through difficult times. This is certainly
the impression one gets in Psalm 63 where the writer reports a general dissatisfaction,
a dryness and a longing for God. If that dryness and longing were not there, then the
individual would not rejoice to find God, who is often described as the living water
(John 4:10 and John 7:38). Water only tastes good to the thirsty.
d) Finally, the spiritual injunction that one should give up their life in order to save it
could be applied to emotions. Often we seek God only for selfish ends, only to feel
good, rather than for God’s purposes (Matthew 10:39). Feelings of longing or
desolation may actually be positive in that they imply a growth process we are willing
to go through.
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8. Should Statements (SS):
You try to motivate yourself with shoulds and shouldn’ts, as if you had to be whipped
and punished before you could be expected to do anything. “Musts” and “oughts” are also
offenders. The emotional consequence is guilt. When you direct should statements
towards others, you feel anger, frustration, and resentment.
Example: One example is the depressed housewife who says to herself, “I should keep
my house cleaner, and I shouldn’t complain,” or, “I should be able to get my work done
during the day.”
A. Why is this thinking incorrect?
“Should” statements generate a lot of unnecessary emotional turmoil in your daily life,
and, paradoxically, usually do not motivate you to change your behavior. Usually, you
resent the source of the “shoulds.” Saying,”I should do this”, or “I must do this,” usually
causes one to feel pressured and resentful.
B. Theological Reflection
One of the central themes of the New Testament is that Christ has given us a spirit of
freedom and accepted us, and we should not condemn ourselves by getting upset at
ourselves if we do not perform the way we think we should perform (Romans 8: 31), or
the way others think we should. Saying, “I shouldn’t do that,” leads to a spirit of
condemnation. Even if we do not do any “shoulds,” God still loves us, (Romans 5:8). We
are made OK with God simply by grace, not by our pressured determination to keep all
the “shoulds” in one’s life. (Romans 5:1-2).
9. Labeling and Mislabeling (L or ML):
This is an extreme form of overgeneralization. Instead of describing your error, you
attach a negative label to yourself: “I’m a loser.” When someone else’s behavior rubs you
the wrong way, you attach a negative label to him or her: “You are an idiot.” Mislabeling
involves describing an event with language that is highly colored and emotionally loaded.
Example: An individual fails to get a job which they applied for and they call themselves
a “failure.”
A. Why is this thinking incorrect?
We are not our behavior. Labeling yourself is not only self-defeating, it is irrational. You
cannot be equated with any one thing you do. Your life is made up of many events,
thoughts, actions, and emotions. For example, you do not call yourself a “Breather” just
because you breathe. Likewise, you do not call yourself a “failure” because you made a
mistake.
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B. Theological Reflection
God does not base our worth on our activities. Likewise, He does not label us based on
our activities. God has a great love for us and rejoices in us even when our activities
would not to merit that. The parable of the lost coin in Luke 15:8-10 suggests our worth
is not based on our activities but is a reflection of much more. Likewise, in the story of
the prodigal son, Luke 5: 1-24, we read that the son’s worth was not based on his
behavior.
10. Personalization (P):
You see yourself as the cause of some negative external event for which you were not
primarily responsible.
Example: One example is the child who misbehaves or is rude. The depressed mother
says, “I am a failure or a bad mother,” (as if she could control everything her child did).
A. Why is this thinking incorrect?
Essentially, the person with this problem has confused influence with control. While we
obviously have some influence over people, especially our children, we cannot control
everything they do. What another individual does is ultimately their responsibility and
decision, not yours. We are not omnipotent.
B. Theological Reflection
God has control over the events that happen in the world. However, for the most part, we
do not. We should not presume to be God or try to do so. This is especially important
when negative events happen to us.
[end of categories]
God’s Thoughts are Higher than Our Thoughts
*More helpful information to continue to increase clients’ understanding of the treatment
rationale and their “buy-in.” Don’t underestimate how important explanations of
assignments and benefits can be to clients in terms of their motivation and adherence to
treatment.
As we have gone through these categories of unhelpful thinking, we have examined why
they are unhelpful from a biblical perspective. In Isaiah 55:9, it says “God’s thoughts are
higher than our thoughts and His ways are higher than our ways.” This is another
reason why it is important for us to continually fill our mind with God’s words; we want
our minds to be full of His “higher thoughts.” His thoughts lead to feelings of joy, peace,
and hope, the kind of emotions we would rather feel than depression and hopelessness.
[Get feedback from client on this]
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Contemplative Prayer: Praying God’s Word (10 mins)
Note: The section in blue highlight is provided in the Workbook. You can ask the client
to follow along with you in the Workbook as you explain Contemplative Prayer.
Contemplative prayer is a way to meditate on God’s word and leads to a more intimate
relationship with Him. One of the most common metaphors for contemplative prayer is
of the lover or friend. God desires our simple presence more than any action or service
we might give. Indeed, prayer has been described as a gift to God. Prayer is also a
discipline, undertaken as one would undertake to learn to play the piano. Practice is the
key.
One way to engage in contemplative prayer is to take a verse from the Bible, one of
God’s thoughts, and meditate on it. In other words, you spend some quiet time thinking
about the verse, repeating it to yourself, and saying it as a prayer to God. It’s like letting
yourself be saturated in God’s words. Some forms of meditation have you focus your
attention on your breath. When you notice yourself thinking about something else, you
are to bring your attention back to your breath. Contemplative prayer is different in that
instead of focusing on your breath you focus on God’s words. This leads to a
contemplative, prayerful state.
It’s normal to find that your mind has wandered to thinking about something else. When
you notice that this has happened, don’t get upset with yourself. When you become quiet
in prayer the first thing you are likely to notice is the how busy the mind remains. This is
normal, though unnoticed in everyday life. Some find the interior noise overwhelming at
first. Don’t panic. Think of your thoughts as boats sailing along a deep river. Boats will
sail into view, and they will sail past. Let them sail on; you do not need to be concerned
with them. The quality of your prayer time is not measured by the quality or intensity of
your thoughts or by how often your attention is captured by them. Simply bring your
attention back to the verse.
[Get client’s feedback]
It might be helpful to have the verse written on a piece of paper or underlined in the Bible
in front of you so that you can more easily keep your attention on the words. It is also
normal to find yourself wanting to pray to God as you are in this state. If that happens
just go with it and pray whatever comes up in your heart.
The Method
Practice this for a few minutes with the client using this week’s memory verse. Make sure
she understands how to use this tool (i.e., contemplative prayer) before ending the
session. Inform the client that these instructions and steps are included in the workbook
on page 21.
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1. Choose a scripture. Begin with your memory verse for the week.
2. Sit comfortably, but not too comfortably, back straight, chest open so the breath is
free and open.
3. Read the passage slowly. Savor each phrase. What word phrase or idea speaks to
you?
4. Read the passage again. Where does this passage touch your life? What do you
see, hear, touch, or remember?
5. Read the passage a third time. Listen quietly.
6. Note insights, reflections, and personal response to the reading in your journal.
7. Follow the steps in order or go back and forth between them as you feel moved.
8. Finish by waiting for a few moments in silence.
Homework Assignments (5 mins)
Ask the client to turn to page 20 in the Workbook to follow along with you.
1. Memory Verse
“You, God, will keep in perfect peace all those who trust in You, all whose thoughts are
fixed on You.” Isaiah 26:3
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Thought Log
Please write down your thoughts once a day using the ABC method. Be sure to fill out all
of the sections and categorize each thought into one of the unhelpful thought categories.
If you have more than one stream of ideas in one time period, you can indicate several
categories. There are seven thought logs included in the manual this week so that you can
fill one out each day.
Remember that this is a learning experience; you should not worry about completing the
logs perfectly.
4. Positive Activity
Add another positive activity to your week. Follow the same procedure for scheduling
this activity as we used in Session 2.
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5. Contact Member of Faith Community
Be sure to contact someone from your faith community and ask them to partner with you
during this period or agree to partner with them in their difficult situation. If you are
having trouble doing this, be sure you bring it up when the therapist asks about this.
6. Solicit feedback on how the session went today.
Terminate the Session
Follow the instructions listed in Session 1.
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SESSION 4: Challenging Unhelpful Thoughts: Bringing All Thoughts
Captive
Goals of Session
1) To reinforce and refine the client’s ability to monitor her thoughts, and to clarify
her understanding of the thought distortion categories
2) Introduce how one’s interpretation leads to change in mood
3) Develop alternative ways of responding to negative automatic thoughts, beliefs,
and expectations in light of the client’s personal value system and goals;
i. Religious beliefs can help clients pay attention to more effective ways of
looking at the situation
ii. Religious practices can generate coping responses to negative or
unpleasant events which are forms of direct coping rather than avoidance
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• Disputing Questions
• ABCDE Method for Challenging Beliefs Leading to Negative Emotions
Set Agenda
Our session today is called “Challenging unhelpful thoughts: Bringing all thoughts
captive.” We will learn how one’s interpretation of situations leads to changes in one’s
mood. I will also give you tools to respond differently to your automatic thoughts. We will
examine how your religious beliefs can help you look at situations in a more positive
manner. We will also look at how religious practices can be used as coping resources for
negative or unpleasant events. As always, at the end, I will give you a homework
assignment based on what we discuss today and another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Review Homework Assignment (15 mins)
1. Review Memory Verse:
Ask the client to say the verse from memory, or read it from the Workbook:
“You, God, will keep in perfect peace all those who trust in You, all whose thoughts
are fixed on You.” Isaiah 26:3
2. Review Mood Scale
Using a scale ranging from 0 to 10, where 0 is the worst that you’ve ever felt in your life
and 10 is the best you’ve ever felt, what was your mood like on average this week?
Empathize with response and say that you hope to learn why as you review the thought
log.
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3. Contemplative Prayer:
Did the client spend 20 minutes a day in contemplative prayer? Did she use her memory
verse?
4. ABC Thought Log or Worksheet:
Review the client’s efforts at thought monitoring. Ask them if she had any particular
difficulties. Attempt to clarify her understanding. Examine thought rows to ensure that
actual thoughts were recorded. You will not have time to check all the logs; choose one
or two to review more thoroughly.
Ask about the thoughts recorded to ensure that actual thoughts, not feelings, were
recorded. Also check for relative specificity of thoughts. That is, does the client list each
thought separately, or does she blend a number of thoughts together?
Correct at 1east one entry, if necessary. Be careful to praise the client for her efforts.
Remember that while you are hoping to correct them, it is important to keep the relative
amount of praise and reinforcement greater than the amount of focus on problems and
complaints.
5. Review unhelpful thought categories with the client. Ask her if there are any she does
not understand. Ask the client why she placed a particular thought in a particular
unhelpful thought category. Do this with 2-3 thoughts. Positively reinforce them for their
answers.
If you suspect that one is improperly labeled, ask the client to explain why she placed the
thought in that category. If the explanation is sufficient, suggest why you think it may
belong in an alternative category. This is to be offered only as a suggestion, however, as
clients are usually the best judge of their thoughts.
6. Review whether or not the client added a positive activity (you likely won’t have time
to discuss this in detail; just check for completion).
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Didactic: Interpretation of Events leads to Emotion (8 mins)
Many people believe that the events in our lives cause us to feel certain ways. For
example, if you had plans to go for a walk outside and it starts to rain, some people
would then feel disappointed or angry that they can no longer go for a walk. They think
the rain caused them to feel this way. But other people who saw that it was raining would
feel happy instead of feeling upset because they like the rain and think the walk will be
even more fun in the rain. Others might have a neutral emotional response, shrug their
shoulders, and simply take an umbrella on their walk.
The point is that it was not the rain that caused each of these individuals to feel a certain
way. We know that because the situation was the same for all, but each had a different
emotional response. Rather than the event (in this case the rain), it is our interpretation
of the events that happen in our lives that determine how we feel and how we then behave
(e.g., either going for a walk in the rain or staying inside feeling glum). This is important
to remember when you are dealing with a physical illness. We need to remember that our
quality of life doesn’t just depend on current health status, but largely on the attitude we
have towards the illness and the meaning we give to it. Two people can have the exact
same diagnosis, but one is content and the other is miserable.
[elicit some feedback from the client here]
Religious Application
The Bible is full of examples of how we are to challenge our thoughts and behave in ways
that may not seem consistent with the negative circumstances we find ourselves in. Paul
says in Philippians 4:4 “Rejoice in the Lord always, and again I say, rejoice!” He goes
on to say that “for I have learned how to be content in whatever state I am. I know how
to be abased and live humbly in difficult circumstances, and I know also how to enjoy
plenty and live in abundance. I have learned the secret of facing every situation, whether
well-fed or going hungry, having a sufficiency and enough to spare or going without and
being in want. I have strength for all things in Christ who empowers me.” Paul learned
that no matter what he faced in life, Christ would give him the strength to overcome.
This view in life allowed him to be content and rejoice, no matter what the situation. No
one likes to be beaten up, imprisoned, starved or ship wrecked, like Paul was. But Paul
learned how to interpret these negative events through what he considered his life
purpose—to tell others about Jesus. Being in these difficult situations allowed him to
meet people he never would have met otherwise and gave him a chance to share the
Gospel with them. He interpreted these negative events as positive events because they
furthered his life purpose. We, too, can use our faith and the purpose we derive from our
faith to give meaning to the negative events in our lives. Like Paul, we can learn to
rejoice no matter what the circumstance. Let’s keep this in mind as we learn the next step
in changing our thoughts.
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Ask the client if she has any thoughts or questions about these ideas.
The ABCDE Method of Identifying and Challenging Thoughts (8 mins)
Last week we learned how our emotions are directly linked to what we are thinking and
to how we behave. We used the ABC method (Activating event, Beliefs, Consequences) to
examine these relationships. We also learned about a number of categories of unhelpful
thoughts. This week we are going to take the ABC model a little further; we’re going to
add steps D and E.
D stands for Disputing. This is the step we use to challenge our unhelpful and negative
thinking. We will ask ourselves a number of questions to dispute our original belief, such
as “What evidence do we have that this belief is true? What evidence do I have that the
opposite is true?” Sometimes the situation can’t change. In this case, we need to look for
evidence that you can manage it. Evidence can be found in such things as your talents,
your past experience, your support persons, and resources. The answers we derive from
these disputing questions, such as about evidence, will result in step E: an Effective new
belief and new Emotional and behavioral consequences.
[elicit some feedback from the client here]
As Christians, we are not just challenging unhelpful thoughts and replacing them with
more positive thoughts. We also have the added power of being able to replace our
negative thoughts with the Truth of God, which our memory verses from last week said is
“higher than our thoughts.” The Bible says our mind is a battlefield. We are at war!
Identifying our thoughts and challenging them—making sure they are consistent with
what God says– is serious business.
In 2nd Corinthians 10” 3-5, we are told to challenge our thoughts and not to believe
everything we think. Just because we think it doesn’t mean it’s true. These verses say,
“We are human, but we don’t wage war as humans do. We use God’s mighty weapons,
not worldly weapons, to knock down the strongholds of human reasoning and to destroy
false arguments…We capture rebellious thoughts put them in obedience to Christ.” We
want to win the battle going on in our minds and God’s word is the most powerful way to
do this. When we put His words of truth in our minds we can change the way we think
and as a result how we feel, no matter what the situation.
Therefore, part of step D is examining your religious beliefs and resources to see how
they might help you dispute your automatic negative thought. For example, you can look
to your view of God, the way you believe the world works from a Christian viewpoint, the
Bible and religious writings, spiritual wisdom, and other sources for evidence to
challenge your automatic negative beliefs and your beliefs that you can’t cope with the
situation.
[elicit some feedback from the client here]
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Let’s practice steps D and E using the examples from your thought log this past week. As
we do this, we are going to think about how God’s word and our faith can help us come
up with more helpful and true beliefs. We can also use the Disputing Questions*
worksheet on page 31 of the Workbook to help us challenge our beliefs.
Using the Client’s Faith to Challenge Dysfunctional Thoughts (15 mins)
Go through several examples from last week’s thought log with the client to practice
disputing their negative thoughts and coming up with effective new beliefs. Be sure to
discuss the new emotional and behavioral consequences of these new beliefs. Have her
write her answers down on the ABCDE Worksheet*. Continue practicing until the client
can complete steps D and E without your assistance. The thought log is included below
for your convenience.
Therapist Information:
**The following are a few things for therapists to keep in mind as they proceed with
steps D and E with the client.
Religious Beliefs
In addition to material generated from your general conversation with the client, you have
available other sources of information that pertain to the client’s religious and spiritual
beliefs, such as the Religious Assessment Questionnaire administered in the first session.
Using all this information, choose any that seems most relevant to the topic at hand. For
example, if the client has mentioned trust in God as an important value or as a consoling
aspect of their faith, explore with the client how such beliefs could have been used in any
of the situations the two of you have examined together.
Imagine the client had underestimated their ability to cope with the situation. An
appropriate exploration would be around the degree to which focusing on trusting in God
might have affected the degree to which he believed that he could not cope with the
situation. The idea here would be to have him attend to how religious beliefs are an
additional resource he could have called on in that situation.
Similarly, if the client revealed that considerable avoidance occurred prior to the
situation, examine with the client how attending to their trust in God might have led to
different outcomes. Once again, the religious viewpoint may have provided him with a
resource that could have helped, but which his emotional distress at the time created a
kind of tunnel vision that left this potentially valuable resource unexplored.
Religious Practices
When examining these religious resources, bear in mind that it is not only beliefs that
could be an effective resource, but specific religious practices may also directly change
the situation. For example, it is one thing to know that attending to trust in God might
have made the person feel more courageous in managing the situation, but having this
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skill to attend to that belief might require accessing some type of religious practice, such
as prayer, meditation, or speaking to someone who shares the client’s religious values and
beliefs.
What has proceeded is the heart and soul of religiously integrative CBT. Accessing
individualized faith beliefs is a matter of practice. The counselor’s main goal is to support
clients in discovering creative ways of reminding themselves about these religious
resources. Assignments in-between sessions should focus client attention on this goal.
Asking the client to monitor negative emotional experiences, while at the same time
using religious and other beliefs to challenge negative automatic thoughts, is the most
appropriate way to reinforce such skill building.
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind
when you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or
expectations lead to? Rate each feeling using a scale of 1-10, where 10 is very painful.
What behavior did these beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those
beliefs or expectations are not totally accurate or true? Describe the contrary evidence.
Specify the unhelpful thought category that best describes the error in the belief. Even if
the situation can’t change, what evidence do you have that you could manage it (based on
your talents, past experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview,
the Bible and religious writings, spiritual wisdom, and other sources provide evidence
that challenge your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the
situation? How did your feelings change after you looked at the situation differently?
Rate each feeling using a scale of 1-10, where 10 is very painful.
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Homework Assignments (5 mins)
Ask the client to turn to page 30 in the Workbook to follow along with you.
1. Memory Verse
“We refute arguments and every proud and lofty thing that sets itself up against the
true knowledge of God; and we lead every thought and purpose away captive into the
obedience of Christ.” 2nd Corinthians 10:5
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Thought Log Monitor
Complete the ABCDE thought monitor at least once a day.
Be on the outlook for automatic negative thoughts that trigger emotional upset and
negative behaviors such as avoidance. The goal is to improve on the ability to spot these
negative patterns at the time they occur, and to attempt to develop alternative ways of
responding through the use of more effective beliefs and expectations.
Remember to use your religious beliefs and practices, as well as scriptures, to help
challenge your unhelpful and negative beliefs.
4. Elicit feedback from the client about how the session went today
Terminate the Session
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SESSION 5: Dealing with Loss
Goals of Session:
1. Identify losses in client’s life as a result of illness
2. Identify sacred losses
3. Teach tools for dealing with loss
4. Explain control versus active surrender
5. Emphasize the use of religious resources to understand and make meaning of
losses
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• ABCDE Method for Challenging Beliefs Leading to Negative Emotions
• Active Surrender Exercise
Set Agenda
Our session today is called “Dealing with loss.” We will identify the losses you have
suffered as a result of your illness, including something we refer to as sacred losses. I
will then provide you with some tools to help you deal with your losses. In particular, we
will examine how the use of religious resources can help you better understand your
losses and deal with them in healthy ways. As always, at the end, I will give you a
homework assignment based on what we discuss today and another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Review Homework Assignments (10 mins)
1. Review Memory Verse: “We refute arguments and every proud and lofty thing that
sets itself up against the true knowledge of God; and we lead every thought and
purpose away captive into the obedience of Christ.” 2nd Corinthians 10:5
2. Ask the client whether or not she used contemplative prayer this week and, if so, what
the experience was like.
3. Review a few of the client’s ABCDE Thought Logs.
The goal of this review is to determine whether clients understand the full model
and, in particular, if they understand how to gather evidence to challenge negative
beliefs and to use this to derive alternative beliefs and expectations (Steps D and E).
Make sure clients understand how to complete these steps correctly since this is at
the heart of cognitive processing. Pay special attention to how they went about
integrating religious beliefs and practices as a method for discovering alternative
beliefs and as a method for generating behavioral experiments.
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4. Examine Weekly Mood Rating:
• Using a scale ranging from 0 to 10, where 0 is the worst that you’ve ever felt
in your life and 10 is the best you’ve ever felt, what was your mood like on
average this week?
Discuss any significant events relating to the client’s depression and medical illness.
Encourage discussion around how using religiously integrative CBT strategies helped in
any way to interrupt the negative feelings. Also, examine any situations that resulted in
significant depressive feelings with discussion focused on what he might have done
differently or how he could use this event as a learning experience in case it re-occurs in
the future.
Once again the purpose is to determine if the client understands how to implement
religiously integrative cognitive processing or religiously integrative behavioral
experiments either to combat worldviews which are depression-inducing, or self
defeating ways of behaving that keep the person stuck in a downward depressive spiral.
Issues Pertaining to Loss in the Client’s Life (5-8 mins)
How to Introduce this Theme.
We see essentially three issues related to loss: 1) loss of identity, 2) loss of capacities, and
3) loss of relationships. Many more certainly could be chosen and counselors are free to
take the theme in any direction relevant to the client’s existential situation. We will
discuss sacred losses in the next section, although you may find that material becomes
interwoven in this section.
Counselors should review all the assessment material gathered to this point and identify
whatever relates to the themes of loss in the three areas noted here (or other areas).
Counselors may begin in any way that seems suitable to introduce the topic. The
following is one example:
Dealing with chronic medical illness is in many ways similar to dealing with grief. Grief
results from significant losses in our life whether it is the death of a loved one, loss of
friendships or other significant relationships, loss of a job that was meaningful, loss of an
environment or routine that one had gotten used to, or loss of the sense of who one is as a
person outside of the medical illness. From our discussion, I have noticed some areas
that possibly could be seen as losses to you and wanted to check that out to see how
significant these losses are to you in terms of living a satisfied life.
[Invite client to review topics the counselor has noticed up to this point related to loss].
I also have a few questions about your current losses to help fill in the picture regarding
how bothersome they are to you.
As a result of your illness or depression have you experienced any of the following?
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[For each positive response the counselor asks as a follow-up, “On a scale of zero to 10
with zero being no problem at all and 10 being about as bad as it could get, where would
you place that loss?”]
1. Have you lost one or more important or meaningful relationships?
2. Have you had to reduce the amount of time you spend with friends and family?
3. Have you lost any capacity for recreation or fun that you miss?
4. Has your work capacity been reduced in a way that is bothersome?
5. Has your illness led you to question who you are as a person or whether or not
you will be able to reach the goals that make for a satisfying life?
6. Has your illness led to not being able to participate in social activities that you
once enjoyed? What are they, if any?
7. What is the most important thing you have had to give up as a result of your
illness?
Sacred Losses (10 mins)
Note that these may have already been covered in the section above. If not, introduce the
concept now and discuss the questions listed below.
Some of the losses we suffer as a result of illness are sacred losses. Or, in other words,
losses that are related to our faith and our relationship with God. Some examples of
sacred losses include the loss of relationships with members of your faith community,
feeling abandoned by God, and the loss of specific faith beliefs (e.g., A good God doesn’t
let His children suffer).
1. Have you suffered any sacred losses?
2. How have you dealt with these sacred losses?
3. Have they been harder to deal with or caused more suffering than the other losses
you have had because of your illness?
[elicit client feedback]
Note that some of the following is also included in the Workbook on page 40.
In Romans 15:4, Paul writes, “For everything that was written in the past was written to
teach us, so that through the endurance taught in the Scriptures and the encouragement
they provide we might have hope.” The stories we read about in the Bible are there to
encourage us, to provide a model for us to interpret the events in our own lives, and to
create in us hope. It may be comforting to know that a number of individuals in the Bible
suffered great losses. In fact, one could argue that there isn’t a single individual
mentioned in the Bible that didn’t lose something important to them or who didn’t suffer
in some significant way. Think of King David. He was described as a “man after God’s
own heart.” He and God had a very special relationship. Yet, over and over again in the
Psalms, David cries out to God about his suffering and pain. Just because he had a
special relationship with God and God made him king didn’t mean that David didn’t
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suffer losses or experience pain. Even the disciples suffered greatly, most of whom were
eventually put to death, and these were the individuals with whom Jesus developed the
closest relationship! We can see that it doesn’t matter who we are or what we do in life,
as Christians we will suffer.
Ask the client for his thoughts about the ideas shared above. Has he experienced the
comfort or compassion of Christ?
Identification of Specific Losses to Target (5-8 mins)
Now return to the information you gathered about all the losses the client has suffered,
secular and sacred, and using reflective listening flesh out in more detail which aspects of
the loss(es) are most troublesome.
When this has been completed, counselor and client collaboratively target one or two
areas of loss that will be the focus of the treatment in this session and the next one.
The assignment should be quite concrete, and the counselor brainstorms with the client
any potential barriers that may interfere with attempting these strategies.
Counselors should assess which of the loss topics are more amenable to cognitive
restructuring and which are more amenable to changing behavior. A rough rule of thumb
to use is that losses which seem related to clients’ views of themselves can proceed
initially with cognitive restructuring (i.e., thought log using ABCED method) until it is
determined that changing what the client actually does behaviorally (i.e., behavioral
activation, behavior experiments) will have more impact. Active surrender is another
tool that the client can use, which will be explained in the next section.
For example, if the client’s social life is quite weak and appears to be related to seeing
oneself as unattractive or having nothing to offer in a relationship, cognitive restructuring
would probably be a useful place to start. However, if the medical illness has depleted
the client’s environment of fun things to do, then working on behavioral activation of
pleasant events would seem to be more fruitful.
Control Versus Active Surrender (10 mins)
**Note: You may not have time to cover this material in this session. If not, orient the
client to page 43 in her Workbook on active surrender. Ask her to read the instructions
and carry out the task on her own this week. Answer any questions she may have. This
tool may or may not be useful at this time to deal with the losses she has identified as this
week’s target(s).**
[If time allows, proceed (if not, then skip to Homework Assignment)]
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Some aspects of life are our under our own personal control, while others are beyond our
control. Life becomes more difficult when we try to control the uncontrollable. Some of
the things we believe and feel make letting go difficult. Surrendering to God helps us
begin the process of letting go. It is important to remember that active surrender to God
is different from giving up. Notably, surrender is paradoxical— letting go inadvertently
increases control.
Now I’d like to differentiate the things in your life that you are able to control from the
things you are not able to control. We are also going to talk about why letting go of the
things we cannot control is difficult. Then we will discuss what it means to let go by
surrendering things to God.
I’d like you to make a list of the things you have under your control and of the things
beyond your control.
Examples of things under personal control include: choosing a doctor, the number of
hours one works, eating well, taking medications, exercise, participation in
hobbies/activities.
Examples of things beyond personal control include: course of illness, final outcome of
treatment, how family copes with illness/death.
1. How do you cope with issues under your control? With issues beyond your control?
2. What happens when you try to control aspects that you don’t have control over?
Although it may be our nature to want to take control of every aspect of our lives,
sometimes it makes more sense to give control to God. This is called active surrender.
Active surrender involves a conscious decision to release or let go of those things in your
life that you do not have the power to change. Active surrender is one resource that may
help you better manage those aspects of life that are beyond your control.
Remember that surrendering to God is different that surrendering to an enemy, which
implies defeat. God is loving and kind. When you surrender to God you have faith that
things will work out; that God will take care of things in his own way. Paradoxically,
people often report feeling more in control after surrendering something to God.
Is there anything that you would like to surrender to God?
How do you think this might help you cope with your illness and your losses better?
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Homework Assignment (5 mins)
Ask the client to turn to page 39 in the Workbook to follow along with you.
1. Memory Verse

In all these things we are more than conquerors through him who loved us.
For I am convinced that neither death nor life, neither angels nor demons,
neither the present nor the future, nor any powers, neither height nor depth,
nor anything else in all creation, will be able to separate us from the love of
God that is in Christ Jesus our Lord.” (Romans 8:37-39)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory
verse for this week, and then try with previous weeks’ memory verses or other
favorite scriptures you may have.
3. Thought Log
Use the ABCDE thought log to actively address one or two losses you have
experienced as a result of your illness. You and your therapist should have come
up with a concrete plan to do so in session. Remember that integrating your
religious beliefs and practices into the use of these tools makes them even more
effective.
4. Active Surrender
Reflect on the things in your life that you want to surrender to God. Use the
worksheet provided to make a list. Then, set aside a block of time to surrender
these things to God in prayer. This is another effective tool to address the losses
you have experienced as a result of your illness.
5. Elicit feedback from the client about how today’s session went.
Terminate the Session
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SESSION 6: Coping with Spiritual Struggles and Negative Emotions
Goals of Session
1. Discussion of spiritual struggles
2. Explore core experiences that may have contributed to a change in client’s faith
3. Discussion of forgiveness and repentance and imagery exercise
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• ABCDE Method for Challenging Beliefs Leading to Negative Emotions
Forgiveness Exercise
Set Agenda
Our session today is called “Spiritual Struggles: Dealing with negative emotions.” We
will identify the spiritual struggles and negative emotions that you may have experienced
as a result of your illness, including core experiences that may have contributed to a
change in your faith. We will discuss the meaning of forgiveness and repentance and
other spiritual resources you have available to you. As always, at the end, I will give you
a homework assignment based on what we discuss today and another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Homework Assignment Review (10 mins)
1. Review Memory Verse: “
In all these things we are more than conquerors
through him who loved us. For I am convinced that neither death nor life,
neither angels nor demons, neither the present nor the future, nor any powers,
neither height nor depth, nor anything else in all creation, will be able to
separate us from the love of God that is in Christ Jesus our Lord.” (Romans
8:37-39)
2. Inquire about the client’s use of contemplative prayer. (Note: You may need to
remind the client about how to engage in contemplative prayer this during each
session and ask about problems he is running into if he fails to follow through).
3. Examine Weekly Mood Rating
• Using a scale ranging from 0 to 10, where 0 is the worst that you’ve
ever felt in your life and 10 is the best you’ve ever felt, what was your
mood like on average this week?
4. Review client’s Thought Log that she used to address one or two of the losses in
her life.
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5. Assess integration and use of their religious beliefs/practices/resources.
6. Inquire about the client’s use of Active Surrender. Did she make a list of things
she wanted to surrender? What was on the list? Did she spend time in prayer
surrendering these things to God? What was the outcome?
Note about the use of Cognitive versus Behavioral Strategies
The basic point of the assignment review is to consolidate the clients’ strategies that seem
to be having the most impact on their depression at this point. We want to ensure that the
client is using the strategies properly and suggest additional strategies from the repertoire
provided in this manual. Normally clients resonate with one or two strategies that they
find work for them. Counselors should note whether the strategies are more along the
lines of shifting perspective or taking action, as that may be the pathway for
encapsulating the major thrust of what works for them.
This is a good time to review with clients the distinction between changing perspective
and changing behavior. Both are able to combat depression, but people seem to have
preferences for one or the other. Clients should be made aware that they do not have to
choose between one or the other and can choose both depending on the current problem.
That being the case, when a client uses a strategy successfully counselors should point
out what seemed to have made a strategy work. That is, was it a change of perspective
that encouraged them to change their behavior, or a change of behavior that altered their
perception of the situation?
In this way clients are introduced to what we technically refer to as reciprocal
determinism — the idea that thinking, behaving, and the environment often influence each
other and that one is not more causal than the other.
Introducing Spiritual Struggles (10 mins)
“Spiritual struggles” is a topic that needs to be assessed for its presence within a given
client. It can be thought of as a dimensional quality or experience. That is, not all clients
experience this to the same degree; some experience it not at all, some experience it to a
mild degree, some experience it but it leaves them, and some continue to experience it
intensely. The way spiritual struggles is determined comes from asking several
questions, two of which were on the spiritual assessments questionnaire (RCOPE)
administered early on. You should have been provided with a copy of this baseline
measure by the study coordinator. These questions focused on whether the client has the
feeling that God is punishing him right now or whether God is abandoning him right
now.
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Remember to emphasize the following during this session and call attention to these
points in the workbook:
• It is normal to question God in the face of illness.
 It is normal to feel negative emotions toward God.
 God created us to experience a range of emotions and He can accept all of them.
 God wants us to be true and honest with Him.
Today we’re going to talk about some challenging questions and feelings that can make it
difficult to connect with God. In particular, we will be reflecting on times that we have
felt abandoned by God or angry with God. In the face of illness, tragedies, and suffering,
it is normal to question God. We may ask: “Where was God? Did God forsake me? How
can a loving God allow this to happen? Why is there suffering?”
Sometimes people grow up thinking or learning that they should never question God or
feel angry with God. But, God created all feelings, including negative ones, and loves
them all. God desires us to be honest with ourselves and with others, including Him. It
may be hard to talk to others or even to God. Sometimes there is fear that God does not
hear or that He will punish us. It is important to remember that God feels sadness and
anger for all the pain and suffering we undergo. It can help to express your feelings
towards God. Honesty can lead to healing and restoring one’s relationship with God,
with others, and with oneself. It can also lead towards growth.
[elicit feedback from client about this]
Discussion:
Here are some questions to guide the discussion. Do not ask all of these questions. Just
ask those that are relevant to the type of answers the client provides. Use your clinical
judgment. Remember, there is only 10 minutes allotted for this section.
1. Has your relationship with God changed because of your illness or depression?
2. What kinds of questions do you find yourself asking?
3. Modify as needed: I noticed from a questionnaire you answered earlier in our
treatment that you had [or, that you did not have] a feeling that God was
punishing you or abandoning you. I was wondering if that is still the case and
how it seems to affect you?
OR:
4. Have you ever felt abandoned by God? Describe. How did you cope with this?
5. Have you ever felt angry with God? Describe. What did you do to cope?
6. Additional questions about spiritual struggles(e.g., resentments, bitterness,
questioning, shame, guilt) as deemed appropriate to this particular client
Clients can answer these questions in an infinite number of ways. Counselors need to use
a lot of reflective listening, which permits clients to describe precisely what this religious
experience is like for them. Obviously, there will be little difficulty for clients who are
not experiencing religious struggles, yet the discussion itself may reveal some interesting
things about religious motivations.
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Reflective Listening
The basic goal of the reflective listening portion is simply to have clients hear themselves
express these often unacceptable feelings out loud. Give the client about 10 minutes to
express her feelings. There is a lot to cover in this session so if you have to cut this part
short, reassure the client that you will return to these issues later in the session and in
subsequent session.
Only after the client has spent about ten minutes or so expressing these negative feelings
and understood them in some way from her own perspective should counselors normalize
her feelings in some way.
The point here is to keep it simple without getting into a lot of elaborate theology. Most
of the time people aren’t truly asking “why” questions — more often they are asking “why
me” questions. Simple reflective listening alone often permits clients to sort this out for
themselves.
Biblical Examples of Suffering and Spiritual Struggles
**You can use these examples during this part at of the session if you feel they are
applicable and would be helpful. You can pick and choose between them or offer your
own based on an individual in the Bible.
From an information standpoint, a focus on the biblical stories of Job or Jesus in the
garden of Gethsemane before he died at least puts forward the tension within theistic
religions and Christianity that a caring God and personal suffering can coexist. These
stories are not meant to provide a philosophical answer but a psychological one.
• That Jesus could pray the night before he died for “this cup to pass from me”, and for
his very last words on the cross to be, “My God, my God, why have you forsaken
me?” certainly indicate that he was experiencing God, his own father, abandoning
him. Jesus himself experienced intense negative feelings and separation from his
father. That we cannot be any stronger than Jesus should help normalize our own
spiritual struggles.
• The story of Job is well-known. He experienced loss in every area of his life and felt
many intense negative emotions and had doubts and questions about God’s love. A
verse at the very end of the book of Job shows the meaning that Job was finally able
to draw from his spiritual struggles: “Before I had heard about God with my ears, but
now I KNOW Him.” He went from a superficial knowledge of God to a deep,
intimate, and personal relationship with His Creator. For this, Job counted his
suffering to be not only with purpose, but also worth it in the end.
• Add any other Biblical examples you think would be helpful.
• Christian author, Phillip Yancy, has written extensively on subjects such as
disappointment with God, where God is when it hurts, does faith matter, and so on.
His books are written for the lay public and he has a beautiful, humble, and
compelling writing style. He has been on the New York Times best seller list many
times. You might mention these books as another resource for your client.
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Note: If there is an irrational component to be addressed here from the perspective of
religiously integrative CBT, it would be those beliefs driving spiritual struggles which are
related to feelings of low self-esteem or self-worth. In other words, counselors need to be
on the lookout for people having spiritual struggles because they believe that God is
punishing them or abandoning them because the client deserves to be punished or
abandoned.
Forgiveness and Repentance (15 mins)
***This is a critical component not only of this session, but of the entire treatment. Give
yourself enough time so that you are not rushing through this section. Allow client time
to provide feedback.
Spiritual struggles often involve resentment and unforgiveness. Forgiveness can be a
powerful antidote for some spiritual struggles (e.g., resentment, anger, bitterness) and an
integral part of the process of healing. Indeed, research has shown strong relationships
between emotions such as anger and resentment and physical health problems and
compromised immune functioning.
This can be a sensitive topic for some people. And, it has the potential to come across in a
self-righteous and inconsiderate manner. We want to avoid this at all costs. One way to
introduce this topic is by asking the client about her definition of forgiveness and of
repentance before presenting these as resources. This allows you the chance to discuss
any misperceptions or concerns about these topics and the reason you would like to
discuss them as part of treatment.
In the Bible, forgiveness is mentioned 116 times and repentance is mentioned 131 times,
so we know from sheer numbers that these are important topics to God. These topics are
also highly relevant to our emotional and physical health. Many scientific studies have
revealed that strong negative emotions can harm us physically and emotionally. For
example, our immune system becomes compromised by continuous feelings of anger and
resentment. That means our bodies can’t fight off infections and viruses as effectively as
they can when we are experiencing positive emotions. Indeed, every system in our body
can be negatively impacted by the stress of negative emotions, such as bitterness and
resentment.
[elicit feedback from client]
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There are many passages in the Bible that point to a mind-body relationship. One of the
most powerful is recorded in 3rd John 1:2 “Beloved, I pray that you may prosper in all
things and be in health, just as your soul prospers.” We learn from this verse that our
ability to prosper in life and in our bodies is contingent upon the state of our soul, which
is made up of our mind, will, and emotions. If we harbor unforgiveness and bitterness
toward others, God, or ourselves, our souls are not prospering and because of this
nothing else in our life can prosper either.
The Bible makes it clear that God wants us to be well, physically, emotionally, and
spiritually. We also have a role to play. We have to be obedient and deal with the
unforgiveness, which God calls sin, and the hurt in our lives so that God’s power is able
to flow freely in us and on our behalf. As Christians, repentance and forgiveness are the
main tools we have been given to deal with negative feelings toward others and ourselves
that are due to being wronged.
Before we discuss what Jesus had to say about repentance and forgiveness, I’m interested
in hearing how you define these two concepts.
What does forgiveness mean to you?
How would you define repentance?
Continue this discussion until you feel you have a clear understanding of how the client
defines forgiveness and repentance and whether or not this is a difficult and/or sensitive
topic for the client.
Now I’d like to share with you some of the things that the Bible teaches us about
repentance and forgiveness. We know that because God is all-knowing He can never
forget anything; however, it says that when we ask for forgiveness, when we repent, He
puts our sin as far as the East is from the West. It’s hard for us to even fathom how far
apart that really is! The Bible defines forgiveness as canceling the debt; no longer
holding someone accountable for their action and its consequences. It doesn’t say
forgiveness is seeing the action as okay now. Sin is never okay with God.
We know that the ability to offer us forgiveness was the ultimate reason Jesus came to
earth; He came because we are all guilty of sin, and the penalty of sin is death. Someone
has to die for our sin. Jesus didn’t want it to be us who died so He was willing to take all
of our sins and the consequence of death upon Himself. Because He did this it says that
when we repent, we are cleansed of all our unrighteousness and are considered
righteous, or in right-standing, with God. When we confess our sins, He promises to
forgive us. That doesn’t mean that we won’t suffer any consequences, as we may have
gotten ourselves into a mess because of our action, but we will not suffer death or lose
our right-standing with God. Repentance also allows God to act on our behalf; when we
are walking in sin, we tie his hands because he is a holy God.
[elicit feedback from client]
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God commands us to forgive others as He has forgiven us. That doesn’t mean He wants
you to change your mind and decide that what happened to you was right or justified. As
I mentioned, God never changes His mind about our sin—He always sees it as evil. What
forgiving someone does mean is that we give up the right to hold this action against the
person. We give up our right to feel resentful, bitter, and angry. When we make a
decision with our will to forgive someone, even when we don’t feel like it, God can then
begin to change our feelings. Usually our feelings are the last part to change. That
doesn’t mean you haven’t forgiven, it just means your feelings having yet come into
alignment with the decision you made with your will to forgive.
What do you think about this definition of repentance and forgiveness?[elicit feedback]
Some of the most common spiritual struggles people face include resentment, anger, and
bitterness.
If you have not already discussed these above, ask the client now if she has experienced
any of these emotions as a result of her medical illness and/or depression:
Have you experienced any of these emotions as a result of your medical illness and/or
depression?.
Do you think repentance and forgiveness would be helpful tools for helping you to
overcome your feelings of (insert specific feelings here)?
Is there anyone you would like to forgive? That could include others, yourself, and even
God (although He never sinned against us, we can perceive a wrong against us in our
minds).
Is there anything you would like to ask forgiveness for (repent of), either from God or
from others?
Forgiveness and Repentance List (10 mins)
**Note: You may not have time to generate the list and/or pray the prayers of forgiveness
and repentance in this session. There are worksheets for both of these activities in the
client workbook. You can direct the client’s attention to these worksheets (Instructions on
pages 44-45 and exercise on page 46) and review the instructions so that the client can
complete this exercise on her own this week.**
1. If there is time, and if the client answered positively to either or both of these
questions, ask the client if she’d like to make a list of those she needs to forgive or
the things for which she needs forgiveness.
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2. If there is time, you can give her the choice of praying prayers of forgiveness
and/or repentance now or at a later time. If she chooses the latter, come up with a
specific plan of how and when she will do this and have her write a reminder note
for herself.
Do not push the client to engage in anything she does not wish to do. If there is no one
she needs to or wants to forgive, or anything she wants to seek forgiveness for, let her
know that this is okay and move on to other spiritual resources that help us with spiritual
struggles. Let this didactic be food for thought and leave it at that. It may be that in time
the client may want to revisit this topic with you. As you end this section on forgiveness,
give her permission to discuss it with you again should she so desire in the future.
Forgiveness Imagery Exercise
Again, if there is time, you can lead the client through her list and ask her to pray
something like the following for each item on her list. It is important that the prayers be
specific and that she does not just offer one blanket prayer for all the things listed.
“Heavenly Father, I purpose and choose to forgive ___ (the person) for ___ (the action).
I release him/her and cancel their debt to me completely. I will no longer hold any
accusation against them. Even now I release them from this sin. I ask that you would
forgive them for this sin and separate the sin from them forever. Please forgive me for the
unforgiveness/bitterness (or other feelings against this person) that I have stored in my
heart. I give you all my feelings of ____ and ask that You would cause my feelings to line
up with my decision to forgive ___ (the person). I also purpose and choose to forgive
myself. Thank you for forgiving me and making me righteous in your sight. Holy Spirit,
please heal my heart and tell me your truth about the situation.”
You can then lead her in prayer, having her say the prayer out loud herself. After she has
finished praying, you can lead her through an imagery exercise such as the following:
Instruct the client to close her eyes and to imagine herself standing or kneeling before
Jesus or before the cross (you can ask her which image she prefers before beginning this
exercise). Then instruct her to give the list of wrongs that others have done to her, and
that she has just forgiven, to Jesus. Have her hand the list of her own sins to Jesus, too,
and see Him nailing these lists to the cross. Ask her to listen as Jesus says, “You are
forgiven. Go in peace.” Ask her to continue to listen to hear what else Jesus might have
to say to her or what else He might do as she stays in this image. When the client
indicates that she is finished, have her thank Jesus for what He has just done for her.
Be sure to process this experience with her.
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ABCDE Method and Forgiveness
It is often very helpful for the client to use the ABCDE method to help see the situation
from the other’s perspective, causing the development of empathy, and allowing the
client’s feelings to come into alignment with their decision to forgive. The ABCDE
method used in previous weeks may have already brought some issues to the client’s
attention that she would like to attend to through forgiveness. Use your knowledge from
previous sessions to guide you in this discussion.
Homework Assignment (10 mins)
Ask the client to turn to page 44 of the Workbook to follow along with you.
1. Memory Verse
“The righteous cry out and the Lord hears them; He delivers them from all their
troubles. The Lord is close to the brokenhearted and saves those who are crushed
in spirit. The righteous person may have many troubles, but the Lord delivers him
from them all.” Psalm 34:17-19
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer.
3. Spiritual Struggles
It is important to remember the following points:
• It is normal to question God in the face of illness.
 It is normal to feel negative emotions toward God
 God created us to experience a range of emotions and He can accept all of them
 God wants us to be honest with Him and to bring all of our concerns to Him
If you and your therapist identified spiritual resources that would be helpful in
addressing any spiritual struggles you have, make a plan to use these resources this
week to address that issue. Spiritual resources include, but are not limited to, prayer,
journaling, social support from friends, conversations/counseling with clergy, Bible
studies, repentance and forgiveness, attending religious or spiritual services, attending
support groups like Alcoholics Anonymous, attending activities sponsored by
spiritual or religious groups like pot-lucks, bingo, and discussion groups. Several
ABCDE thought logs have also been included in the workbook for this session; this
may also be a helpful tool in addressing spiritual struggles this week.
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4. Repentance and Forgiveness
Is there anyone you would like to forgive? That could include others, yourself, and
even God (although He never sinned against us, we can perceive a wrong against us
in our minds). Is there anything you would like to ask forgiveness for (i.e., repent
of), either from God or from others? If yes, and if you did not address these in
session, make a list of the people you want to forgive or the things for which you
need forgiveness.
Take some time to pray about each item on your list. It is important that your prayers
be specific and that you do not just offer one blanket prayer for all the items listed.
You can use a prayer such as the following:
“Heavenly Father, I purpose and choose to forgive ___ (the person) for ___ (the
action). I release him/her and cancel their debt to me completely. I will no longer
hold any accusation against them. Even now I release them from this sin. I ask that
you would forgive them for this sin and separate the sin from them forever. Please
forgive me for the unforgiveness/bitterness (or other feelings against this person)
that I have stored in my heart. I give you all my feelings of ____ and ask that You
would cause my feelings to line up with my decision to forgive ___ (the person). I
also purpose and choose to forgive myself. Thank you for forgiving me and making
me righteous in your sight. Holy Spirit, please heal my heart and tell me your truth
about the situation.”
After you have finished praying, you might try closing your eyes and imagining
yourself standing or kneeling before Jesus or before the cross. See yourself giving
the list of wrongs that others have done to you, and that you have just forgiven, to
Jesus. Give the list of your own sins to Jesus, too, and see Him nailing these lists to
the cross. Listen as Jesus says, “You are forgiven. Go in peace.” Continue to listen to
hear what else Jesus might have to say to you or what else He might do as you stay
in this image. When you are done thank Jesus for what He has just done for you.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Solicit feedback on how the session went today.
At this point it would be natural and easy for clients to become overwhelmed with the
plethora of religiously integrative CBT strategies introduced. Counselor clinical acumen
is necessary for choosing a strategy that seems to resonate best with a client at this point
and go with it.
Terminate the Session
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SESSION 7: Gratitude
Goals of Session
1. Introduction to gratitude and how this relates to the client’s illness experience
2. Practice cognitive restructuring from a gratitude framework
3. Focus on religious gratitude
4. Introduce concept of giving thanks in all situations
5. Grateful behavior directed toward others
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• ABCDE Method for Challenging Beliefs Leading to Negative Emotions
• Gratitude Exercise: Counting Our Blessings
• Gratitude Exercise: Celebrating Our Blessings
Set Agenda
Our session today is called “Gratitude.” We will discuss what it means to be a grateful
person and how your feelings of gratitude may have been impacted by your experience
with illness. We will particularly focus on religious gratitude and the things in your life
for which you are grateful. We will also discuss gratitude toward others. As always, at
the end, I will give you a homework assignment based on what we discuss today and
another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Homework Assignment Review (10 mins)
1. Memory Verse Review: “The righteous cry out and the Lord hears them; He
delivers them from all their troubles. The Lord is close to the brokenhearted and
saves those who are crushed in spirit. The righteous person may have many
troubles, but the Lord delivers him from them all.” Psalm 34:17-19
2. Ask the client about his experience with contemplative prayer
3. Examine Weekly Mood Rating.
• Using a scale ranging from 0 to 10, where 0 is the worst that you’ve
ever felt in your life and 10 is the best you’ve ever felt, what was your
mood like on average this week?
4. Inquire whether the client met with a companion from the faith community and
what transpired. Of particular interest is the effect of the interaction on client
mood.
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5. Process any issues regarding spiritual struggles as discussed in the previous
session. It can be difficult to talk about spiritual struggles and to express painful
feelings towards God. Ask the client if he would you like to discuss what it was
like to express these feelings and thoughts about God?
6. Discuss the strategies the client implemented to manage spiritual struggles. How
did they work? What was effective? What was less effective? Identify whether
anything fit into the religiously integrative CBT model for improving depression.
7. Discuss the forgiveness exercise. Did she complete the list? Did she pray prayers
of repentance and forgiveness? If so, what was that like for her?
For situations that did not go particularly well try to make this a win-win situation; that
is, how can the client turn what did not work particularly well into a learning experience?
At minimum clients can observe that they managed to survive the situation despite its
unpleasantness. This information can be used to point out to clients their
unacknowledged reserves to battle against difficult environmental situations. In other
words, their ability to hang in without being totally defeated can strengthen their belief in
their own self-efficacy to manage and cope with worries and anxiety.
Introduce Religious Gratitude (5 mins)
Much recent research has indicated a strong association between experiencing gratitude
with both subjective well-being and positive mental health. The approach for using
gratitude is slightly different from approaches used to this point. Except for increasing
the number of pleasant events, most of the emphasis has been on reducing emotional pain
rather than increasing positive emotions. With gratitude, however, the results of positive
psychology research is that some sadness and human discomfort can coexist with strong
positive feelings to distract from or directly combat the depression.
It is important that the counselor focus this session on religious gratitude, not just on
gratitude in general, which is what the CBT intervention will be focusing on (i.e., we
need to differentiate our intervention, RCBT, from the CBT intervention). For example,
you can focus on how gratitude is an important part of the client’s faith tradition and
involves being grateful to God and the things, people, and experiences God has provided.
Gratitude can be a difficult emotion for some people to grasp, especially when currently
experiencing pain and suffering. Counselors need to be sensitive to this fact both for
gratitude and for the upcoming session on stress-related growth. One way to approach
this would be the following:
Sometimes the best way to drive out negative emotions is to find alternative emotions that
capture our attention and also improve our mood. It seems that we have difficulty
focusing on things that make us feel depressed or nervous when we are feeling grateful
about something.
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The Bible has a lot to say about being thankful. In fact, it’s hard to find a book of the
Bible or even a single Psalm that does not mention gratitude, praise, or thankfulness. We
are told in Revelation that the angels praise God and that they do so without ceasing.
Even Jesus was recorded as giving thanks to God many times in the Gospels. Paul told
the Thessalonians to “Thank God in everything no matter what the circumstances may
be; be thankful and give thanks, for this is the will of God for you who are in Christ
Jesus.” (1st Thessalonians 5:18). This verse tells us that it doesn’t matter whether we feel
like giving thanks or what negative or painful thing we are experiencing in our lives; God
wants us to be thankful at all times. Indeed, many times the word “thanksgiving” is
paired with the words “sacrifice” and “offering.” This suggests that giving thanks to
God when we don’t feel like giving thanks is seen as a pleasing sacrifice of our wills and
desires to God.
Why do you think being thankful is God’s will for us no matter what we are going
through in life?
This question can lead to a fruitful discussion that ties in with the themes of focusing on
the positive, not letting our lives be driven by our feelings, and reframing our situations
to see things from God’s perspective.
Gratitude List Exercise (10 mins)
Our goal is to pay more attention to what we are grateful for instead of what is not going
our way in life. This will not only induce positive emotions and help to reduce depression,
but it will also be pleasing to God. A useful way to start this process is simply to make a
list of the many different things in life for which you feel grateful. This can include
people, places, and things which are either a regular part of life now, or which were
present in y our life in the past and made it enjoyable, satisfying, or else effective.
Ask the client to turn to page 51 in the Workbook. Take five to ten minutes to guide the
client in generating a gratitude list which is fairly comprehensive in terms of people in
relationships, past and present experiences and opportunities, along with environmental
features, such as one’s living conditions, nature, or creation. This can be accomplished
using the Gratitude Exercise – Counting Our Blessings* worksheet (pg. 51). Have the
client write the items down on her worksheet.
I see that you have a number of things and people on your list about which you feel
grateful. The next step is to put a number from 1 to 10 next to each item to indicate the
degree of gratitude you experience from each one, where 10 is very grateful. This step
should be completed fairly quickly; it’s not necessary to give this part a lot of thought.
Let’s take a look at some of the items you ranked as feeling the most grateful about.
Could you share a little bit about what it is that generates that feeling in you? What
about it that touches you when you think or imagine it?
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Counselors take a few minutes allowing clients to explore the meaning of their gratitude.
This information should be most useful for placing it within cognitive restructuring and
other ways of accessing grateful feelings to shift moods.
Practicing Cognitive Restructuring from a Gratitude Framework. (10 mins)
Now that we have this nice list of experiences for which you feel grateful, let’s see if we
can make gratitude feelings work for you in a positive direction. The way we can do this
is similar to what we have done before when we have used the ABCDE approach to
challenging our thoughts. The only difference this time is that when we come to the part
where we challenge our negative beliefs we want to look at your gratitude list to see if
any of these experiences are a good challenge or refutation of the negative beliefs and
expectations.
Let’s begin with any specific concern or depressive thought that you have had recently —
perhaps even today. Let’s use our ABCDE Method for Challenging Beliefs Worksheet
which can be found in your workbook to analyze the experience. (Or, you can work with
a completed thought log from a previous week).
Work with the client to complete this worksheet so there is enough data to continue the
exercise.
Sample Dialogue for Cognitive Restructuring using Religious-Based Gratitude
Counselor. For persons like yourself who mention feeling grateful to God and for your
faith, you may experience an added burst of positive feelings when you think about God
or the divine in terms of gratitude. You mentioned on your list that one of the things that
makes you grateful is the idea that the world right here is not the end of things. Could
you elaborate on that a bit?
Client. With my condition I’m grateful that I can think of being with my friends and
family in the next life. I’m grateful there is a loving God who is watching over us and
who will bring us together eventually.
Counselor. How do you think that belief could help you with negative thoughts when they
pop up such as resentment or self-pity?
Client. It helps to know that God is in charge and that there’s some plan behind all this
even though I’m not sure what it is. It also helps to know that in the end everything is
going to turn out well.
Counselor. It’s pleasing to know there’s a plan and the outcome will be good.
Client. Yes.
Counselor. What if we go through your worksheet again, and when we get to the
challenging section with religious resources think about those two ideas that God has a
plan and the outcome will be good. Could you give that a try?
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Here the client and counselor pause as the client tries the cognitive processing.
Counselor. What did you notice?
Client. This time it was more a sense of peace; knowing in my head that everything was
going to work out for the good.
Counselor. And how did that work against the resentment and self-pity beliefs?
Client. I didn’t think so much about that because I was focusing on the fact that someone
was in charge for the long-range. I wasn’t so much focused on this minute feeling
resentful. It was kind of like, “This is temporary”.
Counselor. And how much change did you notice in your mood improvement? What
number did you reach?
Client. I guess I got down to a three or four.
Counselor. So you experienced noticeable change in your negative experience and mood.
Client. Yes.
Counselor. Once again, it would be important to think about whether this can work for
you at the time these negative feelings pop up. Do you think that is worth a try?
Client. Yes I do.
Counselor. Well then this would be a second thing to try before next session. The idea
would be to consider your gratitude to God when these negative feelings rise up and see
whether they help improve your mood.
Counselor and client collaboratively identify the kinds of feelings and situations where
using this strategy might be helpful.
Gratitude Behavior Directed Toward Others (10 mins)
Up until this point we’ve been discussing generating grateful feelings toward people,
events, and God. It is not necessary to leave it at that. We can also generate grateful
behaviors toward others. For example, when someone does a favor for you, what do you
usually say or how do you usually respond to that person?
Here clients typically note that they say ‘thank you’ or sometimes return the favor.
Exactly. That is a typical grateful behavior. Often, however, it’s an automatic reaction
that we don’t give a great deal of thought to. What we want to do here is think more
carefully about what others – friends, family, God – have done for us, and see if we have
perhaps more to say or do for them with regard to grateful responses than we have in the
past. Perhaps we have said simply ‘thank you’ but have not fully expressed in depth what
their kindness or behavior meant to us.
This next exercise to which this dialogue is directed can be an extremely powerful one,
yet needs to be carefully coordinated. Full instructions are included in the Gratitude
Exercise – Celebrating Our Blessings* worksheet. Ask the client to turn to page 52 in the
Workbook. Complete steps 1 to 3 with the client now. Steps 4 and 5 are for the client to
do on his own after the session. The idea is for the clients to identify some person in their
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life whom they have “more to say” regarding how grateful they are for what that person
has done and for how they have contributed to the person’s well-being. Start by asking
about two or three people to whom the client would have more to say regarding gratitude.
The exercise works best when the person selected is a living person. Often people regret
that they did not express their gratitude to people who have died, but that is more suitable
for healing shame or guilt rather than generating the positive emotion of gratitude.
Therefore, in this dialogue the goal is to identify living people; in some cases people will
want to intentionally name God but that is not a necessary or even a desirable part of the
exercise. Just as the person needs to be alive they should be in some way able to be
contacted by the client. The contact can be ideally in person. Telephone can be a
powerful form of contact as well. Writing a letter sometimes is the only behavior a client
is willing to choose. They do so because they themselves feel it would be too intense, or
they are concerned that the person on the other end will be overwhelmed. Counselors can
gently suggest the more direct modality of in person or telephone, but should not push the
client into a form he or she does not desire.
For this exercise people select a wide variety of persons: former teachers, spouses,
siblings, parents, other friends and relatives. This same strategy will also be used in the
next session on altruism. That is, a very specific person should be selected along with
concrete times and places as well as the means of delivery for the expression of gratitude.
1. Elaborate on the selected gratitude behavior.
a. Generally the gratitude behavior will be in the form of expressing the client’s
feelings of gratitude toward the individual. This ordinarily takes place in person,
by phone, or letter. Counselor and client together must outline the content of the
communication to ensure it touches all the important bases. Once again it should
be done by writing out together the topics to be communicated.
b. The points that should be made universally are the following:
• Precisely and specifically what it was that the other person did for you. Thus,
“you were a nice person to me”, is not as suitable as, “when I was in the hospital
you came to visit me and you prayed for me every day.”
• Counselors should elicit as many of these concrete activities as possible for which
clients feel grateful.
• Clients should note what the meaning of the person’s activities for them was. That
is, how the activity or way of being made the clients feel, influenced their life,
caused them to grow, taught them things they needed to know, etc.
• Have the client complete Step 3 now (listing the person’s qualities and traits)
2. Pick the time, place, and modality for expressing client gratitude.
a. Counselors and clients together should identify the specific way in which the
gratitude will be expressed, as well as the specific time and place. This prevents
the exercise from becoming too vague and thus not able to be accomplished.
Counselors should make clear that they expect to review the gratitude exercise
within the remaining sessions.
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Homework Assignment (5 mins)
Ask the client to turn to page 50 in the Workbook to follow along with you.
1. Memory Verse
“Thank God in everything no matter what the circumstances may be; be
thankful and give thanks, for this is the will of God for you who are in Christ
Jesus.” 1st Thessalonians 5:18
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory
verse for this week, and then try with previous weeks’ memory verses or other
favorite scriptures you may have.
3. Grateful Feelings Exercise: Counting Our Blessings
Use your gratitude list, particularly your gratitude toward God for all that He is
and all that He has done, as well as gratitude for those in your faith community, to
help challenge negative thoughts and to replace negative emotions. Continue to
add to your gratitude list this week as you think of more things for which you are
grateful.
4. Gratitude Expression Exercise: Celebrating Our Blessings
Express your feelings of gratitude toward the individual you identified in session (see p 52 of
workbook). This ordinarily takes place in person, by phone, or letter. Complete at the
specific time and place you chose in session. Remember to include the following:
• Precisely and specifically what it was that the other person did for you. Thus,
“you were a nice person to me”, is not as suitable as, “when I was in the hospital you
came to visit me and you prayed for me every day.”
• Include as many of these concrete activities for which you feel grateful
as possible
• Be sure to note what the meaning of the person’s activities was for you. That is,
how the activity or way of being made you feel, influenced your life, caused you to
grow, taught you things you needed to know, etc.
5. Solicit feedback on how the session went today.
Terminate the session
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SESSION 8: Altruism and Generosity
Goals of Session:
1. Review gratitude exercises: Gratitude Expression and Grateful Feelings
2. Introduce the notion of expressing religious gratitude by being generous and
practicing altruism.
3. Religious motivation for altruism: The two Great Commandments and Jesus’
teaching on ‘doing unto the least of them’
4. Altruism Exercise
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• ABCDE Method for Challenging Beliefs Leading to Negative Emotions
• Altruistic Acts
Set Agenda
Our session today is called “Altruism and Generosity.” This session builds on our
session on gratitude last week. We will explore how we can express religious gratitude by
being generous and engaging in altruistic (positive, kind) acts for others. We will discuss
the two Great Commandments and Jesus’ teaching on loving others and how these relate
to altruism. As always, at the end, I will give you a homework assignment based on what
we discuss today and another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Homework Assignment Review (10 mins)
1. Review Memory Verse: Thank God in everything no matter what the circumstances
may be; be thankful and give thanks, for this is the will of God for you who are in
Christ Jesus.” 1st Thessalonians 5:18
2. Inquire about use of contemplative prayer
3. Review Mood Rating Scale
• Using a scale ranging from 0 to 10, where 0 is the worst that you’ve ever felt
in your life and 10 is the best you’ve ever felt, what was your mood like on
average this week?
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4. Review gratitude exercise, if the client has carried it out. It is likely that the client
carried out either the gratitude expression exercise or the grateful feelings exercise.
Time should be made for either or both. In the event that neither was carried out,
explore this with the client and tweak, if necessary, whichever exercise to make it
more possible to be accomplished.
Review of Grateful Feelings Exercise: Counting Our Blessings
Begin with the grateful feelings exercise and review the impact that carrying out the
exercise had for the client. The focus of this review should be on what happened as the
client maintained her attention on people, places, and things for which she is grateful. In
general, clients report that such focus has an uplifting effect on their feelings. Counselors
should inquire as to why clients think this effect occurred.
The goal of the inquiry is to get at the meaning of being grateful — that is, when I focus
on things to be grateful about, what kind of person do I become, what does that say about
me? Clients may only say it made them feel better and this is okay. However, to get the
most out of the exercise it is useful to have the client reflect back on what gratitude does
to and for their character.
It is especially useful to connect grateful feelings to any events, experiences, or situations
that have a direct or indirect religious meaning. For example, people may speak about
feeling grateful for the beauty of the universe, and with some gentle questioning this may
come back to feeling grateful for a God who created the universe.
Review of Grateful Expression Exercise: Celebrating Our Blessings
Follow this up with a review of the grateful expressions exercise. The point of the review
is to help clients see the value in explicit expressions of gratitude. Once again, careful
inquiry may relate these feelings to the kind of person clients want to be. At times, this
exercise can be quite powerful emotionally so counselors need to pay attention and
debrief with sufficient focus so that clients fully process what has happened.
Once again, counselors should attend to whether or not grateful expression was
connected directly or indirectly to religious meaning. If so, that meeting should be
explored in some detail.
Assess Client’s Desire to Continue to Develop Value of Gratitude
Finally, the ultimate goal of both generating grateful feelings and generating grateful
expressions is to determine whether not clients wish to continue developing these values
in their life, and what this connection can have for them in light of their present suffering.
The more immediate goal is to determine whether clients are willing to incorporate
generating grateful feelings into their everyday life. This can be done via conscious focus
using the worksheet
Catch up Time (5-10 mins)
Use a few minutes now to catch up on any material you may have run out of time to
address in previous sessions.
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Introduce Altruism and Generosity (10 mins)
The purpose of this part of our treatment is to re-focus our attention to the healing
aspects of giving to others and being generous, even if to a limited degree. Research tells
us that if we pay even a little attention to giving to others that, over time, we end up
feeling better ourselves. We also know that no behavioral feature characterizes
Christianity more than its focus on caring for and loving other people. The Great
Commandment which Jesus tells the young man asking him what he needs to do in order
to gain eternal life is quite direct: Love the Lord your God with your whole heart, mind,
and soul; and love your neighbor as yourself. Jesus also made it very plain that we are to
be generous people: “Freely you have received, freely give.” God has a neat way of
rewarding us when we obey him: giving to others and being generous has just as positive
an effect, if not more, on the giver as it does on the receiver!
[elicit feedback from client]
The dark side of depression and physical illness is how easy it is to forget the curative
nature and importance of giving to others. It is part of our human dignity to care for and
take care of people in need. When we cut ourselves off from that quality, we have lost
something of ourselves. However, because of our own pain it is easy to become selffocused — and this is quite natural. It is very difficult to think about a neighbor’s needs
when you are experiencing acute pain yourself. In those situations it is necessary to take
care of yourself first. However, most of us fortunately do not experience this intense level
of pain every moment of our lives — even though we have a chronic illness. Most of us
have windows of peace or relative calm where we could be available to others if we
planned properly
Jesus told his disciples that we are to serve one another. He even called himself a
servant, and indeed he was the greatest servant of all because he gave his life up for us.
Jesus says in Mark that “whoever desires to be great among you must be your servant.
And whoever wishes to be most important among you must be the slave of all. For even
the Son of Man came not to have service rendered to him, but to serve and give his life as
a ransom for many.” (Mark 10:43-45).
Although one of our motivators to engage in altruistic acts is for our emotional benefit,
the most important motivator to give to others should be to obey Jesus’ command and
follow his example. Jesus was generous with his time, his energy, his resources; indeed,
his generosity involved great sacrifice: he gave up all of his rights as God and Creator of
the universe and his very life to restore us to a right relationship with God. We are made
in his image and are being transformed to be more like him. Part of this transformation to
be more like him is to give generously, even if it means sacrificing something to do so.
1. Assess what the client what thinks of the notion of altruism and generosity and how
this is (or is not) tied into their identity and practice as a Christian.
2. Assess the change in mood they may have experienced when being generous and
giving to others. Ask for specific examples in their past
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3. Assess how their illness and/or depression have impacted their altruistic focus and
activities.
Example of Dialogue with Client:
Counselor. In what ways have you been able to give to others since you have been ill?
Client. Not too often really. It seems like everyone around me has to pay attention to me,
so I’m the center of attention all the time.
Counselor. And what does that feel like?
Client. In some ways it’s okay. It’s good to know others are around. But in some ways it
gets to be tiresome. Everyone doing for you and you not doing for anyone else.
Counselor. Are you still interested in carrying out this value?
Client. Yes I am. I just can’t seem to figure out how.
Counselor. That’s great. That’s exactly what we want to spend some time talking about
right now.
If the client goes in the other direction of mentioning ways in which he or she has
continued to be generous and altruistic, then the counselor should explore what that feels
like on the occasions when that has happened. Usually people will talk about how it felt
good. The counselor than should pick up on this and talk about how systematically
planning to reach out to others and help them is what the focus of this time will be.
Religious Motivation for Altruism (5 mins)
From the religious perspective, remind the client to connect their own goals of helping
others with the famous passage in the gospel of Matthew 25: 35-40, in which Jesus
describes anyone who has done something for another person, such as giving them a cup
of cold water, visiting them when they were sick or in jail, and so on, was really doing it
to Jesus.
For some clients this will be a familiar passage; for others it will be vaguely familiar. In
either event discussion around the meaning of this passage for the clients personally at
this point in their life can help generate additional motivation for being altruistic.
In the gospel of Matthew (25:35-40), Jesus says something startling about serving others.
He says that everything we do for others is actually done to him, and that everything we
don’t do for others, all the needs we do not meet, we failed to do for him. Listen to this
passage in Matthew (25:35-40):
“35For I was hungry and you gave Me food, I was thirsty and you gave Me something to
drink, I was a stranger and you brought Me together with yourselves and welcomed and
entertained and lodged Me,
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36I was naked and you clothed Me, I was sick and you visited Me with help and
ministering care, I was in prison and you came to see Me.
37Then the just and upright will answer Him, Lord, when did we see You hungry and
gave You food, or thirsty and gave You something to drink?
38And when did we see You a stranger and welcomed and entertained You, or naked
and clothed You?
39And when did we see You sick or in prison and came to visit You?
40And the King will reply to them, Truly I tell you, in so far as you did it for one of the
least in the estimation of men, My brothers, you did it for Me.”
Most of us never think about our actions being done to Jesus himself. It is both a sobering
thought and a joyful one, as it makes giving to others even more meaningful and
rewarding.
[elicit feedback from client]
Caution
At the same time, counselors want to be on alert for clients whose lives start to resemble
slavery; where they are constantly doing for others, even in their impaired condition. For
these clients the focus of the session should be on the obligation to take care of
themselves, as the Great Commandment demands (Love others as you love yourself).
Altruistic Exercise (10-15 mins)
The worksheet Altruist Acts* is provided in the client’s workbook on page 56. Please
have the client turn to this worksheet. There is space available to plan three altruistic acts.
It is important to ensure that the client is not expecting a reward or gratitude from the
person helped, but is motivated by her relationship with God and reward and praise from
God (not man).
1. The counselor discusses with the client ways in which the client has been helpful
in the past and ways in which he sees he is able to be helpful now.
2. Together counselor and client collaboratively make a list of situations and
possibilities. Then, as we typically do with strategies such as this before
implementation, the client is asked to rank them from easiest to most difficult.
This can be done by using a simple percentage such as from zero to a hundred,
with 100 being the most difficult of all.
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3. Together counselor and client select which of the easier altruistic acts the client
would like to initiate. This is discussed in some detail in terms of the questions
who, what, when, where, why, and how of carrying out the activity. This makes
the activity concrete and provides a visual picture of what is needed to carry it
out, and also anticipates any barriers that could be present.
4. Next, client decides on the frequency of the altruistic acts. One trap is for clients
to get very enthusiastic but then find that they have overreached and give up
making any attempts. Counselors should be alert to this trap and consider reining
in activities that will be ultimately too much at this point.
5. A second concern is how others in their environment will react to these behaviors
on the part of the client. Sometimes family and friends in their concern will
worry that such activities tax the clients’ emotional or physical energy and caution
clients about carrying them out. Counselors should ask whether or not family and
friends will support them in doing these activities and, if not, what they might
want to say to them. Here the counselor can brainstorm ways to describe their
goals and perhaps even role-play what to say in such an event.
6. In order to increase motivation for selecting altruistic acts, counselors should
explore with clients how they will probably end up feeling should they carry out
their goal of giving to others. The idea here is to accentuate whatever is related to
positive desires, ability, and importance or benefits from giving to others.
7. Remind the client to connect their own goals of helping others with the famous
passage in the gospel of Matthew 25: 35-40, in which Jesus describes that anyone
who has done something for another person, such as giving them a cup of cold
water, visiting them when they were sick or in jail etc., was really doing it to
Jesus. If you have not already read this passage to the client or had him read it
himself, do so now.
For some clients this will be a familiar passage; for others it will be vaguely
familiar. In either event discussion around the meaning of this passage for the
clients personally at this point in their life can help generate additional motivation
for being altruistic.
8. In addition to the altruistic acts the client has chosen, ask the client to pray for
someone Daily this week. Help her to choose the person she will lift up in prayer.
Perhaps the person she has made contact with from her faith community. Pray for
this person each day. Emphasize that praying for another helps to get one’s mind
off of one’s own problems and is a great way to be generous with one’s time and
energy. It also helps to put one’s own problems in perspective.
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Homework Assignment (5 mins)
Ask the client to turn to page 55 in the Workbook and follow along with you.
1. Memory Verse
“And the King will answer them, ‘Truly, I say to you, as you did it to one of the
least of these, my brothers, you did it to me.” (Matthew 25:40)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory
verse for this week, and then try with previous weeks’ memory verses or other
favorite scriptures you may have.
3. Altruistic Acts
Carry out the specific altruistic acts to be done for the particular persons at a
particular time you and your therapist chose in session. Be sure to have more than
one option in case other people are unavailable. These assignments, like others,
should be written down so that no confusion remains.
4. Pray for Someone Daily
If you have not been doing so already, begin to pray daily for the person in your
faith community with whom you have begun to have contact. Praying for someone
other than ourselves helps to get our minds off of our own problems and is a great
way to be generous with our time and energy. It also helps to put our own
problems in perspective.
5. Solicit feedback on how the session went today.
Terminate the Session
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SESSION 9: Stress-Related and Spiritual Growth
Goals of Session
1. Introduce and develop the concept of stress-related growth, especially from a
spiritual perspective
2. Explore ways the client may have experienced positive growth through the illness
experience
3. Help the client “look for the positives” through a series of exercises.
4. Revisit the importance of interpretation: Story of Paul in prison and the 12 spies’
account of the Promised Land.
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• ABCDE Method for Challenging Beliefs Leading to Negative Emotions
• Looking for the Positive
• Spiritual Reflections
Set Agenda
Our session today is called “Stress-related and Spiritual Growth.” We will explore the
concept of stress related-growth, especially from a spiritual perspective. We will
complete a series of exercises that will help you to look for the positives in your life, even
in the midst of the negative things you have been experiencing. To remind ourselves
about the importance of the interpretations we make, we will read how several
individuals in the Bible were able to change their perspective about an event that seemed
quite negative on first glance. As always, at the end, I will give you a homework
assignment based on what we discuss today and another verse to memorize.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Homework Assignment Review (7 mins)
1. Memory Verse Review: “And the King will answer them, ‘Truly, I say to you, as you
did it to one of the least of these, my brothers, you did it to me.” (Matthew 25:40)
2. Review experience with contemplative prayer.
3. Review Mood Rating Scale
• Using a scale ranging from 0 to 10, where 0 is the worst that you’ve
ever felt in your life and 10 is the best you’ve ever felt, what was your
mood like on average this week?
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4. Review altruism exercise.
5. Review exercise to pray daily for someone. Did they do this? What was the experience
like?
Counselors should carefully explore the emotional reaction to carrying out these
activities, as well as the effect on their physical well-being.
The goal of this review is to determine to what degree the client desires to make altruistic
activities an ordinary part of his or her life. Clients have any number of common
responses:
1. For some, these are activities they commonly engage in so that such practices do
not significantly alter how they operate. For such people, the discussion should
center on what it was like to intentionally connect these events to the religious
motivation discussed in the previous session. Thereafter, the discussion should
focus around ways in which they can continue to carry out such activities and
plans for themselves despite their medical condition.
2. For others, it will be a return to activities that they once engaged in. For these
individuals the discussion will be whether this is something they want to continue.
Also discuss what it was like to intentionally connect these events to the religious
motivation discussed in the previous session. Thereafter, the discussion should
focus around ways in which they can continue to carry out such activities and
plans despite their medical condition.
3. For others, it will be like a breath of fresh air and will create a whole new way of
thinking about who they are and what they are doing. For such people the
counselor will want to take considerable time in discussing the implications of
these activities in terms of their well-being and religious perspective. Also discuss
what it was like to intentionally connect these events to the religious motivation
discussed in the previous session. Tying these activities into ABCDE model will
connect it to the overall CBT model.
Introduce Stress-Related Growth (8 mins)
The research literature in positive psychology offers ample evidence that many people
who are suffering from serious trauma, losses, or intense medical conditions are able to
find something positive about a painful experience or one that causes suffering.
Naturally, this is an extremely sensitive area and one in which counselors can come
across as boorish and unfeeling. Also, depending on how it is introduced, clients may
end up feeling even more shame and guilt because they have not been able to experience
any positive outcomes as a result of their suffering. Thus, this whole topic can have
exactly the opposite effect as intended and come across as still one more demand clients
are unable to fulfill.
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To help steer the conversation in a productive manner, counselors can begin broadly by
asking about changes rather than by first talking about positive outcomes.
Before we finish our work together there is one last topic that may be helpful. We have
reviewed many topics that are related both to your depression and your medical
condition. We would like to finish by taking a bird’s eye view of all the changes that have
occurred as a result of your medical illness and/or depression. Some of the changes are
things you definitely did not want and some of the changes might have been unexpected.
I’m wondering if you can talk about some of the changes that were expected and some
that were not expected.
Some such opening gives the client permission, so to speak, to delve into the positive
changes that have occurred. Counselors can word this opening in any general way they
like as long as it does not descend into the pitfalls mentioned above. After that opening
counselors listen carefully for anything that strikes them as related to a positive shift.
What you are looking for specifically are positive changes in their own personal
relationships with other people (e.g., I didn’t know how much so-and-so really cared
about me), positive changes that may have occurred for the people close to them (e.g.,
bringing people closer together, having family members who were formerly estranged
now speaking to each other), positive changes in their own character or abilities (e.g., I
am a much stronger person than I was before; I can tolerate so much more than I thought
I could; I am a much less selfish person than I was).
When clients mention those kinds of changes this is what counselors should zone in on
with their reflective listening skills and explore these in detail.
Once positive changes have been broached as a topic it is relatively easy to tag these
changes onto religiously integrative CBT. Counselors now have a very large database of
information about the client on which to draw. For example, if the client has admitted to
spiritual struggles, counselors can invite clients to consider what these positive changes
mean in reference to their strong negative feelings about being abandoned by God. The
ABCDE Thought Monitor worksheet* and Dispute Questions* from Session 4 can be
used to generate alternative beliefs for the negative ones driving emotional distress and
self-defeating behavior. Thus, the client has come full circle from focusing on beliefs that
lead him or her into a negative downward spiral and now has a new toolkit for generating
a positive upward spiral.
Looking for Positives (10 mins)
In this section, introduce clients to the Looking for Positives* worksheet (page 60). It is
hoped that this exercise will top off their experience over the last nine weeks, and at least
create the potential for a positive summary of the experience, as well as the thrust of the
therapy itself.
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Feelings of discouragement, sadness, and helplessness are common and normal when
dealing with physical and mental illness. What happened to you may seem terribly
unfair. It may be terrifying. It may feel like your body or medical system has betrayed
you and can no longer be trusted. These thoughts and feelings are certainly
understandable. The challenge of coping effectively with illness is to learn how to both
acknowledge and accept these changes, losses, and your feelings, and at the same time
actively pursue growth, meaning, purpose, an appropriate sense of control, and a healthy
relationship with your body, others, and God. Many describe illness as an end of life;
others as an end of a way of life. Some are able to see the possibility of a new beginning;
that perhaps even though they never asked for this experience of illness, nor would they
wish it on anyone else, that something positive can come from it.
[elicit feedback from client]
Paul provides a good model of how we can find meaning and even good when our
dreams are thwarted and we suffer from negative experiences. In the first chapter of the
letter he wrote to the Philippians, he tells them he is unable to visit them in person as he
had planned and hoped to do because he is in chains in prison. The reason he is in prison
is because he was preaching the gospel. Here he was being obedient to God and His
calling, telling others the good news about salvation, and this landed him in prison! He
sure had a reason to be resentful and frustrated. But, remarkably, he has the opposite
response. Listen to some of what he says to the Philippians:
[You may want to summarize the following verses or just read part of this to shorten this
section a little]
“Now I want you to know, brothers and sisters, that what has happened to me has
actually served to advance the gospel. As a result, it has become clear throughout the
whole palace guard and to everyone else that I am in chains for Christ. And because of
my chains, most of the brothers and sisters have become confident in the Lord and are all
the more able to proclaim the gospel without fear….Yes, and I will continue to rejoice,
for I know that through your prayers and God’s provision of the Spirit of Jesus Christ
what has happened to me will turn out for my deliverance. I eagerly expect and hope that
I will in no way be ashamed, but will have sufficient courage so that now as always
Christ will be exalted in my body, whether by life or by death…. Whatever happens,
conduct yourselves in a manner worthy of the gospel of Christ. … For it has been granted
to you on behalf of Christ not only to believe in him, but also to suffer for him, since you
are going through the same struggle you saw I had, and now hear that I still have.”
Paul isn’t angry about being imprisoned for preaching the gospel or for not being able to
do what he wanted to do: visit the Philippians. Instead, he sees his chains as a means to
fulfill his purpose of advancing the gospel! No matter what situation he finds himself in,
he trusts that God will take care of him and that God has a purpose for the situation,
even if it seems negative or confusing. When we encounter these types of situations in our
lives, we can be encouraged by Paul’s response and ask God to help us see the meaning,
purpose, and even the positives in the situations we face
[elicit feedback from client]
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“Looking for the Positives” Exercise (10 mins)
(Note: these are the exact words at the top of the client’s Looking for Positives*
worksheet).
It may sound insensitive to suggest there is anything positive in pain and suffering, yet
many people who cope admit they eventually make sense of the situation or find
something that benefited them or others. This does not mean they like what happened or
stop wishing it had never happened. They discovered that despite the pain they went
through they could also describe positive changes in themselves and others or found
parts of it that made sense. In the long run, finding benefits seems to give people a
measure of serenity.
Have the client turn to the Looking for Positives* worksheet in her Workbook on page
60. Answer the three questions in session. Have the client write down her answers during
this time so that she can refer back to them later. (Note: The Spiritual Reflections*
worksheet on p 61 will be assigned as homework so you will not ask these questions in
session.)
1. In what ways, if any, can you make sense of what happened to you?
2. What positive changes have you noticed as a result of what happened?
– In you?
– In others and the people close to you?
– In the way you look at the world?
– In your religious views and belief?
3. How can these changes help you live your life more fully?
Need to Remind Self Often
It does little good for clients to simply list the positive changes or benefits that have
occurred as a function of their struggles. It is absolutely essential for benefit-finding to
be effective that clients remind themselves at regular intervals of these benefits.
Focus on Meaning of Benefits or Changes
The bulk of the discussion should focus on the meaning of the benefits or changes and
what the client can do in order to remind himself or herself of these changes.
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Incorporation in Prayer Life
The suggestion should be raised about how these changes can fit into the client’s prayer
life. If he has a brief morning or evening prayer, what does he want to say to God about
these changes? How do these changes affect his relationship with God? What do they say
about how he wants to relate to God given that good and bad can co-exist with each
other?
Religion and Benefit Finding
Benefits and positive changes have embedded within many aspects of consolation. At
some point, most people turn to their religion and faith for consolation. Up until this point
this has only been mentioned marginally. Now, however, it is easier to point out the
connection between benefit-finding and its associated consolations. This feature should
be emphasized when it is apparent.
You may or may not want to address the following questions with the client.
• When people attend to new capacities and strengths, what does this say about
their ability to manage their lives with its pain and suffering?
• If some people are now more conscious of God’s presence in the universe, how
does this console them as they face their uncertain futures?
• If positive outcomes are possible, and you – the client – have witnessed them,
what does this say about the possibilities in the future as you deal with what you
are handed?
The Importance of Interpretations (10 mins)
**If you have time, this is a good illustration to share with the client to demonstrate,
again, the importance of our interpretations. It also ties in well with today’s theme of
seeing the positive in a seemingly negative situation.**
[Therapist may need to shorten the following]
I’d like to share a story with you from the Bible that demonstrates how important our
interpretations can be. The story of Moses sending spies to scout out the land that God
promised to give to the Israelites is good example of how people can have very different
interpretations of the same situation that results in different outcomes. The spies’ various
interpretations of the land caused them to experience different emotions from one
another, which led to different behaviors and outcomes. Let me just briefly summarize the
recount that is found in Numbers chapters 13 and 14. Through God’s miraculous
intervention, Moses had led the Israelites out of slavery in Egypt into the desert on their
way to the Promised Land. Moses sent twelve spies into the land of Canaan, the
Promised Land, to see what the land was like and whether the people living there were
strong or weak. He asked them to bring back a scouting report so that they would know
how to proceed.
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The spies went and explored the land. When they came back to the camp, ten of
the spies told Moses and the Israelites that the land was wonderful and full of good food,
but that the people living there were powerful and gigantic, and the cities were large and
very fortified. They said, “they were so big we looked like grasshoppers to them.” They
told the Israelites that they could not attack the Canaanites because they were stronger
than the Israelites. This upset all of the Israelites who wept and complained to Moses and
to God all night long, accusing God of taking them out of Egypt just to be killed by the
Canaanites. They said it was better for them to go back to being slaves in Egypt!
There were two spies, however, who gave a very different account. These spies
were Joshua and Caleb. They also reported that the land was “exceedingly good.” But
unlike the other ten spies they said, “We should go up and take possession of the land for
we can certainly do it! If the Lord is pleased with us”, they said, “He will give the land to
us.” They encouraged the people not to be afraid of the giants in Canaan because God
was with the Israelites and if God was for them their enemies didn’t stand a chance of
survival. So, what did the Israelites do after this good report? They tried to stone Joshua
and Caleb!
This reaction and the other spies’ negative report made God very angry. He was
upset that his people didn’t believe him when he said he had given them the land and had
performed so many miracles for them already that proved his power and provision. He
was so angry that he said none of them would ever enter the Promised Land. The people
eventually asked for forgiveness and God forgave them of their sin of grumbling and
disbelief, but every one of them older than 20 years of age, with the exception of Joshua
and Caleb, died in the desert. On top of that, the spies that gave the negative report were
all struck with a plague and died.
I share this story not to suggest that God is going to harm you if you complain or
have a negative view of things—if He was doing that today we’d all be dead, myself
included! I shared it with you so that you could see that we can look at a situation from
many different viewpoints. Joshua and Caleb chose to look at the land of Canaan and the
giants that lived there as easy to defeat, the same giants that the other spies trembled in
fear at and predicted their certain death. Joshua and Caleb based their report on what
God had told them—“I will give you this land for you and your decedents to live in and I
will provide bountifully for you in this land.” They chose to trust God and his promises to
them and this gave them courage and allowed them to choose to fight against these literal
giants.
Every day we are faced with the same sort of choices. We can choose to look at
the negative things in our lives and predict doom and destruction—because it can
certainly look that way! Or, we can go to God’s Word and see what he has promised his
children and base our view of ourselves, our lives, and our futures on his words. This will
lead to feelings of peace, joy, and hope, and will allow you to move forward and through
the difficult things in your life instead of retreating from them or giving up. We’ll never
be perfect with this. We all fall into complaining and seeing things from a negative
perspective and always will—Thank God for grace! But the important thing is to become
aware of this and to challenge those negative beliefs and predictions as soon as you
notice them using the promises of God. It gets easier with practice!
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What are your thoughts about this story?
How would you summarize the moral of the story?
(Note: You just summarized the moral of the story for the client, but asking her to tell
you in her own words allows you to check her understanding of it and correct any
misinterpretations. This is particularly important if she thinks it means God is going to
strike her dead if she has a negative report or complains; that certainly wasn’t the point of
the story).
Paradoxes in Christianity (5 min)
**Encourage the client to read this worksheet on page 62 for homework this week. It is
provided below for your information, not to be discussed in session.**
1. When you are weak, then you are strong. God’s power is most evident when we
are weak.
• “But he said to me, ‘My grace is sufficient for you, for my power is made perfect
in weakness.’ Therefore I will boast all the more gladly about my weaknesses, so
that Christ’s power may rest on me. That is why, for Christ’s sake, I delight in
weaknesses, in insults, in hardships, in persecutions, in difficulties. For when I am
weak, then I am strong.” (2 Corinthians 12:9-11)
2. In Christ, you can do all things; without Him you can do nothing.
• “
I can do all this through him who gives me strength.” (Phil 4:13)
• “
Remain in me, as I also remain in you. No branch can bear fruit by itself; it must
remain in the vine. Neither can you bear fruit unless you remain in me. I am the
vine; you are the branches. If you remain in me and I in you, you will bear much
fruit; apart from me you can do nothing. If you do not remain in me, you are like a
branch that is thrown away and withers; such branches are picked up, thrown into
the fire and burned.” (John 15: 4-6)
3. God chooses the foolish things of the world rather than the wise.
• “
Brothers and sisters, think of what you were when you were called. Not many of
you were wise by human standards; not many were influential; not many were of
noble birth. But God chose the foolish things of the world to shame the wise; God
chose the weak things of the world to shame the strong. God chose the lowly things
of this world and the despised things—and the things that are not—to nullify the
things that are, so that no one may boast before him.” (1st Corinthians
26-29)
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4. We are called to be holy and perfect, but Jesus said that even the religious experts
of His day were not perfect enough; no one is good except God.
• “
For I tell you that unless your righteousness surpasses that of the Pharisees and
the teachers of the law, you will certainly not enter the kingdom of heaven.”
(Matthew 5:20)
• “
God made him who had no sin to be sin for us, so that in him we might become
the righteousness of God.” (2 Corinthians 5:21)
• “
The words ‘it [righteousness] was credited to him’ were written not for him
alone, but also for us, to whom God will credit righteousness—for us who believe in
him who raised Jesus our Lord from the dead. He was delivered over to death for our
sins and was raised to life for our justification.” (Romans 4:23-25)
Homework Assignments (5 mins)
Ask the client to turn to page 59 in the Workbook to follow along with you.
1. Memory Verse
“Consider it wholly joyful whenever you encounter trials of any sort or fall into
various temptations. Be assured that the trial and proving of your faith bring
out endurance and patience. But let endurance and patience do a thorough
work, so that you may be fully developed, lacking in nothing.” James 1:2-3
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory
verse for this week, and then try with previous weeks’ memory verses or other
favorite scriptures you may have.
3. Complete the Spiritual Reflections Worksheet on p 61
4. Positive Changes
Add to your list of the changes in your life that you could view as positive or that have
caused growth, including spiritual growth. It will be helpful to look to your faith
and God’s promises in the Bible to help you view some of the changes that have
occurred as positive. Also think about the paradoxes in Christianity and how these
might help you reframe your situation.
Reflect on the meaning of these changes in terms of your character and the predictions
you make regarding negative beliefs. In particularly, what power do these changes
give you to stop avoiding unpleasant experiences and to face them courageously?
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5. Read Paradoxes in Christianity worksheet
If you can think of other paradoxes in Christianity, add them to the worksheet.
6. Daily Prayer for Someone
Continue to contact the person in your faith community and to pray daily for this
person daily.
7. Solicit feedback on how the session went today.
Terminate the Session
Remind the client that next week is that last week of treatment. Your client will likely
have many feelings about ending treatment with you. Let them know that next week you
will be processing her experience in treatment and how to maintain the gains she has
made.
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SESSION 10: Hope and Relapse Prevention
Goals of Session
1. Introduce the topic of hope as a general way of being that results from using
religious cognitive and behavioral strategies
2. Discuss dreams and goals
3. Discuss what the client has learned/gained through these ten weeks
4. Review spiritual resources
5. Discuss how to maintain the gains in therapy through their faith, involvement in
their faith community (receiving and giving support), and other spiritual resources
6. Termination of treatment
Materials Needed in Client Workbook
• Homework Assignment Worksheet
• ABCDE Method for Challenging Beliefs Leading to Negative Emotions
Set Agenda
Our last session is called “Hope and Relapse Prevention.” We will explore the concept
of hope and faith, and how these two things can help us create and achieve new dreams
and goals despite illness and suffering. We will then review what you have learned over
the past ten weeks and the spiritual resources you have available to you. We will also
discuss how to maintain the gains you have made in treatment. Finally, I will be
interested in your feedback about your experience in this treatment study and what you
found most helpful. And, as always, I will leave you with an encouraging memory verse
from the Word of God.
[elicit feedback from client at this point]
Before we begin, I’d like to review your homework assignments and mood this week.
Review Homework Assignments (8 mins)
1. Memory Verse Review: “Consider it wholly joyful whenever you encounter trials of
any sort or fall into various temptations. Be assured that the trial and proving of your
faith bring out endurance and patience. But let endurance and patience do a thorough
work, so that you may be fully developed, lacking in nothing.” James 1:2-3
2. Review experience with contemplative prayer.
3. Review Mood Scale
• Using a scale ranging from 0 to 10, where 0 is the worst that you’ve
ever felt in your life and 10 is the best you’ve ever felt, what was your
mood like on average this week?
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4. Looking for the Positives and Spiritual Reflections worksheets:
Explore what worked in terms of being effective benefit-finding reminders. What did
he experience when he found himself noticing any positive changes in his life as a
result of his learning to cope with his medical and environmental struggles?
When clients mention any aspect of benefit-finding, counselors need to explore what
is the meaning of this. That is, the fact that they can see positives even under their
current difficult circumstances says something about the following:
• Who they are as persons.
• What their capacities are.
• How their worldviews can influence their everyday mood and life.
Such reflections help us end on a note of empowerment and a sense of control over
life’s vicissitudes.
5. How did the client use his faith and God’s promises to help view life changes as
positive? Did he think about the paradoxes in Christianity? Was this helpful?
Hope (10 mins)
Benefit-finding and positive changes naturally lend themselves to discussion about hope.
Share this with the client and ask him the following questions:
• What does hope mean for someone in a seemingly hopeless situation?
• Where can you find hope?
• What does hope mean concretely for you?
• How does your faith relate to your experience of hope?
• How can you hang on to hope?
These questions are just different ways of benefit-reminding but couched in the
framework of different religious terminology that may open up other perspectives.
The Bible describes hope as “a sure and steadfast anchor of the soul” (Hebrews 6:19). In
this sense, hope is something that grounds the soul, which is comprised of our mind, will,
and emotions. In Hebrews 11:1 it says that “faith is the substance of things hoped for…”
In other words, hope is the “blueprint for our faith.” Hope is the plan that faith carries
out. One Christian author has described hope as “the inner image—the picture that the
Holy Spirit paints on the inside of you, a picture that is based on the Word of God…It is
based on His Word, not on our wishes.”
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We can see that as we read God’s Word and His “great and precious promises” we will
begin to hope for the things God describes in His Word. In Romans 15:13 it says, “May
the God of your hope so fill you with all joy and peace in believing that by the power of
the Holy Spirit you may be overflowing with hope.” God wants us to hope in Him and he
wants it to be a joyful experience. With that in mind, we are going to discuss the new
meaning, dreams, and goals you may now have at the end of our work together.
[elicit feedback from client]
Meaning, New Dreams, and Spiritual Goals (7 mins)
• Do you feel that there is a greater purpose or meaning in what has happened to
you?
• Do you have any new dreams as a result of your diagnosis?
• What about new spiritual goals?
• How might God help you change and achieve your dreams and goals?
Termination Protocol (10 mins)
The main idea before the nitty-gritty items that follow will be to offer the client an
opportunity to reflect on the meaning of the therapy process overall.
• What parts of the process did you find most helpful?
• Why?
• What parts seemed to help you with your depression?
• How and why?
• What parts helped you deal with your physical condition?
• How and why?
• Did anything in particular surprise you about the experience?
• Are there any other things you want to discuss before we end?
At no point should counselors be defensive about any client response; rather, the use of
reflective listening and empathy is especially called for here at the end. If the client asks a
question which requires gathering information, let the client know someone from the
research team will address that with him.
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Maintenance and Relapse Prevention (10 mins)
*Note: The following are included in their workbook. Please review these points with the
client now. You can direct his attention to page 63 in his Workbook.
1. Continue to Use the Tools Daily
In order to maintain the gains you have achieved in treatment you need to keep
using the tools you have learned.
Ask the client to list some of the tools he has learned over the last ten weeks.
These tools include the following:
• Challenging and changing your negative interpretations
• Gratitude
• Altruism (encourage a specific activity for a specific person)
• Finding the positives in your life
• Praying for member of faith community
• Maintaining communication with God
• Look for examples in the Bible for encouragement
• Spending time with others
• Connecting with your faith community, specifically the person(s)
identified earlier in treatment
• Filling your mind and heart with the Word of God
One way to remind yourself to continue to put into practice the things you have
learned is to incorporate them into a daily devotional period. Each day during this
time you can review your thoughts and’ behavior with God to make sure they line
up with the truth in His Word. You might find it helpful to use a journal during
this time.
2. Make Use of Your Spiritual Resources
Spiritual resources include, but are not limited to, prayer, journaling, social
support from friends, conversations/counseling with clergy, Bible studies,
repentance and forgiveness, attending religious or spiritual services, attending
support groups, such as Alcoholics Anonymous, attending activities sponsored by
spiritual or religious groups, such as pot-lucks, bingo, and discussion groups.
3. Anticipate Set Backs
Remember that there will be set backs and times that are more challenging and
difficult than others. It is at these times that it is even more important to engage in
the activities and resources you learned, especially if you don’t feel like it.
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Final Homework Assignment (10 mins)
1. Memory Verse
“He gives power to the faint and weary, and to him who has no might He
increases strength. Even youths shall faint and be weary, and young men
shall stumble and fall exhausted; But those who wait for the Lord [who
expect, look for, and hope in Him] shall change and renew their strength and
power; they shall lift their wings and mount up [close to God] as eagles
[mount up to the sun]; they shall run and not be weary, they shall walk and
not faint or become tired.” (Isaiah 40:29-31, Amplified Bible)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory
verse for this week, and then try with previous weeks’ memory verses or other
favorite scriptures you may have.
3. Daily Prayer for Someone
Continue to contact the person in your faith community and to pray daily for this
person daily.
4. Solicit feedback on how the therapy has gone overall for them.
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Final Thoughts
1. Be sure to thank your client for what he has contributed to the therapy experience,
his hard work, courage and honesty in facing these most difficult times and topics.
2. Be appropriately open with what your client taught you personally so your client
can have a sense of his own altruism despite his receiving help at the same time.
3. End with Poem by St. Francis of Assisi. “Read” the prayer together (It is included
on page 64 in the Workbook), i.e., give client time to read and you do likewise,
and then ask for any feedback from client.
Lord, make me an instrument of Thy peace;
where there is hatred, let me sow love;
where there is injury, pardon;
where there is doubt, faith;
where there is despair, hope;
where there is darkness, light;
and where there is sadness, joy.
O Divine Master,
grant that I may not so much seek to be consoled as to console;
to be understood, as to understand;
to be loved, as to love;
for it is in giving that we receive,
it is in pardoning that we are pardoned,
and it is in dying that we are born to eternal life.
Amen.
St. Francis of Assisi
Terminate the Session

Religious Cognitive Behavioral Therapy for Depression in Clients with Chronic Physical Illness (Participant Workbook)

rcbt_participant_workbook__final_christian_version_3-14-14

(Christian version)
Participant Workbook
Joseph W. Ciarrocchi, Ph.D.
Debbie Schechter
Michelle J. Pearce, Ph.D.
Harold G. Koenig, M.D.
2014
With contributions from Rebecca Propst, Ph.D.
This workbook is a variant of the treatment protocol
originally designed by A. T. Beck, M.D.
Workbook developed largely by
Michelle J. Pearce, Ph.D.
** Please cite appropriately**
1
Session 1: Assessment and Introduction to RCBT
Home Practice Activities
1. Memory Verse
“Finally, whatever is true, whatever is noble, whatever is right, whatever is pure,
whatever is lovely, whatever is admirable—if anything is excellent or
praiseworthy—think about such things.” (Philippians 4:8)
Write the verse down and post it somewhere you will see it often, perhaps on a sticky
note placed on your mirror or fridge. You may want to make several copies and post
them in places you will see it throughout the day.
2. Activity and Mood Monitor
The goal of the first session’s homework assignment is begin developing skills in selfmonitoring daily mood and daily activities. The goal at this stage is not to change any
regular habits. The self-monitoring logs have a place for recording your activities and
mood every two hours. Please complete this log daily. It may be easiest to fill out the
activity log twice during the day. For example, you could record all of your morning
activities when you eat lunch and all of your afternoon and evening activities just before
you go to bed. This record will give us some information as to which activities may lead
to better moods and which activities may lead to worsened moods.
Here are few guidelines about self-monitoring:
a. Keep the self-monitoring log with you throughout the day and record your activities as
close as possible to the end of the time periods.
b. Record the activity in a very few words. For example, you could record “went out to
dinner” or “washed my clothes” or “read a book” or even “watched TV.”
c. Immediately after recording your activities, record your mood.
d. Purchase a notebook to put the logs in, so that you will have a record of your activities.
We will make use of them later.
e. Make sure you have your logs with you during each session. They are necessary for the
rest of the program
f. Be sure and include even trivial events on your chart such as missed the bus or read the
newspaper.
3. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
2
Thinking and Depression
Signs of Depression
“I don’t have a purpose in life anymore now that my chronic pain makes it too difficult to work.”
“I am a very poor Christian because I am depressed. A Christian should not be depressed.”
“I just can’t motivate myself to do any of the things which I need to do. I’m a lazy person.”
All of the above are statements that a depressed individual might make. While some of these
statements and notions may seem to be correct on the surface they actually reflect a change in the
way an individual thinks about him or herself. When people become depressed, they think about
themselves and their environment in a different and more negative way.
Recent research has shown that depressed individuals are more likely to interpret an event more
negatively than a non-depressed individual. Thus, depressive symptoms are related to the way in
which individuals interpret and think about their situation in life. These thoughts and
interpretations are also a reflection of one’s past experiences. Not only are depressed individuals’
interpretations more negative, but research also shows that their perceptions and interpretations
are less accurate than those who are not depressed.
The interpretations that an individual makes of a situation influence his or her behavior, as
illustrated in the following example. Imagine that you have a flat tire on a deserted highway and
do not have anything to change the tire with, including a car jack. As you are standing there
stranded, your next-door neighbor drives by and looks up briefly but keeps going. How would
you feel about the fact that your neighbor kept driving? What would you most likely be telling
yourself about the situation?
Now let’s imagine, further, that you see your neighbor the next day and he comes over to you and
apologizes for driving by you. “I’m so sorry I couldn’t stop; my son fell and was bleeding from
his head and I was rushing him to the emergency room.” How might you be feeling now? What
changed? What are you now telling yourself about the situation that is different from when you
were standing on the road?
The following diagram represents the relative relationship that thoughts, feelings, and behavior
have on each other.
Thoughts
Feelings
Behavior
3
The idea that our thoughts and assumptions play an important role in influencing not only our
emotions but also our behaviors is actually a very common idea in both the Old and New
Testaments. Indeed, for Christians the cognitive behavior model is 2000 years old! Let me give
you some examples from the Bible:
• The first words of both John the Baptist and Jesus in their public ministries were,
“Metanoia” literally meaning “Change your mind” or “Change how you think”, which
the Bible translated as “Repent”. To repent means to change your attitude, change your
mind, change how you think (Matthew 4:17).
• The apostle Paul told the Roman Christians, “Do not be conformed to this world, but be
transformed by the renewing of your minds, so that you may discern what is the will of
God — what is good and acceptable and perfect” (Romans: 12:2). In other words, Paul is
saying that transformation comes about by renewing your mind.
• The Old Testament speaks about the same idea: ‘ . . . for as he thinks in his heart, so is
he’ (Proverbs 23:7. KJV).
4
Activity and Mood Monitor
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
5
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
6
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
7
Session 2: Behavioral Activation and Walking by Faith
Home Practice Activities
1. Memory Verse
“We walk by faith and not by sight.” (2nd Corinthians 5:7)
As you did last week, write the verse down and put it in a place, or ideally more than
one place, where you will see it many times a day. The more you meditate on these
verses the more your mind is renewed and the greater improvement you will begin to
see in your mood.
2. Plan and Complete Pleasant Events
Complete the two pleasant events you selected with your therapist between now and
our next session. When you are finished the activity, complete the Planning Pleasant
Activities Worksheet. Remember to complete the worksheets for both activities.
3. Identify and Contact Member of Faith Community
Identify several possible faith companions and make contact with at least one of
them. This is important over the long-term and relates directly to depression. Both
the receiving and especially the giving of support to others (as will be addressed in
the session on altruism) is key in this regard. Identifying people worse off than you
are helps to get your mind off your problems, helps you realize that things could be
worse, helps you to feel grateful for what you do have, and gives a sense of purpose
and meaning that will result in eternal rewards as a service to God by caring for
another. In approaching another person, you might say something like:
“I’m having a pretty difficult time now and I’m wondering if you would agree to
pray for and with me during this period, and perhaps we could talk on the phone or go
out for coffee once a week or every other week.”
4. Reading
Please read the pages in your workbook titled, “The Categories of Unhelpful
Thinking” to prepare for next week’s session. This is somewhat lengthy and to make
the most of the limited time in session it very important that you have already
reviewed this material
5. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
8
As Christians, we have the comfort of knowing that we have a High Priest—Jesus
Christ—whom the Bible says is familiar with all of our pain, suffering, and trials. He
knows how depression makes you feel; He knows how hard it is to deal with your
physical illness. The Bible says that we can boldly approach the throne of grace to
receive help in our time of need (Hebrews 4:16). If you find yourself struggling to
complete these activities, ask Jesus for His grace and His help. He understands your
struggle and He will give you the strength and encouragement you need.
9
Pleasant Activities List
Put a plus sign (+) next to any activity likely to generate some positive reaction in you.
Put two (++) next to those that are positive and you are almost certain to do so.
1. Call a friend
2. Attend a movie
3. Clean the kitchen
4. Daydream
5. Rearrange furniture
6. Prepare a meal
7. Wash the car.
8. Outdoor yard work or gardening.
9. Buy a plant
10. Watch television
11. Take a mini-vacation
12. Go to an amusement park
13. Dinner with friends
14. Attend a play
15. Attend a concert
16. Visit a museum
17. Play a sport
18. Watch a sporting event in person
19. Watch sports with friends
20. Dance
21. Attend church or another religious service
22. Speak to a friend(s) on the Internet
23. Play video games
24. Text messaging
25. Twitter
26. Visit family members
27. Provide childcare for family or friends
28. Exercise alone
29. Exercise with others
30. Get a massage
31. Read a book or magazine
32. Write in a journal
33. Write a poem or short story
34. Play a musical instrument
35. Listen to music
36. Engage in a hobby, such as photography, scrapbooking, stamp/coin collecting,
genealogy, knitting, crocheting, etc.
37. Take a bath or shower
38. Take a nap
39. Go shopping
40. Sailing, boating, fishing, or other water-related activity
41. Attend an educational class
10
Planning Pleasant Activities Instructions
Implicit in the idea that mood is rea1ted to activity is the concept that mood can be
improved by increasing specific activities. From the records you kept last week, you may
be able to identify particular classes of activity that are associated with better mood. Even
in the Gospels we read of Jesus spending time alone with His disciples away from
demands. The purpose of this exercise is to schedule more of these activities in order to
improve your mood.
You can look at your Self-Monitoring Logs and the Pleasant Activity List for ideas.
Choose activities that you have some control over, that bring a sense of mastery or
accomplishment, and that you enjoy. Choose activities that take more than 10 or 15
minutes to perform, yet which can be accomplished in one day. Schedule activities that
are additions to what you would ordinarily do. The following are some examples of
pleasant activities:
Have your hair done
Browse in a bookstore
Prepare a Chinese dinner
Play tennis
Visit an art museum
Buy a new plant
Next, using the following worksheet, schedule and complete at least two activities
between now and the next session. Be sure to complete the worksheet once you have
engaged in the activity.
11
Planning Pleasant Activity #1 Worksheet
1. Identify Activity #1 from the Pleasant Activity List or your imagination.
Activity planned:________________________________________________________
Who has to be contacted or notified? ________________________________________
2. When will it be accomplished?
Date of activity: ________________________________________________________
3. Prediction
On scale of 0 – 10 how positive will the event be to you? _______________________
(where 0 is not positive and 10 is very positive)
4. Reflect
Date activity was accomplished: ___________________________________________
Outcome: On scale of 0 – 10 how positive was the event for you? ________________
Conclusion: What seems to make events pleasant at this point? What did you learn?
______________________________________________________________________
______________________________________________________________________
Ideas for Future Activities:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
12
Planning Pleasant Activity #2 Worksheet
1. Identify Activity #2 from the Pleasant Activity List or your imagination.
Activity planned:________________________________________________________
Who has to be contacted or notified? ________________________________________
2. When will it be accomplished?
Date of activity: ________________________________________________________
3. Prediction
On scale of 0 – 10 how positive will the event be to you? _______________________
4. Reflect
Date activity was accomplished: ___________________________________________
Outcome: On scale of 0 – 10 how positive was the event for you? ________________
Conclusion: What seems to make events pleasant at this point? What did you learn?
______________________________________________________________________
______________________________________________________________________
Ideas for Future Activities:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
13
Unhelpful Thinking Styles and Theological Reflections
1. All-or-Nothing Thinking (AN):
You see things in black-and-white categories. If your performance falls short of perfect,
you see yourself as a total failure.
Example: An example would be a straight-A student who received a B on an exam and
concluded, “Now I’m a total failure.”
A. Why is this thinking incorrect?
This type of thinking causes one to fear any mistake or imperfection because that is taken
as an indication of being worthless. This way of evaluating things is unrealistic because
life is rarely completely either one way or the other. For example, no one is absolutely
brilliant or totally stupid. Nothing on earth is totally one way or the other. Rarely, does
everyone always like us, or rarely do we always find the perfect solution.
B. Theological reflection
The idea that nothing on earth will ever be perfect, including people and their activities is
certainly a common theme in the New Testament. Romans 3:23, for example, says that
everyone has failed in some way, or to use the New Testament language, they have
sinned. However, Romans 3:24 goes on to say that even though we are not OK, that is
OK. In other words, we are accepted by God anyway, through His forgiveness. This
theme is expressed in Romans 8:1: “there is no condemnation for those who are in
Christ.” Romans 5:12 continues this theme and says that “we are justified by faith, and
we therefore have peace with God.” In other words, we need merely to have faith in the
perspective that we are OK as far as God is concerned.
2. Overgeneralization (OG):
You see a single negative event as a never-ending pattern of defeat.
Example: An example of this type of thinking would occur when a shy young man, who
is self-conscious of his artificial leg, mustered up his courage to ask a woman for a date.
When she politely declined because of a previous engagement, he said to himself, “I’m
never going to get a date. No one wants to date a guy with only one leg.” He believed that
all women will turn him down just because one declined his offer. And, he erroneously
assumed it was because of his artificial leg. The pain of rejection is generated almost
entirely from overgeneralization.
A. Why is this thinking incorrect?
It is logically incorrect to conclude that one thing that happened to you once will occur
over and over again. It is also incorrect to assume that all situations are similar; or that all
individuals are similar.
14
B. Theological reflection
There are also several stories in the Bible that suggest that one failure does not therefore
mean that there will always be failure. Perhaps the most vivid story is that of Jesus and
Peter. In John 18: 15-17 we read that Peter denied that he even knew Jesus. This could
surely be considered a major affront. One might assume with some justification that Peter
had failed as a friend and could never again consider himself to be a worthy friend of
anyone, especially Jesus. However, later we see Jesus asking Peter if he loves Him and
Peter responding in a positive manner. We then see Jesus being willing to trust Peter with
something that is very important to Jesus. (John 21:15-19 describes this situation). It
certainly sounds as if one major catastrophe or mistake does not mean that the individual
will continue to make those mistakes.
3. Mental Filter (MF):
You pick out a single negative detail and dwell on it exclusively so that your vision of all
reality becomes darkened, like a drop of ink that discolors an entire beaker of water.
Example: A woman with severe arthritis failed to complete one task that she had hoped to
complete. She became more depressed and angry at herself for not completing that task.
She overlooked the fact that there had been many tasks that she had, in fact, completed.
A. Why is this thinking incorrect?
It is more sensib1e to clearly view one’s environment and be aware of the positive things
one has done in addition to negative occurrences. It is not adaptive to filter out anything
positive. It is irrational to say, “I should preoccupy myself with dangerous or negative
ideas.” Nothing is gained by dwelling on them.
B. Theological reflections:
The Scriptures usually emphasize that one should reflect on the positive rather than the
negative. One should certainly reflect on what is true, and that includes seeing the
positive things you have accomplished. This theme is reflected in Philippians 4:8 which
says, “…. whatever is true, or lovely, or gracious … think on that. If there is any
excellence, if there is anything worthy of praise …think about that.” Whi1e the emphasis
here might be on values and ideas, it could also refer to one’s actions.
4. Disqualifying the Positive (DP):
You disqualify positive experiences by insisting they “don’t count” for some reason or
other. In this way you can maintain a negative belief that is contradicted by your
everyday experiences. You don’t just ignore positive experiences as in the Mental Filter,
but you clearly and swiftly turn them into their very opposite.
Example: An example would occur when someone praises your appearance or your work
and you automatically tell yourself, “They’re just being nice.”
15
A. Why is this thinking incorrect?
Again, it is maladaptive not to pay attention to feedback you get from your environment.
We should take that feedback at face value and incorporate it into our understanding of
ourselves. If we disbelieved everything everyone told us, we might still believe the world
was flat. An adjusted person is one who pays attention to everything in their environment.
B. Theological Reflections
We must not be like the Israelites in the wilderness who made a negative interpretation of
God’s actions towards them. (They also probably thought the worse about other people’s
actions towards them.) When God took them into the wilderness, they distorted the
situation and said, “God has brought us here to slay us.”
Similarly, in the New Testament, a constant theme is put forth that every individual has
some valuable important talents. This applies to even the individual who may think they
were sitting in the back row when talents were handed out. One place where such a theme
is discussed is in I Corinthians 12:4-31, especially verses 15-17 and 21-14. Those
seemingly less important individuals are actually very valuable people in the larger
scheme of things and have much to offer.
5. Jumping to Conclusions (JC):
You make a negative interpretation even though there are no definite facts that
convincingly support your conclusions. There are two areas in which depressed
individuals jump to conclusions.
Mind Reading (MR):
This is one area in which depressed individuals jump to conclusions. You arbitrarily
conclude that someone is reacting negatively to you, and you do not bother to check this
out.
Example: Suppose a friend says she does not have time to have a conversation with you
on the telephone at a certain point. The depressed individual may conclude, “She is
ignoring me and does not want to talk with me, because she does not like me anymore.”
A. Why is this thinking incorrect?
One should never make an assumption about what someone is thinking without asking
them because it is usually impossible to know what another person is thinking, no matter
how sure we are we know. Jumping to conclusions about what the other is thinking is
also maladaptive because our negative reactions to their imagined thoughts may set up a
self-fulfilling prophecy. That is, we may react negatively to them when we suspect they
do not like us, when in fact they do. However, our negative reactions will soon turn them
off.
B. Theological reflections
In the New Testament, Jesus provides a perfect example of someone who chooses to
16
check out what people were actually thinking about him, rather than merely make
assumptions. A good example of this is in Mark 8:27, when He said, “who do men say
that I am?” It may be also that we begin to try to read other’s minds because we are
overly concerned about their perceptions of us, to the extent of basing our worth on their
perceptions of us. Jesus, however, presents an example of someone ‘who was not overly
concerned about others’ impression of Him, and indeed, surely did not have the favor of
most people. He even went so far as to contend that, “Blessed are you when men hate
you,” (Luke 6:22).
The Fortune Telling Error (FT):
The second way in which depressed individuals jump to conclusions is they anticipate
that things will turn out badly. They feel convinced that their predictions are an already
established fact.
Example: Depressed individuals will tell themselves that they are never going to recover,
“I will feel miserable forever.”
A. Why is this thinking incorrect?
No one has ever successfully predicted the future; there are so many factors that could
have an impact upon the future. Furthermore, our predictions are likely to be even more
off base if we predict only negative events because probability suggests that both positive
and negative events will occur.
B. Theological Reflections
Often our jumping to conclusions regarding the future implies a fear about the future. The
New Testament certainly emphasizes the idea that God will give us a spirit of power and
love, the ability to control our fears rather than a spirit of timidity (2 Timothy 1:7). There
is also the theme of anxiety concerning the future in Matthew 6:25-34. Essentially, by
worrying and imaging a negative future we do not improve the situation. Our thoughts
should be on the present. (verse 34).
6. Magnification (Catastrophizing) or Minimization (MM):
You exaggerate the importance of things (such as your goof-up or someone else’s
achievement), or you inappropriately shrink things until they appear tiny (your own
desirable qualities or the other fellow’s imperfections). This is also called the “binocular
trick”.
Example: A depressed individual accidentally misfiled some papers while working at his
job. He concluded, “I made a mistake. How horrible! Everyone will think I am
incompetent.” An example of minimization would occur when the same employee was
told by one of his or her colleagues that he had done a good job on a report. His reaction
was to think , “0h well, doing the report was very simple and anyone could do a good job
on it.”
17
A. Why is this thinking incorrect?
It is important to have an accurate perception of ourselves and our performance. It is also
important to realize that everyone makes mistakes and that they are to be expected. It is
impossible for anyone to be perfect.
B. Theological reflections
Perhaps Christ’s temptation in the garden (recorded in Matthew 26:39, 42) was a
temptation not to drink the cup of humanness, not to identify with humanity in their
imperfections. Often the negative events that happen to us are merely part of that
humanness, and we do not wish to accept that. Becoming close to Christ, therefore, does
not mean perfection; but rather sharing in His poverty.
In the Old Testament, Psalm 88 goes even further in lessening the sting of negative
events. In that particular Psalm, the suggestion is made that perhaps the negative events
are precipitated by God, the implication being that God has a good purpose behind them.
Indeed, this was the theme of a Christian writer, Juliana of Norwich, writing in
Revelations of Divine Love she contends that the Lord rejoices at the tribulations of His
servants… and He lays on His beloved something that is no lack in His (God’s) sight but
by which the person is lowered in the world. This He does to preserve the individual from
pomp, and to make them holy.
As far as the minimization of our positive aspects, we have only to recall again the New
Testament discussion of gifts. More specifically, every individual has something that is
valuable, and should consider it so (I Corinthians 12:4-31).
7. Emotional Reasoning (ER):
You assume that your negative emotions necessarily reflect the way things really are: “I
feel it, therefore, it must be true.”
Example: A depressed individual may tell himself, “I feel overwhelmed and hopeless,
therefore, my problems must be impossible to solve, or I’ll feel inadequate, therefore, I
must be a worthless person.
A. Why is this thinking incorrect?
One cannot assume that one’s emotions are a reflection of the true state of things. Our
emotions are a reflection of our thoughts and beliefs, which as we have seen are a product
of our past and may be distorted. Emotions may also be a reflection of our physiology
and how tired we are, but they are not necessarily a reflection of the true state of affairs.
B. Theological Reflections
Both the Old Testament and the New Testament speak much about negative emotions
and their role in our life.
a) John 1:12 suggests that our standing with God may be dependent upon our
actions and belief, but it says nothing about it being dependent upon our feelings.
18
b) Christian writers have often commented that faith is only faith when there is
darkness, when the individual does not even feel God. As long as there is a feeling of
God’s presence, we do not have to go on blind faith. Juliana of Norwich has commented
that our prayers are most precious to God when we feel nothing because then we have
faith.
c) Often in our growth as a Christian, we must go through difficult times. This is
certainly the impression one gets in Psalm 63 where the writer reports a general
dissatisfaction, a dryness and a longing for God. If that dryness and longing were not
there, then the individual would not rejoice to find God, who is often described as the
living water (John 4:10 and John 7:38). Water only tastes good to the thirsty.
d) Finally, the spiritual injunction that one should give up their life in order to
save it could be applied to emotions. Often we seek God only for selfish ends, only to
feel good, rather than for God’s purposes (Matthew 10:39). Feelings of longing or
desolation may actually be positive in that they imply a growth process we are willing to
go through.
8. Should Statements (SS):
You try to motivate yourself with shoulds and shouldn’ts, as if you had to be whipped
and punished before you could be expected to do anything. “Musts” and “oughts” are also
offenders. The emotional consequence is guilt. When you direct should statements
towards others, you feel anger, frustration, and resentment.
Example: One example is the depressed housewife who says to herself, “I should keep
my house cleaner, and I shouldn’t complain,” or, “I should be able to get my work done
during the day.”
A. Why is this thinking incorrect?
“Should” statements generate a lot of unnecessary emotional turmoil in your daily life,
and, paradoxically, usually do not motivate you to change your behavior. Usually, you
resent the source of the “shoulds.” Saying,”1 should do this”, or “I must do this,” usually
causes one to feel pressured and resentful.
B. Theological Reflection
One of the central themes of the New Testament is that Christ has given us a spirit of
freedom and accepted us, and we should not condemn ourselves by getting upset at
ourselves if we do not perform the way we think we should perform (Romans 8: 31), or
the way others think we should. Saying, “I shouldn’t do that,” leads to a spirit of
condemnation. Even if we do not do any “shoulds,” God still loves us, (Romans 5:8). We
are made OK with God simply by grace, not by our pressured determination to keep all
the “shoulds” in one’s life. (Romans 5:1-2).
19
9. Labeling and Mislabeling (L or ML):
This is an extreme form of overgeneralization. Instead of describing your error, you
attach a negative label to yourself: “I’m a loser.” When someone else’s behavior rubs you
the wrong way, you attach a negative label to him or her: “You are an idiot.” Mislabeling
involves describing an event with language that is highly colored and emotionally loaded.
Example: An individual fails to get a job which they applied for and they call themselves
a “failure.”
A. Why is this thinking incorrect?
We are not our behavior. Labeling yourself is not only self-defeating, it is irrational. You
cannot be equated with any one thing you do. Your life is made up of many events,
thoughts, actions, and emotions. For example, you do not call yourself a “Breather” just
because you breathe. Likewise, you do not call yourself a “failure” because you made a
mistake.
B. Theological Reflection
God does not base our worth on our activities. Likewise, He does not label us based on
our activities. God has a great love for us and rejoices in us even when our activities
would not to merit that. The parable of the lost coin in Luke 15:8-10 suggests our worth
is not based on our activities but is a reflection of much more. Likewise, in the story of
the prodigal son, Luke 5: 1-24, we read that the son’s worth was not based on his
behavior.
10. Personalization (P):
You see yourself as the cause of some negative external event for which you were not
primarily responsible.
Example: One example is the child who misbehaves or is rude. The depressed mother
says, “I am a failure or a bad mother,” (as if she could control everything her child did).
A. Why is this thinking incorrect?
Essentially, the person with this problem has confused influence with control. While we
obviously have some influence over people, especially our children, we cannot control
everything they do. What another individual does is ultimately their responsibility and
decision, not yours. We are not omnipotent.
B. Theological Reflection
God has control over the events that happen in the world. However, for the most part, we
do not. We should not presume to be God or try to do so. This is especially important
when negative events happen to us.
20
Session 3: Identifying Unhelpful Thoughts: The Battlefield of the Mind
Home Practice Activities
1. Memory Verse
“You, God, will keep in perfect peace all those who trust in You, all whose thoughts
are fixed on You.”(Isaiah 26:3)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have. Turn to the next page in this workbook for instructions. Remember,
“God’s thoughts are higher than our thoughts and His ways are higher than our ways”
(Isaiah 55:9). We need to continually fill our mind with God’s words so that our can be
full of God’s “higher thoughts. His thoughts lead to feelings of joy, peace, and hope, the
kind of emotions we would rather feel than depression and hopelessness.
3. Thought Log
Please write down your thoughts once a day using the ABC method. Be sure to fill out all
of the sections and categorize each thought into one of the unhelpful thought categories.
If you have more than one stream of ideas in one time period, you can indicate several
categories. There are seven thought logs included in the manual this week so that you can
fill one out each day.
Remember that this is a learning experience; you should not worry about completing the
logs perfectly.
4. Positive Activity
Add another positive activity to your week. Follow the same procedure for scheduling
this activity as we used in Session 2.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
21
Contemplative Prayer: Praying God’s Word
Contemplative prayer is a way to meditate on God’s word and leads to a more intimate
relationship with Him. One of the most common metaphors for contemplative prayer is
of the lover or friend. God desires our simple presence more than any action or service
we might give. Indeed, prayer has been described as a gift to God. Prayer is also a
discipline, undertaken as one would undertake to learn to play the piano. Practice is the
key.
One way to engage in contemplative prayer is to take a verse from the Bible, one of
God’s thoughts, and meditate on it. In other words, you spend some quiet time thinking
about the verse, repeating it to yourself, and saying it as a prayer to God. It’s like letting
yourself be saturated in God’s words. Some forms of meditation have you focus your
attention on your breath. When you notice yourself thinking about something else, you
are to bring your attention back to your breath. Contemplative prayer is different in that
instead of focusing on your breath you focus on God’s words. This leads to a
contemplative, prayerful state.
It’s normal to find that your mind has wandered to thinking about something else. When
you notice that this has happened, don’t get upset with yourself. Simply bring your
attention back to the verse. It might be helpful to have the verse written on a piece of
paper or underlined in the Bible in front of you so that you can more easily keep your
attention on the words. It is also normal to find yourself wanting to pray to God as you
are in this state. If that happens just go with it and pray whatever comes up in your heart.
The Method
1. Choose a scripture. Begin with your memory verse for the week.
2. Sit comfortably, but not too comfortably, back straight, chest open so the breath is free
and open.
3. Read the passage slowly. Savor each phrase. What word phrase or idea speaks to you?
4. Read the passage again. Where does this passage touch your life? What do you see,
hear, touch, or remember?
5. Read the passage a third time. Listen quietly.
6. Note insights, reflections, and personal response to the reading in your journal.
7. Follow the steps in order or go back and forth between them as you feel moved.
8. Finish by waiting for a few moments in silence.
Instructions
Practice this for 20 minutes once or twice daily, and then discuss with your therapist any
problems you encountered in doing this, or share how praying in this way made you feel.
22
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 1
(*To be Completed During Session 3*)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
23
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 2
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
24
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 3
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
25
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 4
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
26
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 5
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
27
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 6
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
28
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 7
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
29
Planning Pleasant Activity #3 Worksheet
1. Identify Activity #3 from the Pleasant Activity List or your imagination.
Activity planned:________________________________________________________
Who has to be contacted or notified? ________________________________________
2. When will each be accomplished?
Date of activity: ________________________________________________________
3. Prediction
On scale of 0 – 100 how positive will the event be to you? _______________________
4. Reflect
Date activity was accomplished: ___________________________________________
Outcome: On scale of 0 – 100 how positive was the event for you? ________________
Conclusion: What seems to make events pleasant at this point? What did you learn?
______________________________________________________________________
______________________________________________________________________
Ideas for Future Activities:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
30
Session 4: Challenging Unhelpful Thoughts: Bringing All Thoughts Captive
Home Practice Activities
1. Memory Verse
“We refute arguments and every proud and lofty thing that sets itself up against the
true knowledge of God; and we lead every thought and purpose away captive into
the obedience of Christ.” (2nd Corinthians 10:5)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Thought Log Monitor
Complete the ABCDE thought monitor at least once a day.
Be on the outlook for automatic negative thoughts that trigger emotional upset and
negative behaviors such as avoidance. The goal is to improve on the ability to spot these
negative patterns at the time they occur, and to attempt to develop alternative ways of
responding through the use of more effective beliefs and expectations.
Remember to use your religious beliefs and practices, as well as scriptures, to help
challenge your unhelpful and negative beliefs.
4. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
5. Be sure to have your completed homework sheets readily available to you during your
next session so that you can review them with your therapist.
Remember, the Bible says our mind is a battlefield. We are at war! Identifying our
thoughts and challenging them—making sure they are consistent with what God says– is
serious business. In 2nd Corinthians 10” 3-5, we are told to challenge our thoughts and
not to believe everything we think. Just because we think it doesn’t mean it’s true. These
verses say, “We are human, but we don’t wage war as humans do. We use God’s mighty
weapons, not worldly weapons, to knock down the strongholds of human reasoning and
to destroy false arguments…We capture rebellious thoughts put them in obedience to
Christ.” We want to win the battle going on in our minds and God’s word is the most
powerful way to do this. When we put His words of truth in our minds we can change the
way we think and as a result how we feel, no matter what the situation.
31
Disputing Questions
Use these questions to challenge your automatic thoughts. Be sure to answer each question you
pose to yourself. You will find each question helpful for many different thoughts. Several
examples are also presented to help you get started.
1. Do I know for certain that ______________________________________________?
Example: Do I know for certain that I won’t have anything to say?
2. Am I 100% sure that __________________________________________________?
Example: Am I 100% sure that my anxiety will show?
3. What evidence do I have that ____________________________________________?
What evidence do I have that the opposite is true?
Example: What evidence do I have that they did not understand my speech?
What evidence do I have that they did understand my speech?
4. What is this worst that could happen? How bad is that? How can I cope with that?
5. Do I have a crystal ball?
6. Is there another explanation for __________________________________________?
Example: Is there another explanation for his refusal to have coffee with me?
7. Does _____________________ have to lead to or equal ______________________?
Example: Does “being nervous” have to lead to or equal “looking stupid”?
8. Is there another point of view?
9. What does ________ mean? Does ________ really mean that I am a(n) __________?
Example: What does “looking like an idiot” mean? Does the fact that I stumbled over my
words really mean that I look like an idiot?
32
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 1)
(*To Complete During Session 4*)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
33
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
34
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 3)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
35
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 4)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
36
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 5)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
37
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 6)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
38
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 7)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
39
Session 5: Dealing with Loss
Home Practice Activities
1. Memory Verse

In all these things we are more than conquerors through him who loved us. For
I am convinced that neither death nor life, neither angels nor demons, neither
the present nor the future, nor any powers, neither height nor depth, nor
anything else in all creation, will be able to separate us from the love of God that
is in Christ Jesus our Lord.” (Romans 8:37-39)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse
for this week, and then try with previous weeks’ memory verses or other favorite
scriptures you may have.
3. Thought Log
Use the ABCDE thought log to actively address one or two losses you have
experienced as a result of your illness. You and your therapist should have come up
with a concrete plan to do so in session. Two ABCDE thought log worksheets have
been included in this section of the workbook for this exercise. Remember that
integrating your religious beliefs and practices into the use of each of these tools
makes them even more effective.
4. Active Surrender
Reflect on the things in your life that you want to surrender to God. Use the
worksheet provided to make a list. Then, set aside a block of time to surrender these
things to God in prayer. This is another effective tool to address the losses you have
experienced as a result of your illness.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
40
Words of Encouragement
It may be comforting to know that a number of individuals in the Bible suffered great
losses. In fact, one could argue that there isn’t a single individual mentioned in the Bible
that didn’t lose something important to them or who didn’t suffer in some significant way.
Even the disciples suffered greatly, most of whom were eventually put to death, and these
were the individuals with whom Jesus developed the closest relationship! We can see
that it doesn’t matter who we are or what we do in life, as Christians we will suffer.
Thankfully, God offers us many, many words of comfort and encouragement in the Bible.
Before He ascended to heaven, Jesus said to his disciples, “In the world you will have
trials and distress; but be of good cheer and be courageous for I have overcome the
world.” (John 16:33). Although, Jesus said problems and suffering are inevitable while
we are on earth, He promised to see us through each one of them. Indeed, in Matthew 5:4
Jesus said, “Blessed are all those who mourn for they will be comforted.” Paul later says
to the Corinthians “Praise be to the God and Father of our Lord Jesus Christ, the Father
of compassion and the God of all comfort, who comforts us in all our troubles, so that we
can comfort those in any trouble with the comfort we ourselves receive from God” (2
Corinthians 1:3-4). Perhaps the reason Jesus calls us blessed when we mourn is because
we get to be comforted by Jesus Himself, and His comfort and compassion are so great
that we are then able to comfort others that are facing troubles.
41
ABCDE Method for Challenging Beliefs (Session 5, Worksheet 1)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
42
ABCDE Method for Challenging Beliefs (Session 5, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
43
Active Surrender Exercise
Some aspects of life are our under our own personal control, while others are beyond our
control. Life becomes more difficult when we try to control the uncontrollable. Some of
the things we believe and feel make letting go difficult. Surrendering to God helps us
begin the process of letting go. It is important to remember that active surrender to God is
different from giving up. Notably, surrender is paradoxical— letting go inadvertently
increases control.
Make a list of the things you would like to surrender to God. These might include
situations, experiences, memories, hurts, people, and other things that have been
bothering you. Then spend some time in prayer turning over each of the things on your
list to God. Thank Him for telling you in His Word to “cast your cares upon Him because
He cares for you” (1 Peter 5:7).
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Session 6: Coping with Spiritual Struggles and Negative Emotions
Home Practice Activities
1. Memory Verse
“The righteous cry out and the Lord hears them; He delivers them from all
their troubles. The Lord is close to the brokenhearted and saves those who are
crushed in spirit. The righteous person may have many troubles, but the Lord
delivers him from them all.” (Psalm 34:17-19)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer.
3. Spiritual Struggles and Spiritual Resources
It is important to remember the following points:
• It is normal to question God in the face of illness.
 It is normal to feel negative emotions toward God.
 God created us to experience a range of emotions and He can accept all of them.
 God wants us to be honest with Him and to bring all of our concerns to Him.
If you and your therapist identified spiritual resources that would be helpful in
addressing any spiritual struggles you have, make a plan to use these resources this
week to address that issue. Spiritual resources include, but are not limited to, prayer,
journaling, social support from friends, conversations/counseling with clergy, Bible
studies, repentance and forgiveness, attending religious or spiritual services, attending
support groups like Alcoholics Anonymous, attending activities sponsored by
spiritual or religious groups like pot-lucks, bingo, and discussion groups. Several
ABCDE thought logs have also been included in the workbook for this session; this
may also be a helpful tool in addressing spiritual struggles this week.
4. Repentance and Forgiveness
Forgiveness can be a powerful antidote for some spiritual struggles (e.g., resentment,
anger, bitterness) and an integral part of the process of healing. Indeed, research has
shown strong relationships between emotions such as anger and resentment and
physical health problems and compromised immune functioning.
One of the most powerful verses about the relationship between our mind, body, and
spirit is recorded in 3rd John 1:2: “Beloved, I pray that you may prosper in all things
and be in health, just as your soul prospers.” We learn from this verse that our ability
to prosper in life and in our bodies is contingent upon the state of our soul, which is
made up of our mind, will, and emotions. If we harbor unforgiveness and bitterness
toward others, God, or ourselves, our souls are not prospering and because of this
nothing else in our life can prosper either.
God instructs us to forgive others as He has forgiven us. That doesn’t mean He wants
45
you to change your mind and decide that what happened to you was right or justified.
God never changes His mind about our sin—He always sees it as evil. What forgiving
someone does mean is that we give up the right to hold this action against the person.
We give up our right to feel resentful, bitter, and angry. When we make a decision
with our will to forgive someone, even when we don’t feel like it, God can then begin
to change our feelings. Usually our feelings are the last part to change. That doesn’t
mean you haven’t forgiven, it just means your feelings having yet come into
alignment with the decision you made with your will to forgive.
Is there anyone you would like to forgive? That could include others, yourself, and
even God (although He never sins, we can perceive a wrong against us in our minds).
Is there anything you would like to ask forgiveness for (i.e., repent of), either from
God or from others? If yes, and if you did not address these in session, make a list of
the people you want to forgive or the things for which you need forgiveness.
Take some time to pray about each item on your list. It is important that your prayers
be specific and that you do not just offer one blanket prayer for all the items listed.
You can use a prayer such as the following:
“Heavenly Father, I purpose and choose to forgive ___ (the person) for ___ (the
action). I release him/her and cancel their debt to me completely. I will no longer
hold any accusation against them. Even now I release them from this sin. I ask that
you would forgive them for this sin and separate the sin from them forever. Please
forgive me for the unforgiveness/bitterness (or other feelings against this person) that
I have stored in my heart. I give you all my feelings of ____ and ask that You would
cause my feelings to line up with my decision to forgive ___ (the person). I also
purpose and choose to forgive myself. Thank you for forgiving me and making me
righteous in your sight. Holy Spirit, please heal my heart and tell me your truth about
the situation.”
After you have finished praying, you might try closing your eyes and imagining
yourself standing or kneeling before Jesus or before the cross. See yourself giving the
list of wrongs that others have done to you, and that you have just forgiven, to Jesus.
Give the list of your own sins to Jesus, too, and see Him nailing these lists to the
cross. Listen as Jesus says, “You are forgiven. Go in peace.” Continue to listen to
hear what else Jesus might have to say to you or what else He might do as you stay in
this image. When you are done thank Jesus for what He has just done for you.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally some time this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
46
Forgiveness Exercise
Is there anyone you would like to forgive? That could include others, yourself, and
even God (although He never sinned against us, we can perceive a wrong against us
in our minds). Is there anything you would like to ask forgiveness for (i.e., repent of),
either from God or from others? If yes, make a list of the people you want to forgive
or the things for which you need forgiveness.
Take some time to pray about each item on your list. It is important that your prayers
be specific and that you do not just offer one blanket prayer for all the items listed.
You can use a prayer such as the following:
“Heavenly Father, I purpose and choose to forgive ___ (the person) for ___ (the
action). I release him/her and cancel their debt to me completely. I will no longer
hold any accusation against them. Even now I release them from this sin. I ask that
you would forgive them for this sin and separate the sin from them forever. Please
forgive me for the unforgiveness/bitterness (or other feelings) that I have stored in my
heart. I give you all my feelings of ____ and ask that You would cause my feelings to
line up with my decision to forgive ___ (the person). I also purpose and choose to
forgive myself. Thank you for forgiving me and making me righteous in your sight.
Holy Spirit, please heal my heart and tell me your truth about the situation.”
I need forgiveness for….___________________________________________________
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I need to forgive……______________________________________________________
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ABCDE Method for Challenging Beliefs (Session 6, Worksheet 1)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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ABCDE Method for Challenging Beliefs (Session 6, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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ABCDE Method for Challenging Beliefs (Session 6, Worksheet 3)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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Session 7: Gratitude
Home Practice Activities
1. Memory Verse
“Thank God in everything no matter what the circumstances may be; be
thankful and give thanks, for this is the will of God for you who are in Christ
Jesus.” (1st Thessalonians 5:18)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse
for this week, and then try with previous weeks’ memory verses or other favorite
scriptures you may have.
3. Grateful Feelings Exercise: Counting our Blessings
Use your gratitude list, particularly your gratitude toward God for all that He is and
all that He has done, as well as gratitude for those in your faith community, to help
challenge negative thoughts and to replace negative emotions. Continue to add to
your gratitude list this week as you think of more things for which you are grateful.
4. Gratitude Expression Exercise: Celebrating our Blessings
Express your feelings of gratitude toward the individual you identified in session.
This ordinarily takes place in person, by phone, or letter. Complete at the specific
time and place you chose in session. Remember to include the following:
• Precisely and specifically what it was that the other person did for you. Thus, “you
were a nice person to me”, is not as suitable as, “when I was in the hospital you came
to visit me and you prayed for me every day.”
• Include as many of these concrete activities for which you feel grateful as possible.
• Be sure to note what the meaning of the person’s activities was for you. That is, how
the activity or way of being made you feel, influenced your life, caused you to grow,
taught you things you needed to know, etc.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
51
Gratitude Exercise
Counting Our Blessings
Rate your current mood on a scale from 0 to 10 where 0 means “very sad” and 10
means “very happy”: _____

List below the people, things, events, opportunities, and situations for which you are
grateful. You can include God and any other things related to your faith beliefs and
practices.
_______________________________________________________ Rating___
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Now go back over your list and rate each item from 1-10 (10 being most grateful).
Again rate your current mood on a scale from 0 to 10 where 0 means “very sad” and
10 means “very happy”: _____
If there was a change in mood, how do you make sense of that?
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Gratitude Exercise
Celebrating Our Blessings
1. List three living persons whose lives have been especially important to you and
toward whom you feel a deep sense of gratitude. The person’s contribution may have
been large or small; in any case it was meaningful and benefited you.
_____________________________________________________________________
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2. Select one person for a celebration visit or contact:
Name: ___________________________________________________________
3. Make a list of this person’s positive qualities that were truly helpful to you or others.
As you list each trait or quality, describe the impact it had on your life and how it
continues to influence you. Use as much space as you need.
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4. Now, using this list, write a letter or a thank you card expressing your gratitude for
these qualities.
5. Follow-though: 1) Plan a phone call or visit to the person; 2) Read the letter to him or
her; 3) If possible, celebrate the event in a small way.
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ABCDE Method for Challenging Beliefs (Session 7, Worksheet 1)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
54
ABCDE Method for Challenging Beliefs (Session 7, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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Session 8: Altruism and Generosity
Home Practice Activities
1. Memory Verse
“And the King will answer them, ‘Truly, I say to you, as you did it to one of the least
of these, my brothers, you did it to me.” (Matthew 25:40)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Altruistic Acts
Carry out the specific altruistic acts to be done for the particular persons at a particular
time you and your therapist chose in session. Be sure to have more than one option in
case other people are unavailable.
4. Pray for Someone Daily
Pick one person for whom you will pray for daily this week. This might be the person
you have made contact with from your faith community, another friend, or relative. Pray
for this person each day. Praying for someone other than ourselves helps to get our minds
off of our own problems and is a great way to be generous with our time and energy. It
also helps to put our own problems in perspective.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during your
next session so that you can review them with your therapist.
Remember, the Great Commandment that Jesus told the young man asking him what he
needs to do in order to gain eternal life: Love the Lord your God with your whole heart,
mind, and soul; and love your neighbor as yourself. Jesus also said we are to be
generous: “Freely you have received, freely give.” God has a neat way of rewarding us
when we obey him: giving to others has just as positive an effect, if not more, on the giver
as it does on the receiver! Jesus called himself a servant, and indeed he was the greatest
servant of all because he gave his life up for us. Jesus says in Mark that “whoever desires
to be great among you must be your servant. And whoever wishes to be most important
among you must be the slave of all. For even the Son of Man came not to have service
rendered to him, but to serve and give his life as a ransom for many.” (Mark 10:43-45).
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Altruistic Acts
Make a list of the ways you have been helpful in the past and ways that you could be
helpful now. Then rank each item on your list from easiest to most difficult (0-100 with
100 being the most difficult of all).
Helpful/Generous Act Degree of
Difficulty (0-100)
Activity
Chosen
Next, select several of the easier acts you would like to initiate. Answer the following
questions for each act you choose:
Helpful/Generous Act #1: __________________________________________
1. For Whom?
2. When will you do it?
3. Why will you do it?
4. How will you do it?
5. How frequently will you do it?
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Helpful/Generous Act #2: __________________________________________
1. For Whom?
2. When will you do it?
3. Why will you do it?
4. How will you do it?
5. How frequently will you do it?
Helpful/Generous Act #3: __________________________________________
1. For Whom?
2. When will you do it?
3. Why will you do it?
4. How will you do it?
5. How frequently will you do it?
Remember to connect your goal of helping others with the famous passage in the gospel
of Matthew 25: 35-40 in which Jesus describes that anyone who has done something for
another person, such as giving them a cup of cold water, visiting them when they were
sick or in jail, and so on, was really doing it to Jesus.
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ABCDE Method for Challenging Beliefs (Session 8: Optional)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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Session 9: Stress-Related and Spiritual Growth
Home Practice Activities
1. Memory Verse
“Consider it wholly joyful whenever you encounter trials of any sort or fall into
various temptations. Be assured that the trial and proving of your faith bring out
endurance and patience. But let endurance and patience do a thorough work, so that
you may be fully developed, lacking in nothing.”(James 1:2-3)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Complete the Spiritual Reflections Worksheet
4. Positive Changes
Add to your list of the changes in your life that you could view as positive or that have
caused growth, including spiritual growth. It will be helpful to look to your faith and
God’s promises in the Bible to help you view some of the changes that have occurred as
positive. Also think about the paradoxes in Christianity and how these might help you
reframe your situation.
Reflect on the meaning of these changes in terms of your character and the predictions
you make regarding negative beliefs. In particularly, what power do these changes give
you to stop avoiding unpleasant experiences and to face them courageously?
5. Read Paradoxes in Christianity worksheet
If you can think of other paradoxes in Christianity, add them to the worksheet.
6. Daily Prayer for Someone
Continue to pray daily for someone other than yourself this week. It could be the same
person you prayed for last week or someone different.
7. Be sure to have your completed homework sheets readily available to you during your
next session so that you can review them with your therapist.
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Looking for the Positive
It may sound insensitive to suggest there is anything positive in pain and suffering, yet many
people who cope admit they eventually make sense of the situation or find something that
benefited them or others. This does not mean they like what happened or stop wishing it had
never happened. They discovered that despite the pain they went through they could also
describe positive changes in themselves and others or found parts of it that made sense. In the
long run finding benefits seems to give people a measure of serenity.
1. In what ways, if any, can you make sense of what happened to you?
2. What positive changes have you noticed as a result of what happened?
a. In you?
b. In others and the people close to you?
c. In the way you look at the world?
d. In your religious views and belief?
3. How can these changes help you live your life more fully?
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Spiritual Reflections
1. What does it say or what could it mean spiritually if you find some benefit from your
tragedy or loss?
2. If there was any positive change in you, your perspective, or relationships, how do you
make sense of that from a spiritual point of view? How does it make faith real for you?
3. What does having this faith or spiritual view mean in terms of coping with day-to-day
struggles?
4. How can this view help you when you start to feel discouraged?
5. Any spiritual or faith perspective fades in and out. What concrete steps can you take on a
regular basis to remind yourself of these helpful perspectives?
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Paradoxes in Christianity
There are many paradoxes in Christianity. These paradoxes can help us see situations in
our lives from another perspective. Some of these paradoxes include the following:
1. When you are weak, then you are strong. God’s power is most evident when we
are weak.
• “But he said to me, ‘My grace is sufficient for you, for my power is made perfect
in weakness.’ Therefore I will boast all the more gladly about my weaknesses, so
that Christ’s power may rest on me. That is why, for Christ’s sake, I delight in
weaknesses, in insults, in hardships, in persecutions, in difficulties. For when I am
weak, then I am strong.” (2 Corinthians 12:9-11)
2. In Christ, you can do all things; without Him you can do nothing.
• “
I can do all this through him who gives me strength.” (Phil 4:13)
• “
Remain in me, as I also remain in you. No branch can bear fruit by itself; it must
remain in the vine. Neither can you bear fruit unless you remain in me. I am the
vine; you are the branches. If you remain in me and I in you, you will bear much
fruit; apart from me you can do nothing. If you do not remain in me, you are like a
branch that is thrown away and withers; such branches are picked up, thrown into
the fire and burned.” (John 15: 4-6)
3. God chooses the foolish things of the world rather than the wise.
• “
Brothers and sisters, think of what you were when you were called. Not many of
you were wise by human standards; not many were influential; not many were of
noble birth. But God chose the foolish things of the world to shame the wise;
God chose the weak things of the world to shame the strong. God chose the lowly
things of this world and the despised things—and the things that are not—to
nullify the things that are, so that no one may boast before him.”
(1st Corinthians 26-29)
4. We are called to be holy and perfect, but Jesus said that even the religious experts
of His day were not perfect enough; no one is good except God.
• “
For I tell you that unless your righteousness surpasses that of the Pharisees and
the teachers of the law, you will certainly not enter the kingdom of heaven.”
(Matthew 5:20)
• “
God made him who had no sin to be sin for us, so that in him we might become
the righteousness of God.” (2 Corinthians 5:21)
• “
The words ‘it [righteousness] was credited to him’ were written not for him
alone, but also for us, to whom God will credit righteousness—for us who believe
in him who raised Jesus our Lord from the dead. He was delivered over to death
for our sins and was raised to life for our justification.” (Romans 4:23-25)
63
Session 10: Hope and Relapse Prevention
Home Practice Activities
1. Memory Verse
“He gives power to the faint and weary, and to him who has no might He increases
strength. Even youths shall faint and be weary, and young men shall stumble and
fall exhausted; But those who wait for the Lord [who expect, look for, and hope in
Him] shall change and renew their strength and power; they shall lift their wings
and mount up [close to God] as eagles [mount up to the sun]; they shall run and
not be weary, they shall walk and not faint or become tired.” (Isaiah 40:29-31,
Amplified Bible)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have. This is an important practice that we encourage you to continue to do
daily.
3. Continue to Use the Tools Daily
In order to maintain the gains you have achieved in treatment you need to keep using
the tools you have learned. These tools include the following:
• Challenging and changing your negative interpretations (Additional
ABCDE sheets are included at the end of this workbook. Feel free to make
extra copies for yourself)
• Gratitude
• Altruism (choose a specific activity for a specific person)
• Finding the positives in your life
• Praying for someone else
• Maintaining communication with God
• Look for examples in the Bible for encouragement
• Spending time with others
• Connecting with your faith community, specifically the person(s)
identified earlier in treatment
• Filling your mind and heart with the Word of God
One way to remind yourself to continue to put into practice the things you have learned
is to incorporate them into a daily devotional period. Each day during this time you can
review your thoughts and’ behavior with God to make sure they line up with the truth in
His Word. You might find it helpful to use a journal during this time.
64
4. Make Use of Your Spiritual Resources
Spiritual resources include, but are not limited to, prayer, journaling, social support
from friends, conversations/counseling with clergy, Bible studies, repentance and
forgiveness, existential psychotherapy, attending religious or spiritual services,
attending support groups, such as Alcoholics Anonymous, attending activities
sponsored by spiritual or religious groups, such as pot-lucks, bingo, and discussion
groups.
5. Anticipate Set Backs
Remember that there will be set backs and times that are more challenging and difficult
than others. It is at these times that it is even more important to engage in the activities
and resources you learned, especially if you don’t feel like it.
6. Continue Contact Member of Faith Community
Continue to be in regular contact with the member of your faith community. Remember
to pray for him or her daily, too.
Congratulations on a job well done!
Lord, make me an instrument of Thy peace;
where there is hatred, let me sow love;
where there is injury, pardon;
where there is doubt, faith;
where there is despair, hope;
where there is darkness, light;
and where there is sadness, joy.
O Divine Master,
grant that I may not so much seek to be consoled as to console;
to be understood, as to understand;
to be loved, as to love;
for it is in giving that we receive,
it is in pardoning that we are pardoned,
and it is in dying that we are born to eternal life.
Amen.
St. Francis of Assisi
65
ABCDE Method for Challenging Beliefs
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative beliefs or expectations automatically went through you mind when
you were in that situation?
Consequent Feelings and Behavior: What painful feelings did these beliefs or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very painful. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.

Religious Cognitive Behavioral Therapy for Depression In Clients with Chronic Physical Illness (Christian version) Therapist Workbook

rcbt_therapist_workbook_christian_version_3-14-14

Religious Cognitive Behavioral Therapy
for Depression In Clients with Chronic Physical Illness
(Christian version)
Therapist Workbook
Joseph W. Ciarrocchi, Ph.D.
Debbie Schechter
Michelle J. Pearce, Ph.D.
Harold G. Koenig, M.D.
2014
With contributions from Rebecca Propst, Ph.D.
This workbook is a variant of the treatment protocol
originally designed by A. T. Beck, M.D.
Workbook developed largely by
Michelle J. Pearce, Ph.D.
**Please cite appropriately**
Contact Information:
Michelle Pearce, Ph.D.
Department of Family and Community Medicine
Center for Integrative Medicine
University of Maryland School of Medicine
520 W. Lombard Street, East Hall
Baltimore, MD 21201
Office: (410) 706-6164
1
Session 1: Assessment and Introduction to RCBT
Home Practice Activities
1. Memory Verse
“Finally, whatever is true, whatever is noble, whatever is right, whatever is pure,
whatever is lovely, whatever is admirable—if anything is excellent or
praiseworthy—think about such things.” (Philippians 4:8)
Write the verse down and post it somewhere you will see it often, perhaps on a sticky
note placed on your mirror or fridge. You may want to make several copies and post
them in places you will see it throughout the day.
2. Activity and Mood Monitor
The goal of the first session’s homework assignment is begin developing skills in selfmonitoring daily mood and daily activities. The goal at this stage is not to change any
regular habits. The self-monitoring logs have a place for recording your activities and
mood every two hours. Please complete this log daily. It may be easiest to fill out the
activity log twice during the day. For example, you could record all of your morning
activities when you eat lunch and all of your afternoon and evening activities just before
you go to bed. This record will give us some information as to which activities may lead
to better moods and which activities may lead to worsened moods.
Here are few guidelines about self-monitoring:
a. Keep the self-monitoring log with you throughout the day and record your activities as
close as possible to the end of the time periods.
b. Record the activity in a very few words. For example, you could record “went out to
dinner” or “washed my clothes” or “read a book” or even “watched TV.”
c. Immediately after recording your activities, record your mood.
d. Purchase a notebook to put the logs in, so that you will have a record of your activities.
We will make use of them later.
e. Make sure you have your logs with you during each session. They are necessary for the
rest of the program
f. Be sure and include even trivial events on your chart such as missed the bus or read the
newspaper.
2
3. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
3
Thinking and Depression
Signs of Depression
“I don’t have a purpose in life anymore now that my chronic pain makes it too difficult to work.”
“I am a very poor Christian because I am depressed. A Christian should not be depressed.”
“I just can’t motivate myself to do any of the things which I need to do. I’m a lazy person.”
All of the above are statements that a depressed individual might make. While some of these
statements and notions may seem to be correct on the surface they actually reflect a change in the
way an individual thinks about him or herself. When people become depressed, they think about
themselves and their environment in a different and more negative way.
Recent research has shown that depressed individuals are more likely to interpret an event more
negatively than a non-depressed individual. Thus, depressive symptoms are related to the way in
which individuals interpret and think about their situation in life. These thoughts and
interpretations are also a reflection of one’s past experiences. Not only are depressed individuals’
interpretations more negative, but research also shows that their perceptions and interpretations
are less accurate than those who are not depressed.
The interpretations that an individual makes of a situation influence his or her behavior, as
illustrated in the following example. Imagine that you have a flat tire on a deserted highway and
do not have anything to change the tire with, including a car jack. As you are standing there
stranded, your next-door neighbor drives by and looks up briefly but keeps going. How would
you feel about the fact that your neighbor kept driving? What would you most likely be telling
yourself about the situation?
Now let’s imagine, further, that you see your neighbor the next day and he comes over to you and
apologizes for driving by you. “I’m so sorry I couldn’t stop; my son fell and was bleeding from
his head and I was rushing him to the emergency room.” How might you be feeling now? What
changed? What are you now telling yourself about the situation that is different from when you
were standing on the road?
The following diagram represents the relative relationship that thoughts, feelings, and behavior
have on each other.
Thoughts
Feelings
Behavior
4
The idea that our thoughts and assumptions play an important role in influencing not only our
emotions but also our behaviors is actually a very common idea in both the Old and New
Testaments. Indeed, for Christians the cognitive behavior model is 2000 years old! Let me give
you some examples from the Bible:
• The first words of both John the Baptist and Jesus in their public ministries were,
“Metanoia” literally meaning “Change your mind” or “Change how you think”, which
the Bible translated as “Repent”. To repent means to change your attitude, change your
mind, change how you think (Matthew 4:17).
• The apostle Paul told the Roman Christians, “Do not be conformed to this world, but be
transformed by the renewing of your minds, so that you may discern what is the will of
God — what is good and acceptable and perfect” (Romans: 12:2). In other words, Paul is
saying that transformation comes about by renewing your mind.
• The Old Testament speaks about the same idea: ‘ . . . for as he thinks in his heart, so is
he’ (Proverbs 23:7. KJV).
5
Activity and Mood Monitor
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
6
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
7
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
Day: Activity Engaged In Mood
6-8 am
8-10 am
10 am-12 pm
12 pm-2 pm
2 pm-4 pm
4 pm-6 pm
6 pm-8 pm
8 pm-10 pm
10 pm-12 am
8
Session 2: Behavioral Activation and Walking by Faith
Home Practice Activities
1. Memory Verse
“We walk by faith and not by sight.” (2nd Corinthians 5:7)
As you did last week, write the verse down and put it in a place, or ideally more than
one place, where you will see it many times a day. The more you meditate on these
verses the more your mind is renewed and the greater improvement you will begin to
see in your mood.
2. Plan and Complete Pleasant Events
Complete the two pleasant events you selected with your therapist between now and
our next session. When you are finished the activity, complete the Planning Pleasant
Activities Worksheet. Remember to complete the worksheets for both activities.
3. Identify and Contact Member of Faith Community
Identify several possible faith companions and make contact with at least one of
them. This is important over the long-term and relates directly to depression. Both
the receiving and especially the giving of support to others (as will be addressed in
the session on altruism) is key in this regard. Identifying people worse off than you
are helps to get your mind off your problems, helps you realize that things could be
worse, helps you to feel grateful for what you do have, and gives a sense of purpose
and meaning that will result in eternal rewards as a service to God by caring for
another. In approaching another person, you might say something like:
“I’m having a pretty difficult time now and I’m wondering if you would agree to
pray for and with me during this period, and perhaps we could talk on the phone or go
out for coffee once a week or every other week.”
4. Reading
Please read the pages in your workbook titled, “The Categories of Unhelpful
Thinking” to prepare for next week’s session. This is somewhat lengthy and to make
the most of the limited time in session it very important that you have already
reviewed this material
5. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
9
As Christians, we have the comfort of knowing that we have a High Priest—Jesus
Christ—whom the Bible says is familiar with all of our pain, suffering, and trials. He
knows how depression makes you feel; He knows how hard it is to deal with your
physical illness. The Bible says that we can boldly approach the throne of grace to
receive help in our time of need (Hebrews 4:16). If you find yourself struggling to
complete these activities, ask Jesus for His grace and His help. He understands your
struggle and He will give you the strength and encouragement you need.
10
Pleasant Activities List
Put a plus sign (+) next to any activity likely to generate some positive reaction in you.
Put two (++) next to those that are positive and you are almost certain to do so.
1. Call a friend
2. Attend a movie
3. Clean the kitchen
4. Daydream
5. Rearrange furniture
6. Prepare a meal
7. Wash the car.
8. Outdoor yard work or gardening.
9. Buy a plant
10. Watch television
11. Take a mini-vacation
12. Go to an amusement park
13. Dinner with friends
14. Attend a play
15. Attend a concert
16. Visit a museum
17. Play a sport
18. Watch a sporting event in person
19. Watch sports with friends
20. Dance
21. Attend church or another religious service
22. Speak to a friend(s) on the Internet
23. Play video games
24. Text messaging
25. Twitter
26. Visit family members
27. Provide childcare for family or friends
28. Exercise alone
29. Exercise with others
30. Get a massage
31. Read a book or magazine
32. Write in a journal
33. Write a poem or short story
34. Play a musical instrument
35. Listen to music
36. Engage in a hobby, such as photography, scrapbooking, stamp/coin collecting,
genealogy, knitting, crocheting, etc.
37. Take a bath or shower
38. Take a nap
39. Go shopping
40. Sailing, boating, fishing, or other water-related activity
41. Attend an educational class
11
Planning Pleasant Activities Instructions
Implicit in the idea that mood is rea1ted to activity is the concept that mood can be
improved by increasing specific activities. From the records you kept last week, you may
be able to identify particular classes of activity that are associated with better mood. Even
in the Gospels we read of Jesus spending time alone with His disciples away from
demands. The purpose of this exercise is to schedule more of these activities in order to
improve your mood.
You can look at your Self-Monitoring Logs and the Pleasant Activity List for ideas.
Choose activities that you have some control over, that bring a sense of mastery or
accomplishment, and that you enjoy. Choose activities that take more than 10 or 15
minutes to perform, yet which can be accomplished in one day. Schedule activities that
are additions to what you would ordinarily do. The following are some examples of
pleasant activities:
Have your hair done
Browse in a bookstore
Prepare a Chinese dinner
Play tennis
Visit an art museum
Buy a new plant
Next, using the following worksheet, schedule and complete at least two activities
between now and the next session. Be sure to complete the worksheet once you have
engaged in the activity.
12
Planning Pleasant Activity #1 Worksheet
1. Identify Activity #1 from the Pleasant Activity List or your imagination.
Activity planned:________________________________________________________
Who has to be contacted or notified? ________________________________________
2. When will each be accomplished?
Date of activity: ________________________________________________________
3. Prediction
On scale of 0 – 10 how positive will the event be to you? _______________________
(where 0 is not positive and 10 is very positive)
4. Reflect
Date activity was accomplished: ___________________________________________
Outcome: On scale of 0 – 10 how positive was the event for you? ________________
Conclusion: What seems to make events pleasant at this point? What did you learn?
______________________________________________________________________
______________________________________________________________________
Ideas for Future Activities:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
13
Planning Pleasant Activity #2 Worksheet
1. Identify Activity #2 from the Pleasant Activity List or your imagination.
Activity planned:________________________________________________________
Who has to be contacted or notified? ________________________________________
2. When will each be accomplished?
Date of activity: ________________________________________________________
3. Prediction
On scale of 0 – 10 how positive will the event be to you? _______________________
4. Reflect
Date activity was accomplished: ___________________________________________
Outcome: On scale of 0 – 10 how positive was the event for you? ________________
Conclusion: What seems to make events pleasant at this point? What did you learn?
______________________________________________________________________
______________________________________________________________________
Ideas for Future Activities:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
14
Unhelpful Thinking Styles and Theological Reflections
1. All-or-Nothing Thinking (AN):
You see things in black-and-white categories. If your performance falls short of perfect,
you see yourself as a total failure.
Example: An example would be a straight-A student who received a B on an exam and
concluded, “Now I’m a total failure.”
A. Why is this thinking incorrect?
This type of thinking causes one to fear any mistake or imperfection because that is taken
as an indication of being worthless. This way of evaluating things is unrealistic because
life is rarely completely either one way or the other. For example, no one is absolutely
brilliant or totally stupid. Nothing on earth is totally one way or the other. Rarely, does
everyone always like us, or rarely do we always find the perfect solution.
B. Theological reflection
The idea that nothing on earth will ever be perfect, including people and their activities is
certainly a common theme in the New Testament. Romans 3:23, for example, says that
everyone has failed in some way, or to use the New Testament language, they have
sinned. However, Romans 3:24 goes on to say that even though we are not OK, that is
OK. In other words, we are accepted by God anyway, through His forgiveness. This
theme is expressed in Romans 8:1: “there is no condemnation for those who are in
Christ.” Romans 5:12 continues this theme and says that “we are justified by faith, and
we therefore have peace with God.” In other words, we need merely to have faith in the
perspective that we are OK as far as God is concerned.
2. Overgeneralization (OG):
You see a single negative event as a never-ending pattern of defeat.
Example: An example of this type of thinking would occur when a shy young man, who
is self-conscious of his artificial leg, mustered up his courage to ask a woman for a date.
When she politely declined because of a previous engagement, he said to himself, “I’m
never going to get a date. No one wants to date a guy with only one leg.” He believed that
all women will turn him down just because one declined his offer. And, he erroneously
assumed it was because of his artificial leg. The pain of rejection is generated almost
entirely from overgeneralization.
A. Why is this thinking incorrect?
It is logically incorrect to conclude that one thing that happened to you once will occur
over and over again. It is also incorrect to assume that all situations are similar; or that all
individuals are similar.
15
B. Theological reflection
There are also several stories in the Bible that suggest that one failure does not therefore
mean that there will always be failure. Perhaps the most vivid story is that of Jesus and
Peter. In John 18: 15-17 we read that Peter denied that he even knew Jesus. This could
surely be considered a major affront. One might assume with some justification that Peter
had failed as a friend and could never again consider himself to be a worthy friend of
anyone, especially Jesus. However, later we see Jesus asking Peter if he loves Him and
Peter responding in a positive manner. We then see Jesus being willing to trust Peter with
something that is very important to Jesus. (John 21:15-19 describes this situation). It
certainly sounds as if one major catastrophe or mistake does not mean that the individual
will continue to make those mistakes.
3. Mental Filter (MF):
You pick out a single negative detail and dwell on it exclusively so that your vision of all
reality becomes darkened, like a drop of ink that discolors an entire beaker of water.
Example: A woman with severe arthritis failed to complete one task that she had hoped to
complete. She became more depressed and angry at herself for not completing that task.
She overlooked the fact that there had been many tasks that she had, in fact, completed.
A. Why is this thinking incorrect?
It is more sensib1e to clearly view one’s environment and be aware of the positive things
one has done in addition to negative occurrences. It is not adaptive to filter out anything
positive. It is irrational to say, “I should preoccupy myself with dangerous or negative
ideas.” Nothing is gained by dwelling on them.
B. Theological reflections:
The Scriptures usually emphasize that one should reflect on the positive rather than the
negative. One should certainly reflect on what is true, and that includes seeing the
positive things you have accomplished. This theme is reflected in Philippians 4:8 which
says, “…. whatever is true, or lovely, or gracious … think on that. If there is any
excellence, if there is anything worthy of praise …think about that.” Whi1e the emphasis
here might be on values and ideas, it could also refer to one’s actions.
4. Disqualifying the Positive (DP):
You disqualify positive experiences by insisting they “don’t count” for some reason or
other. In this way you can maintain a negative belief that is contradicted by your
everyday experiences. You don’t just ignore positive experiences as in the Mental Filter,
but you clearly and swiftly turn them into their very opposite.
Example: An example would occur when someone praises your appearance or your work
and you automatically tell yourself, “They’re just being nice.”
16
A. Why is this thinking incorrect?
Again, it is maladaptive not to pay attention to feedback you get from your environment.
We should take that feedback at face value and incorporate it into our understanding of
ourselves. If we disbelieved everything everyone told us, we might still believe the world
was flat. An adjusted person is one who pays attention to everything in their environment.
B. Theological Reflections
We must not be like the Israelites in the wilderness who made a negative interpretation of
God’s actions towards them. (They also probably thought the worse about other people’s
actions towards them.) When God took them into the wilderness, they distorted the
situation and said, “God has brought us here to slay us.”
Similarly, in the New Testament, a constant theme is put forth that every individual has
some valuable important talents. This applies to even the individual who may think they
were sitting in the back row when talents were handed out. One place where such a theme
is discussed is in I Corinthians 12:4-31, especially verses 15-17 and 21-14. Those
seemingly less important individuals are actually very valuable people in the larger
scheme of things and have much to offer.
5. Jumping to Conclusions (JC):
You make a negative interpretation even though there are no definite facts that
convincingly support your conclusions. There are two areas in which depressed
individuals jump to conclusions.
Mind Reading (MR):
This is one area in which depressed individuals jump to conclusions. You arbitrarily
conclude that someone is reacting negatively to you, and you do not bother to check this
out.
Example: Suppose a friend says she does not have time to have a conversation with you
on the telephone at a certain point. The depressed individual may conclude, “She is
ignoring me and does not want to talk with me, because she does not like me anymore.”
A. Why is this thinking incorrect?
One should never make an assumption about what someone is thinking without asking
them because it is usually impossible to know what another person is thinking, no matter
how sure we are we know. Jumping to conclusions about what the other is thinking is
also maladaptive because our negative reactions to their imagined thoughts may set up a
self-fulfilling prophecy. That is, we may react negatively to them when we suspect they
do not like us, when in fact they do. However, our negative reactions will soon turn them
off.
B. Theological reflections
In the New Testament, Jesus provides a perfect example of someone who chooses to
17
check out what people were actually thinking about him, rather than merely make
assumptions. A good example of this is in Mark 8:27, when He said, “who do men say
that I am?” It may be also that we begin to try to read other’s minds because we are
overly concerned about their perceptions of us, to the extent of basing our worth on their
perceptions of us. Jesus, however, presents an example of someone ‘who was not overly
concerned about others’ impression of Him, and indeed, surely did not have the favor of
most people. He even went so far as to contend that, “Blessed are you when men hate
you,” (Luke 6:22).
The Fortune Telling Error (FT):
The second way in which depressed individuals jump to conclusions is they anticipate
that things will turn out badly. They feel convinced that their predictions are an already
established fact.
Example: Depressed individuals will tell themselves that they are never going to recover,
“I will feel miserable forever.”
A. Why is this thinking incorrect?
No one has ever successfully predicted the future; there are so many factors that could
have an impact upon the future. Furthermore, our predictions are likely to be even more
off base if we predict only negative events because probability suggests that both positive
and negative events will occur.
B. Theological Reflections
Often our jumping to conclusions regarding the future implies a fear about the future. The
New Testament certainly emphasizes the idea that God will give us a spirit of power and
love, the ability to control our fears rather than a spirit of timidity (2 Timothy 1:7). There
is also the theme of anxiety concerning the future in Matthew 6:25-34. Essentially, by
worrying and imaging a negative future we do not improve the situation. Our thoughts
should be on the present. (verse 34).
6. Magnification (Catastrophizing) or Minimization (MM):
You exaggerate the importance of things (such as your goof-up or someone else’s
achievement), or you inappropriately shrink things until they appear tiny (your own
desirable qualities or the other fellow’s imperfections). This is also called the “binocular
trick”.
Example: A depressed individual accidentally misfiled some papers while working at his
job. He concluded, “I made a mistake. How horrible! Everyone will think I am
incompetent.” An example of minimization would occur when the same employee was
told by one of his or her colleagues that he had done a good job on a report. His reaction
was to think , “0h well, doing the report was very simple and anyone could do a good job
on it.”
18
A. Why is this thinking incorrect?
It is important to have an accurate perception of ourselves and our performance. It is also
important to realize that everyone makes mistakes and that they are to be expected. It is
impossible for anyone to be perfect.
B. Theological reflections
Perhaps Christ’s temptation in the garden (recorded in Matthew 26:39, 42) was a
temptation not to drink the cup of humanness, not to identify with humanity in their
imperfections. Often the negative events that happen to us are merely part of that
humanness, and we do not wish to accept that. Becoming close to Christ, therefore, does
not mean perfection; but rather sharing in His poverty.
In the Old Testament, Psalm 88 goes even further in lessening the sting of negative
events. In that particular Psalm, the suggestion is made that perhaps the negative events
are precipitated by God, the implication being that God has a good purpose behind them.
Indeed, this was the theme of a Christian writer, Juliana of Norwich, writing in
Revelations of Divine Love she contends that the Lord rejoices at the tribulations of His
servants… and He lays on His beloved something that is no lack in His (God’s) sight but
by which the person is lowered in the world. This He does to preserve the individual from
pomp, and to make them holy.
As far as the minimization of our positive aspects, we have only to recall again the New
Testament discussion of gifts. More specifically, every individual has something that is
valuable, and should consider it so (I Corinthians 12:4-31).
7. Emotional Reasoning (ER):
You assume that your negative emotions necessarily reflect the way things really are: “I
feel it, therefore, it must be true.”
Example: A depressed individual may tell himself, “I feel overwhelmed and hopeless,
therefore, my problems must be impossible to solve, or I’ll feel inadequate, therefore, I
must be a worthless person.
A. Why is this thinking incorrect?
One cannot assume that one’s emotions are a reflection of the true state of things. Our
emotions are a reflection of our thoughts and beliefs, which as we have seen are a product
of our past and may be distorted. Emotions may also be a reflection of our physiology
and how tired we are, but they are not necessarily a reflection of the true state of affairs.
B. Theological Reflections
Both the Old Testament and the New Testament speak much about negative emotions
and their role in our life.
a) John 1:12 suggests that our standing with God may be dependent upon our
actions and belief, but it says nothing about it being dependent upon our feelings.
19
b) Christian writers have often commented that faith is only faith when there is
darkness, when the individual does not even feel God. As long as there is a feeling of
God’s presence, we do not have to go on blind faith. Juliana of Norwich has commented
that our prayers are most precious to God when we feel nothing because then we have
faith.
c) Often in our growth as a Christian, we must go through difficult times. This is
certainly the impression one gets in Psalm 63 where the writer reports a general
dissatisfaction, a dryness and a longing for God. If that dryness and longing were not
there, then the individual would not rejoice to find God, who is often described as the
living water (John 4:10 and John 7:38). Water only tastes good to the thirsty.
d) Finally, the spiritual injunction that one should give up their life in order to
save it could be applied to emotions. Often we seek God only for selfish ends, only to
feel good, rather than for God’s purposes (Matthew 10:39). Feelings of longing or
desolation may actually be positive in that they imply a growth process we are willing to
go through.
8. Should Statements (SS):
You try to motivate yourself with shoulds and shouldn’ts, as if you had to be whipped
and punished before you could be expected to do anything. “Musts” and “oughts” are also
offenders. The emotional consequence is guilt. When you direct should statements
towards others, you feel anger, frustration, and resentment.
Example: One example is the depressed housewife who says to herself, “I should keep
my house cleaner, and I shouldn’t complain,” or, “I should be able to get my work done
during the day.”
A. Why is this thinking incorrect?
“Should” statements generate a lot of unnecessary emotional turmoil in your daily life,
and, paradoxically, usually do not motivate you to change your behavior. Usually, you
resent the source of the “shoulds.” Saying,”1 should do this”, or “I must do this,” usually
causes one to feel pressured and resentful.
B. Theological Reflection
One of the central themes of the New Testament is that Christ has given us a spirit of
freedom and accepted us, and we should not condemn ourselves by getting upset at
ourselves if we do not perform the way we think we should perform (Romans 8: 31), or
the way others think we should. Saying, “I shouldn’t do that,” leads to a spirit of
condemnation. Even if we do not do any “shoulds,” God still loves us, (Romans 5:8). We
are made OK with God simply by grace, not by our pressured determination to keep all
the “shoulds” in one’s life. (Romans 5:1-2).
20
9. Labeling and Mislabeling (L or ML):
This is an extreme form of overgeneralization. Instead of describing your error, you
attach a negative label to yourself: “I’m a loser.” When someone else’s behavior rubs you
the wrong way, you attach a negative label to him or her: “You are an idiot.” Mislabeling
involves describing an event with language that is highly colored and emotionally loaded.
Example: An individual fails to get a job which they applied for and they call themselves
a “failure.”
A. Why is this thinking incorrect?
We are not our behavior. Labeling yourself is not only self-defeating, it is irrational. You
cannot be equated with any one thing you do. Your life is made up of many events,
thoughts, actions, and emotions. For example, you do not call yourself a “Breather” just
because you breathe. Likewise, you do not call yourself a “failure” because you made a
mistake.
B. Theological Reflection
God does not base our worth on our activities. Likewise, He does not label us based on
our activities. God has a great love for us and rejoices in us even when our activities
would not to merit that. The parable of the lost coin in Luke 15:8-10 suggests our worth
is not based on our activities but is a reflection of much more. Likewise, in the story of
the prodigal son, Luke 5: 1-24, we read that the son’s worth was not based on his
behavior.
10. Personalization (P):
You see yourself as the cause of some negative external event for which you were not
primarily responsible.
Example: One example is the child who misbehaves or is rude. The depressed mother
says, “I am a failure or a bad mother,” (as if she could control everything her child did).
A. Why is this thinking incorrect?
Essentially, the person with this problem has confused influence with control. While we
obviously have some influence over people, especially our children, we cannot control
everything they do. What another individual does is ultimately their responsibility and
decision, not yours. We are not omnipotent.
B. Theological Reflection
God has control over the events that happen in the world. However, for the most part, we
do not. We should not presume to be God or try to do so. This is especially important
when negative events happen to us.
21
Session 3: Identifying Unhelpful Thoughts: The Battlefield of the Mind
Home Practice Activities
1. Memory Verse
“You, God, will keep in perfect peace all those who trust in You, all whose thoughts
are fixed on You.”(Isaiah 26:3)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have. Turn to the next page in this workbook for instructions. Remember,
“God’s thoughts are higher than our thoughts and His ways are higher than our ways”
(Isaiah 55:9). We need to continually fill our mind with God’s words so that our can be
full of God’s “higher thoughts. His thoughts lead to feelings of joy, peace, and hope, the
kind of emotions we would rather feel than depression and hopelessness.
3. Thought Log
Please write down your thoughts once a day using the ABC method. Be sure to fill out all
of the sections and categorize each thought into one of the unhelpful thought categories.
If you have more than one stream of ideas in one time period, you can indicate several
categories. There are seven thought logs included in the manual this week so that you can
fill one out each day.
Remember that this is a learning experience; you should not worry about completing the
logs perfectly.
4. Positive Activity
Add another positive activity to your week. Follow the same procedure for scheduling
this activity as we used in Session 2.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
22
Contemplative Prayer: Praying God’s Word
Contemplative prayer is a way to meditate on God’s word and leads to a more intimate
relationship with Him. One of the most common metaphors for contemplative prayer is
of the lover or friend. God desires our simple presence more than any action or service
we might give. Indeed, prayer has been described as a gift to God. Prayer is also a
discipline, undertaken as one would undertake to learn to play the piano. Practice is the
key.
One way to engage in contemplative prayer is to take a verse from the Bible, one of
God’s thoughts, and meditate on it. In other words, you spend some quiet time thinking
about the verse, repeating it to yourself, and saying it as a prayer to God. It’s like letting
yourself be saturated in God’s words. Some forms of meditation have you focus your
attention on your breath. When you notice yourself thinking about something else, you
are to bring your attention back to your breath. Contemplative prayer is different in that
instead of focusing on your breath you focus on God’s words. This leads to a
contemplative, prayerful state.
It’s normal to find that your mind has wandered to thinking about something else. When
you notice that this has happened, don’t get upset with yourself. Simply bring your
attention back to the verse. It might be helpful to have the verse written on a piece of
paper or underlined in the Bible in front of you so that you can more easily keep your
attention on the words. It is also normal to find yourself wanting to pray to God as you
are in this state. If that happens just go with it and pray whatever comes up in your heart.
The Method
1. Choose a scripture. Begin with your memory verse for the week.
2. Sit comfortably, but not too comfortably, back straight, chest open so the breath is free
and open.
3. Read the passage slowly. Savor each phrase. What word phrase or idea speaks to you?
4. Read the passage again. Where does this passage touch your life? What do you see,
hear, touch, or remember?
5. Read the passage a third time. Listen quietly.
6. Note insights, reflections, and personal response to the reading in your journal.
7. Follow the steps in order or go back and forth between them as you feel moved.
8. Finish by waiting for a few moments in silence.
Instructions
Practice this for 20 minutes once or twice daily, and then discuss with your therapist any
problems you encountered in doing this, or share how praying in this way made you feel.
23
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 1
(*To be Completed During Session 3*)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
24
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 2
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
25
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 3
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
26
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 4
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
27
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 5
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
28
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 6
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
29
ABC Method for Challenging Beliefs Leading to Negative Emotions
Session 3: Worksheet 7
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations lead
to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these beliefs
and feelings lead to?
Unhelpful Thought Category: Specify the unhelpful thought category(s). (See Unhelpful
Thinking Styles Worksheet) that best describes the error(s) in the belief.
30
Planning Pleasant Activity #3 Worksheet
1. Identify Activity #3 from the Pleasant Activity List or your imagination.
Activity planned:________________________________________________________
Who has to be contacted or notified? ________________________________________
2. When will each be accomplished?
Date of activity: ________________________________________________________
3. Prediction
On scale of 0 – 100 how positive will the event be to you? _______________________
4. Reflect
Date activity was accomplished: ___________________________________________
Outcome: On scale of 0 – 100 how positive was the event for you? ________________
Conclusion: What seems to make events pleasant at this point? What did you learn?
______________________________________________________________________
______________________________________________________________________
Ideas for Future Activities:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
31
Session 4: Challenging Unhelpful Thoughts: Bringing All Thoughts Captive
Home Practice Activities
1. Memory Verse
“We refute arguments and every proud and lofty thing that sets itself up against the
true knowledge of God; and we lead every thought and purpose away captive into
the obedience of Christ.” (2nd Corinthians 10:5)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Thought Log Monitor
Complete the ABCDE thought monitor at least once a day.
Be on the outlook for automatic negative thoughts that trigger emotional upset and
negative behaviors such as avoidance. The goal is to improve on the ability to spot these
negative patterns at the time they occur, and to attempt to develop alternative ways of
responding through the use of more effective beliefs and expectations.
Remember to use your religious beliefs and practices, as well as scriptures, to help
challenge your unhelpful and negative beliefs.
4. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
5. Be sure to have your completed homework sheets readily available to you during your
next session so that you can review them with your therapist.
Remember, the Bible says our mind is a battlefield. We are at war! Identifying our
thoughts and challenging them—making sure they are consistent with what God says– is
serious business. In 2nd Corinthians 10” 3-5, we are told to challenge our thoughts and
not to believe everything we think. Just because we think it doesn’t mean it’s true. These
verses say, “We are human, but we don’t wage war as humans do. We use God’s mighty
weapons, not worldly weapons, to knock down the strongholds of human reasoning and
to destroy false arguments…We capture rebellious thoughts put them in obedience to
Christ.” We want to win the battle going on in our minds and God’s word is the most
powerful way to do this. When we put His words of truth in our minds we can change the
way we think and as a result how we feel, no matter what the situation.
32
Disputing Questions
Use these questions to challenge your automatic thoughts. Be sure to answer each question you
pose to yourself. You will find each question helpful for many different thoughts. Several
examples are also presented to help you get started.
1. Do I know for certain that ______________________________________________?
Example: Do I know for certain that I won’t have anything to say?
2. Am I 100% sure that __________________________________________________?
Example: Am I 100% sure that my anxiety will show?
3. What evidence do I have that ____________________________________________?
What evidence do I have that the opposite is true?
Example: What evidence do I have that they did not understand my speech?
What evidence do I have that they did understand my speech?
4. What is this worst that could happen? How bad is that? How can I cope with that?
5. Do I have a crystal ball?
6. Is there another explanation for __________________________________________?
Example: Is there another explanation for his refusal to have coffee with me?
7. Does _____________________ have to lead to or equal ______________________?
Example: Does “being nervous” have to lead to or equal “looking stupid”?
8. Is there another point of view?
9. What does ________ mean? Does ________ really mean that I am a(n) __________?
Example: What does “looking like an idiot” mean? Does the fact that I stumbled over my
words really mean that I look like an idiot?
33
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 1)
(*To Complete During Session 4*)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
34
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
35
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 3)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
36
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 4)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
37
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 5)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
38
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 6)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
39
ABCDE Method for Challenging Beliefs (Session 4, Worksheet 7)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
40
Session 5: Dealing with Loss
Home Practice Activities
1. Memory Verse

In all these things we are more than conquerors through him who loved us. For
I am convinced that neither death nor life, neither angels nor demons, neither
the present nor the future, nor any powers, neither height nor depth, nor
anything else in all creation, will be able to separate us from the love of God that
is in Christ Jesus our Lord.” (Romans 8:37-39)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse
for this week, and then try with previous weeks’ memory verses or other favorite
scriptures you may have.
3. Thought Log
Use the ABCDE thought log to actively address one or two losses you have
experienced as a result of your illness. You and your therapist should have come up
with a concrete plan to do so in session. Two ABCDE thought log worksheets have
been included in this section of the workbook for this exercise. Remember that
integrating your religious beliefs and practices into the use of each of these tools
makes them even more effective.
4. Active Surrender
Reflect on the things in your life that you want to surrender to God. Use the
worksheet provided to make a list. Then, set aside a block of time to surrender these
things to God in prayer. This is another effective tool to address the losses you have
experienced as a result of your illness.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
41
Words of Encouragement
It may be comforting to know that a number of individuals in the Bible suffered great
losses. In fact, one could argue that there isn’t a single individual mentioned in the Bible
that didn’t lose something important to them or who didn’t suffer in some significant way.
Even the disciples suffered greatly, most of whom were eventually put to death, and these
were the individuals with whom Jesus developed the closest relationship! We can see
that it doesn’t matter who we are or what we do in life, as Christians we will suffer.
Thankfully, God offers us many, many words of comfort and encouragement in the Bible.
Before He ascended to heaven, Jesus said to his disciples, “In the world you will have
trials and distress; but be of good cheer and be courageous for I have overcome the
world.” (John 16:33). Although, Jesus said problems and suffering are inevitable while
we are on earth, He promised to see us through each one of them. Indeed, in Matthew 5:4
Jesus said, “Blessed are all those who mourn for they will be comforted.” Paul later says
to the Corinthians “Praise be to the God and Father of our Lord Jesus Christ, the Father
of compassion and the God of all comfort, who comforts us in all our troubles, so that we
can comfort those in any trouble with the comfort we ourselves receive from God” (2
Corinthians 1:3-4). Perhaps the reason Jesus calls us blessed when we mourn is because
we get to be comforted by Jesus Himself, and His comfort and compassion are so great
that we are then able to comfort others that are facing troubles.
42
ABCDE Method for Challenging Beliefs (Session 5, Worksheet 1)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
43
ABCDE Method for Challenging Beliefs (Session 5, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
44
Active Surrender Exercise
Some aspects of life are our under our own personal control, while others are beyond our
control. Life becomes more difficult when we try to control the uncontrollable. Some of
the things we believe and feel make letting go difficult. Surrendering to God helps us
begin the process of letting go. It is important to remember that active surrender to God is
different from giving up. Notably, surrender is paradoxical— letting go inadvertently
increases control.
Make a list of the things you would like to surrender to God. These might include
situations, experiences, memories, hurts, people, and other things that have been
bothering you. Then spend some time in prayer turning over each of the things on your
list to God. Thank Him for telling you in His Word to “cast your cares upon Him because
He cares for you” (1 Peter 5:7).
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Session 6: Coping with Spiritual Struggles and Negative Emotions
Home Practice Activities
1. Memory Verse
“The righteous cry out and the Lord hears them; He delivers them from all
their troubles. The Lord is close to the brokenhearted and saves those who are
crushed in spirit. The righteous person may have many troubles, but the Lord
delivers him from them all.” (Psalm 34:17-19)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer.
3. Spiritual Struggles and Spiritual Resources
It is important to remember the following points:
• It is normal to question God in the face of illness.
 It is normal to feel negative emotions toward God.
 God created us to experience a range of emotions and He can accept all of them.
 God wants us to be honest with Him and to bring all of our concerns to Him.
If you and your therapist identified spiritual resources that would be helpful in
addressing any spiritual struggles you have, make a plan to use these resources this
week to address that issue. Spiritual resources include, but are not limited to, prayer,
journaling, social support from friends, conversations/counseling with clergy, Bible
studies, repentance and forgiveness, attending religious or spiritual services, attending
support groups like Alcoholics Anonymous, attending activities sponsored by
spiritual or religious groups like pot-lucks, bingo, and discussion groups. Several
ABCDE thought logs have also been included in the workbook for this session; this
may also be a helpful tool in addressing spiritual struggles this week.
4. Repentance and Forgiveness
Forgiveness can be a powerful antidote for some spiritual struggles (e.g., resentment,
anger, bitterness) and an integral part of the process of healing. Indeed, research has
shown strong relationships between emotions such as anger and resentment and
physical health problems and compromised immune functioning.
One of the most powerful verses about the relationship between our mind, body, and
spirit is recorded in 3rd John 1:2: “Beloved, I pray that you may prosper in all things
and be in health, just as your soul prospers.” We learn from this verse that our ability
to prosper in life and in our bodies is contingent upon the state of our soul, which is
made up of our mind, will, and emotions. If we harbor unforgiveness and bitterness
toward others, God, or ourselves, our souls are not prospering and because of this
nothing else in our life can prosper either.
God instructs us to forgive others as He has forgiven us. That doesn’t mean He wants
46
you to change your mind and decide that what happened to you was right or justified.
God never changes His mind about our sin—He always sees it as evil. What forgiving
someone does mean is that we give up the right to hold this action against the person.
We give up our right to feel resentful, bitter, and angry. When we make a decision
with our will to forgive someone, even when we don’t feel like it, God can then begin
to change our feelings. Usually our feelings are the last part to change. That doesn’t
mean you haven’t forgiven, it just means your feelings having yet come into
alignment with the decision you made with your will to forgive.
Is there anyone you would like to forgive? That could include others, yourself, and
even God (although He never sins, we can perceive a wrong against us in our minds).
Is there anything you would like to ask forgiveness for (i.e., repent of), either from
God or from others? If yes, and if you did not address these in session, make a list of
the people you want to forgive or the things for which you need forgiveness.
Take some time to pray about each item on your list. It is important that your prayers
be specific and that you do not just offer one blanket prayer for all the items listed.
You can use a prayer such as the following:
“Heavenly Father, I purpose and choose to forgive ___ (the person) for ___ (the
action). I release him/her and cancel their debt to me completely. I will no longer
hold any accusation against them. Even now I release them from this sin. I ask that
you would forgive them for this sin and separate the sin from them forever. Please
forgive me for the unforgiveness/bitterness (or other feelings against this person) that
I have stored in my heart. I give you all my feelings of ____ and ask that You would
cause my feelings to line up with my decision to forgive ___ (the person). I also
purpose and choose to forgive myself. Thank you for forgiving me and making me
righteous in your sight. Holy Spirit, please heal my heart and tell me your truth about
the situation.”
After you have finished praying, you might try closing your eyes and imagining
yourself standing or kneeling before Jesus or before the cross. See yourself giving the
list of wrongs that others have done to you, and that you have just forgiven, to Jesus.
Give the list of your own sins to Jesus, too, and see Him nailing these lists to the
cross. Listen as Jesus says, “You are forgiven. Go in peace.” Continue to listen to
hear what else Jesus might have to say to you or what else He might do as you stay in
this image. When you are done thank Jesus for what He has just done for you.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally some time this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
47
Forgiveness Exercise
Is there anyone you would like to forgive? That could include others, yourself, and
even God (although He never sinned against us, we can perceive a wrong against us
in our minds). Is there anything you would like to ask forgiveness for (i.e., repent of),
either from God or from others? If yes, make a list of the people you want to forgive
or the things for which you need forgiveness.
Take some time to pray about each item on your list. It is important that your prayers
be specific and that you do not just offer one blanket prayer for all the items listed.
You can use a prayer such as the following:
“Heavenly Father, I purpose and choose to forgive ___ (the person) for ___ (the
action). I release him/her and cancel their debt to me completely. I will no longer
hold any accusation against them. Even now I release them from this sin. I ask that
you would forgive them for this sin and separate the sin from them forever. Please
forgive me for the unforgiveness/bitterness (or other feelings) that I have stored in my
heart. I give you all my feelings of ____ and ask that You would cause my feelings to
line up with my decision to forgive ___ (the person). I also purpose and choose to
forgive myself. Thank you for forgiving me and making me righteous in your sight.
Holy Spirit, please heal my heart and tell me your truth about the situation.”
I need forgiveness for….___________________________________________________
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I need to forgive……______________________________________________________
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ABCDE Method for Challenging Beliefs (Session 6, Worksheet 1)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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ABCDE Method for Challenging Beliefs (Session 6, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
50
ABCDE Method for Challenging Beliefs (Session 6, Worksheet 3)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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Session 7: Gratitude
Home Practice Activities
1. Memory Verse
“Thank God in everything no matter what the circumstances may be; be
thankful and give thanks, for this is the will of God for you who are in Christ
Jesus.” (1st Thessalonians 5:18)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse
for this week, and then try with previous weeks’ memory verses or other favorite
scriptures you may have.
3. Grateful Feelings Exercise: Counting our Blessings
Use your gratitude list, particularly your gratitude toward God for all that He is and
all that He has done, as well as gratitude for those in your faith community, to help
challenge negative thoughts and to replace negative emotions. Continue to add to
your gratitude list this week as you think of more things for which you are grateful.
4. Gratitude Expression Exercise: Celebrating our Blessings
Express your feelings of gratitude toward the individual you identified in session.
This ordinarily takes place in person, by phone, or letter. Complete at the specific
time and place you chose in session. Remember to include the following:
• Precisely and specifically what it was that the other person did for you. Thus, “you
were a nice person to me”, is not as suitable as, “when I was in the hospital you came
to visit me and you prayed for me every day.”
• Include as many of these concrete activities for which you feel grateful as possible.
• Be sure to note what the meaning of the person’s activities was for you. That is, how
the activity or way of being made you feel, influenced your life, caused you to grow,
taught you things you needed to know, etc.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during
your next session so that you can review them with your therapist.
52
Gratitude Exercise
Counting Our Blessings
Rate your current mood on a scale from 0 to 10 where 0 means “very sad” and 10
means “very happy”: _____

List below the people, things, events, opportunities, and situations for which you are
grateful. You can include God and any other things related to your faith beliefs and
practices.
_______________________________________________________ Rating___
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Now go back over your list and rate each item from 1-10 (10 being most grateful).
Again rate your current mood on a scale from 0 to 10 where 0 means “very sad” and
10 means “very happy”: _____
If there was a change in mood, how do you make sense of that?
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Gratitude Exercise
Celebrating Our Blessings
1. List three living persons whose lives have been especially important to you and
toward whom you feel a deep sense of gratitude. The person’s contribution may have
been large or small; in any case it was meaningful and benefited you.
_____________________________________________________________________
_____________________________________________________________________
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2. Select one person for a celebration visit or contact:
Name: ___________________________________________________________
3. Make a list of this person’s positive qualities that were truly helpful to you or others.
As you list each trait or quality, describe the impact it had on your life and how it
continues to influence you. Use as much space as you need.
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4. Now, using this list, write a letter or a thank you card expressing your gratitude for
these qualities.
5. Follow-though: 1) Plan a phone call or visit to the person; 2) Read the letter to him or
her; 3) If possible, celebrate the event in a small way.
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ABCDE Method for Challenging Beliefs (Session 7, Worksheet 1)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
55
ABCDE Method for Challenging Beliefs (Session 7, Worksheet 2)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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Session 8: Altruism and Generosity
Home Practice Activities
1. Memory Verse
“And the King will answer them, ‘Truly, I say to you, as you did it to one of the least
of these, my brothers, you did it to me.” (Matthew 25:40)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Altruistic Acts
Carry out the specific altruistic acts to be done for the particular persons at a particular
time you and your therapist chose in session. Be sure to have more than one option in
case other people are unavailable.
4. Pray for Someone Daily
Pick one person for whom you will pray for daily this week. This might be the person
you have made contact with from your faith community, another friend, or relative. Pray
for this person each day. Praying for someone other than ourselves helps to get our minds
off of our own problems and is a great way to be generous with our time and energy. It
also helps to put our own problems in perspective.
5. Contact Member of Faith Community
If you have not already done so, please make contact with a person(s) in your faith
community and plan a time to get together with them, ideally sometime this week.
6. Be sure to have your completed homework sheets readily available to you during your
next session so that you can review them with your therapist.
Remember, the Great Commandment that Jesus told the young man asking him what he
needs to do in order to gain eternal life: Love the Lord your God with your whole heart,
mind, and soul; and love your neighbor as yourself. Jesus also said we are to be
generous: “Freely you have received, freely give.” God has a neat way of rewarding us
when we obey him: giving to others has just as positive an effect, if not more, on the giver
as it does on the receiver! Jesus called himself a servant, and indeed he was the greatest
servant of all because he gave his life up for us. Jesus says in Mark that “whoever desires
to be great among you must be your servant. And whoever wishes to be most important
among you must be the slave of all. For even the Son of Man came not to have service
rendered to him, but to serve and give his life as a ransom for many.” (Mark 10:43-45).
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Altruistic Acts
Make a list of the ways you have been helpful in the past and ways that you could be
helpful now. Then rank each item on your list from easiest to most difficult (0-100 with
100 being the most difficult of all).
Helpful/Generous Act Degree of
Difficulty (0-100)
Activity
Chosen
Next, select several of the easier acts you would like to initiate. Answer the following
questions for each act you choose:
Helpful/Generous Act #1: __________________________________________
1. For Whom?
2. When will you do it?
3. Why will you do it?
4. How will you do it?
5. How frequently will you do it?
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Helpful/Generous Act #2: __________________________________________
1. For Whom?
2. When will you do it?
3. Why will you do it?
4. How will you do it?
5. How frequently will you do it?
Helpful/Generous Act #3: __________________________________________
1. For Whom?
2. When will you do it?
3. Why will you do it?
4. How will you do it?
5. How frequently will you do it?
Remember to connect your goal of helping others with the famous passage in the gospel
of Matthew 25: 35-40 in which Jesus describes that anyone who has done something for
another person, such as giving them a cup of cold water, visiting them when they were
sick or in jail, and so on, was really doing it to Jesus.
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ABCDE Method for Challenging Beliefs (Session 8: Optional)
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.
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Session 9: Stress-Related and Spiritual Growth
Home Practice Activities
1. Memory Verse
“Consider it wholly joyful whenever you encounter trials of any sort or fall into
various temptations. Be assured that the trial and proving of your faith bring out
endurance and patience. But let endurance and patience do a thorough work, so that
you may be fully developed, lacking in nothing.” (James 1:2-3)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have.
3. Complete the Spiritual Reflections Worksheet
4. Positive Changes
Add to your list of the changes in your life that you could view as positive or that have
caused growth, including spiritual growth. It will be helpful to look to your faith and
God’s promises in the Bible to help you view some of the changes that have occurred as
positive. Also think about the paradoxes in Christianity and how these might help you
reframe your situation.
Reflect on the meaning of these changes in terms of your character and the predictions
you make regarding negative beliefs. In particularly, what power do these changes give
you to stop avoiding unpleasant experiences and to face them courageously?
5. Read Paradoxes in Christianity worksheet
If you can think of other paradoxes in Christianity, add them to the worksheet.
6. Daily Prayer for Someone
Continue to pray daily for someone other than yourself this week. It could be the same
person you prayed for last week or someone different.
7. Be sure to have your completed homework sheets readily available to you during your
next session so that you can review them with your therapist.
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Looking for the Positive
It may sound insensitive to suggest there is anything positive in pain and suffering, yet many
people who cope admit they eventually make sense of the situation or find something that
benefited them or others. This does not mean they like what happened or stop wishing it had
never happened. They discovered that despite the pain they went through they could also
describe positive changes in themselves and others or found parts of it that made sense. In the
long run finding benefits seems to give people a measure of serenity.
1. In what ways, if any, can you make sense of what happened to you?
2. What positive changes have you noticed as a result of what happened?
a. In you?
b. In others and the people close to you?
c. In the way you look at the world?
d. In your religious views and belief?
3. How can these changes help you live your life more fully?
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Spiritual Reflections
1. What does it say or what could it mean spiritually if you find some benefit from your
tragedy or loss?
2. If there was any positive change in you, your perspective, or relationships, how do you
make sense of that from a spiritual point of view? How does it make faith real for you?
3. What does having this faith or spiritual view mean in terms of coping with day-to-day
struggles?
4. How can this view help you when you start to feel discouraged?
5. Any spiritual or faith perspective fades in and out. What concrete steps can you take on a
regular basis to remind yourself of these helpful perspectives?
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Paradoxes in Christianity
There are many paradoxes in Christianity. These paradoxes can help us see situations in
our lives from another perspective. Some of these paradoxes include the following:
1. When you are weak, then you are strong. God’s power is most evident when we
are weak.
• “But he said to me, ‘My grace is sufficient for you, for my power is made perfect
in weakness.’ Therefore I will boast all the more gladly about my weaknesses, so
that Christ’s power may rest on me. That is why, for Christ’s sake, I delight in
weaknesses, in insults, in hardships, in persecutions, in difficulties. For when I am
weak, then I am strong.” (2 Corinthians 12:9-11)
2. In Christ, you can do all things; without Him you can do nothing.
• “
I can do all this through him who gives me strength.” (Phil 4:13)
• “
Remain in me, as I also remain in you. No branch can bear fruit by itself; it must
remain in the vine. Neither can you bear fruit unless you remain in me. I am the
vine; you are the branches. If you remain in me and I in you, you will bear much
fruit; apart from me you can do nothing. If you do not remain in me, you are like a
branch that is thrown away and withers; such branches are picked up, thrown into
the fire and burned.” (John 15: 4-6)
3. God chooses the foolish things of the world rather than the wise.
• “
Brothers and sisters, think of what you were when you were called. Not many of
you were wise by human standards; not many were influential; not many were of
noble birth. But God chose the foolish things of the world to shame the wise;
God chose the weak things of the world to shame the strong. God chose the lowly
things of this world and the despised things—and the things that are not—to
nullify the things that are, so that no one may boast before him.”
(1st Corinthians 26-29)
4. We are called to be holy and perfect, but Jesus said that even the religious experts
of His day were not perfect enough; no one is good except God.
• “
For I tell you that unless your righteousness surpasses that of the Pharisees and
the teachers of the law, you will certainly not enter the kingdom of heaven.”
(Matthew 5:20)
• “
God made him who had no sin to be sin for us, so that in him we might become
the righteousness of God.” (2 Corinthians 5:21)
• “
The words ‘it [righteousness] was credited to him’ were written not for him
alone, but also for us, to whom God will credit righteousness—for us who believe
in him who raised Jesus our Lord from the dead. He was delivered over to death
for our sins and was raised to life for our justification.” (Romans 4:23-25)
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Session 10: Hope and Relapse Prevention
Home Practice Activities
1. Memory Verse
“He gives power to the faint and weary, and to him who has no might He increases
strength. Even youths shall faint and be weary, and young men shall stumble and
fall exhausted; But those who wait for the Lord [who expect, look for, and hope in
Him] shall change and renew their strength and power; they shall lift their wings
and mount up [close to God] as eagles [mount up to the sun]; they shall run and
not be weary, they shall walk and not faint or become tired.” (Isaiah 40:29-31,
Amplified Bible)
2. Contemplative Prayer
Spend 20 minutes a day in contemplative prayer. Begin by using the memory verse for
this week, and then try with previous weeks’ memory verses or other favorite scriptures
you may have. This is an important practice that we encourage you to continue to do
daily.
3. Continue to Use the Tools Daily
In order to maintain the gains you have achieved in treatment you need to keep using
the tools you have learned. These tools include the following:
• Challenging and changing your negative interpretations (Additional
ABCDE sheets are included at the end of this workbook. Feel free to make
extra copies for yourself)
• Gratitude
• Altruism (choose a specific activity for a specific person)
• Finding the positives in your life
• Praying for someone else
• Maintaining communication with God
• Look for examples in the Bible for encouragement
• Spending time with others
• Connecting with your faith community, specifically the person(s)
identified earlier in treatment
• Filling your mind and heart with the Word of God
One way to remind yourself to continue to put into practice the things you have learned
is to incorporate them into a daily devotional period. Each day during this time you can
review your thoughts and’ behavior with God to make sure they line up with the truth in
His Word. You might find it helpful to use a journal during this time.
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4. Make Use of Your Spiritual Resources
Spiritual resources include, but are not limited to, prayer, journaling, social support
from friends, conversations/counseling with clergy, Bible studies, repentance and
forgiveness, existential psychotherapy, attending religious or spiritual services,
attending support groups, such as Alcoholics Anonymous, attending activities
sponsored by spiritual or religious groups, such as pot-lucks, bingo, and discussion
groups.
5. Anticipate Set Backs
Remember that there will be set backs and times that are more challenging and difficult
than others. It is at these times that it is even more important to engage in the activities
and resources you learned, especially if you don’t feel like it.
6. Continue Contact Member of Faith Community
Continue to be in regular contact with the member of your faith community. Remember
to pray for him or her daily, too.
Congratulations on a job well done!
Lord, make me an instrument of Thy peace;
where there is hatred, let me sow love;
where there is injury, pardon;
where there is doubt, faith;
where there is despair, hope;
where there is darkness, light;
and where there is sadness, joy.
O Divine Master,
grant that I may not so much seek to be consoled as to console;
to be understood, as to understand;
to be loved, as to love;
for it is in giving that we receive,
it is in pardoning that we are pardoned,
and it is in dying that we are born to eternal life.
Amen.
St. Francis of Assisi
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ABCDE Method for Challenging Beliefs
Activating Event: Describe the situation around the time the negative emotion(s) began.
Beliefs: What negative thoughts or expectations automatically went through your mind when you
were in that situation?
Consequent Feelings and Behavior: What painful feelings did these thoughts or expectations
lead to? Rate each feeling using a scale of 1-10, where 10 is very intense. What behavior did these
beliefs and feelings lead to?
Dispute the Beliefs and Deal with the Situation: Is there any evidence that those beliefs or
expectations are not totally accurate or true? Describe the contrary evidence. Specify the
unhelpful thought category that best describes the error in the belief. Even if the situation can’t
change, what evidence do you have that you could manage it (based on your talents, past
experience, support persons, and/or resources)?
Religious Beliefs and Resources: How can your view of God, your Christian worldview, the
Bible and religious writings, spiritual wisdom, and other sources provide evidence that challenge
your automatic negative beliefs and beliefs that you can’t cope?
Effective New Belief and Consequence: What is a different way to now look at the situation?
How did your feelings change after you looked at the situation differently? Rate each feeling
using a scale of 1-10, where 10 is very painful.

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