COGNITIVE-BEHAVIORAL

THERAPY

TREATMENT FOR DEPRESSION

SESSION PROTOCOL
SESSION 1
INTRODUCTORY SESSION

1. INTRODUCTION
(a) Introduce yourself sharing relevant personal information. If the client doesn’t respond
you can share information similar to information you want the adolescent to share by
modeling.

(b) Encourage the client to share personal information such as:

 Where he/she was born, information about his/her history or development
 Things about his/her family
 The school he/she attends
 What his/her principal interests are (goals, likes and dislikes, hobbies)
 Things about him/herself that they consider important

Ask about their main problems (for example, you can ask about worries or difficulties). You can
also ask: “What would you like to change or improve about your life?”

2. Present the purpose of today’s session.

Today’s session has several goals:
 Get to know each other better
 Discuss the rules for the sessions
 Explain the therapy
 Learn what depression is
 Learn how your thoughts affect the way you feel
3. Discuss the rules
 Arrive on time! Be punctual!
 Come every week! This treatment is a commitment you make with yourself and your
therapist.
 Do the homework. By practicing what you learn in these sessions, you can find out
whether these skills can help you control your symptoms of depression.
  What you talk about in session is confidential. However, it’s ok if you what to share what
you’ve learned with other people if you want.
 Try to be as honest as possible, and express yourself just as you are and how you feel.
 Turn off your phone or put it on “vibrate” once you come into the therapy so it doesn’t
interrupt the session.
 Tell me if you are unhappy
 Bring concerns up with me
 Don’t stay mad without letting me know.
 Come back: don’t drop out; let me know if you feel upset, we can work things out
4. Explaining depression

What is depression? What does it mean to be depressed?

Ask this question in a way that will encourage the adolescent to share information about his/her
personal experience. Afterwards, share the following information trying to integrate the
information the adolescent has shared.

The word depression is used in many ways. Depression can mean:

 a feeling that lasts a few minutes

 a mood that lasts a few hours or a few days
 a clinical condition that:
 lasts for at least two weeks
 causes strong emotional suffering
 makes it difficult to carry out our daily activities

This treatment focuses on treating clinical depression.

Using the client’s answers to the previous section, present the symptoms of clinical depression
integrating symptoms that the adolescent has said he/she experiences. Ask if he/she has
experiences any of the following symptoms

People with clinical depression generally have five or more of the following symptoms:

 feeling depressed or down nearly every day

 not being interested in things or unable to enjoy things you used to enjoy
  appetite and/or weight change (eating more or less than you are used to)
 sleeping problems (difficulties falling asleep, waking up often, waking up too early or
being unable to fall back asleep, sleeping too much)
 changes in how fast you move (either being too restless or moving very slow)
 feeling tired all the time
 feeling worthless or guilty
 problems thinking, concentrating, or making decisions
 thinking about death or hurting yourself (suicide)
5. Explaining CBT

The following questions can be used as a guide for a discussion con how cognitivebehavioral
therapy can be applied to the adolescent’s particular experience o situation:

 What kinds of thoughts pass through your mind when you feel depressed or sad?
 What do you do when you feel depressed?
 How do you get along with others when you are depressed?

The purpose of this section is to introduce you to the therapy in which you are going to
participate. The kind of skills we provide are called "COGNITIVE-BEHAVIORAL THERAPY"

 "Cognitive" refers to our thoughts.

 "Behavioral" refers to our actions.
 Depression has most to do with our feelings.

By identifying thoughts and actions that affect our feelings, we can learn to gain more control
over them and improve our mood (feel better).

Use the diagram below to explain Cognitive Behavioral Therapy.

THINK

ACT FEEL
  This treatment for depression consists of 12 therapy sessions.
 We focus on what is going on in your life right now, in the present.
 The therapy is focused on how to control depression in practical ways that can be used
now and in the future.

The twelve sessions are divided into three modules or parts:

 How your thoughts affect your mood. (4 sessions)

 How your actions affect your mood. (4 sessions)
 How your relationships affect your mood. (4 sessions)

In this type of treatment we try to teach people practical things they can use in their daily lives.
We expect that the most important effect of this treatment will be to learn to understand and
manage the things that affect your mood (how you feel).

6. Introduce the concept of how our thoughts affect our mood (how we feel)

Having certain types of thoughts can make you feel more or less depressed. By “thoughts” we
mean “things that we tell ourselves.”

 Thoughts can have an effect on your body

 Thoughts can have an effect on your actions (what you do)
 Thoughts can have an effect on your mood (how you feel)

Provide a good example of how a thought can have an effect on your body, your actions and
your mood. For example:

You’re walking down a deserted street and you see a person walking quickly behind you. He
looks serious, he is looking at you and you think that he is going to mug or rob you. Immediately,
your body, your actions and your mood react to this thought. You start sweating, your heart
races, and you feel a knot in your stomach. You start looking over your shoulder and walking
faster. You feel nervous, afraid. The person reaches you, and quickly walks past you, getting
farther and farther away. You think he was just in a hurry. A good way to think about this type
of therapy is that you will learn specific ways to change your thoughts and your actions so that
you feel better.
7. The purpose of therapy

The purpose of this therapy is to treat depression by teaching your different ways to better
control how you feel. There are four goals we want to work towards:

(i) To lessen or eliminate feelings of depression

(ii) To shorten the time you feel depressed
(iii) To learn ways to prevent or avoid getting depressed again
(iv) To feel more in control of your life
8. Closure and discussion of the homework

Do you have any questions or comments about what we talked about today?

Now we are going to discuss the assignment that you are going to complete during this week
before our next session.

Homework: Daily Mood Scale

This tool lets us evaluate the intensity of depressive symptoms or mood at the end of each day.
Model how to complete the mood scale and practice completing it together based on his/her
mood yesterday.

 This exercise is called the “Daily Mood Scale” and you are going to complete it every
week. We want to see how you feel each day and your mood changes throughout therapy.
 To complete it, at the end of each day, mark how you felt or how your mood was in
general for that day. For example, if it was “the worst” then you should circle number 1,
if it was “regular” then you would circle number 5 and if it was “the best” then you
would circle number 9. Let’s do one to practice using your mood yesterday. (Give the
client the Mood Scale).
 Bring it completed to next week’s session so we can discuss it.
SESSION 2

HOW YOUR THOUGHTS AFFECT YOUR MOOD

PART 1: Review of the homework

Review or summarize briefly the following concepts discussed in Session 1 (promote the client’s
participation in this review):

 Depression
 Cognitive Behavioral therapy for depression
 Daily Mood Scale: How did you feel completing it each day? Any surprises?
 Reinforce the importance of completing the Mood Thermometer as a way to see how
mood fluctuates.

PART 2: What are thoughts?

Ask this open question to facilitate a discussion about thoughts. Include the definition presented
below:

Thoughts are ideas (phrases or sentences) that we tell ourselves. We are constantly talking to
ourselves internally, but often we’re not always aware of it. It is helpful to think about thoughts
as "objects" (ideas) that have a real effect on our bodies and minds.

Your thoughts affect your mood (how you feel): Different types of thoughts produce different
effects on your mood. Some thoughts increase symptoms of depression, while others help you
feel better.

How do people with depression think?

Ask this open question promoting a brainstorm on the typical thoughts people with depression
might have. Some of the thoughts generated during this brainstorm can be used later on and
classified according to the following material.

Of these thoughts you mentioned, which ones have you had?

People with depression tend to have different types of negative thoughts (inflexible, judgmental,
destructive and unnecessary). You can use the contrast between the different types of thoughts.
Negative thoughts are all thoughts that make you feel bad, for example: “I am always going to
feel depressed” or “I am useless.”

Positive thoughts make you feel better, for example: “I can do things to feel better.” “I am
getting better each day.”

Inflexible thoughts are thoughts that are rigid, thoughts that don’t change. For example, a
depressed adolescent might think: “I’m the only one they ask to do things at our house.” “I can’t
do anything right.”

A flexible thought that could help avoid depressed feelings could be: “My parents almost always
ask me to do things, but sometimes they ask my sister.” “There are lots of times when I do things
right.”

Judgmental thoughts are negative thoughts about ourselves. For example, a depressed
adolescent might think: “I’m ugly” or “I’m a loser”. A flexible thought could be: “I might not
be the most attractive person in the world, but I’m not the ugliest.” “I have qualities that make
me a nice person" or “I can't please everybody."

Destructive thoughts harm us. For example, “I am worthless.” “Nothing I do comes out right.”
or “I’ve made so many mistakes there’s no way to solve my problems”. Constructive thoughts
help you feel better. For example, “I can learn to control my life so I can do what I really want.”

Unnecessary thoughts don’t change anything and they make us feel bad. For example, “A
hurricane is going to hit us” or “something bad is going to happen to my parents” or “they’re
not going to give me permission to go”. Necessary thoughts remind you of the things you have to
do, such as: “I have to do my homework to improve my grades” or “Mom asked me to do the
dishes before going to the party.”

How do people who aren’t depressed think?

Illustrate the differences between thoughts that depressed people have versus thoughts that
people who aren’t depressed have.

1. They can see the positive side of things

Depressed: “My family is a disaster.” “I’m stupid."
 Flexible: “My family has their problems, but they also have good things.” “If I can create
good study habits I can improve my grades.”
2. Don’t define themselves by their mistakes, they learn from them
Depressed: “The coach pulled me out of the game, I’m useless” “I got an F, I am a
loser.”
Flexible: “Today I had a bad day, I didn’t play too well. I’ll have to practice a bit more.”
“Math isn’t my strongest subject, but I can work hard on extra credit assignments to
improve my grade.”
3. They have hope for change
Depressed: “Nothing has ever helped.” “Nothing will ever change.”
Flexible: “None of the things I have tried up to now have helped, but this is new and it
could be a good time to start to feel better.” “I could start changing some things that are
under my control.” “I’m going to keep trying until I find a solution.”

PART 3: Learning to identify different types of harmful or counterproductive thoughts

Discuss the List of Thinking Errors:

Facilitator may say:

We are going to discuss different types of negative thoughts, or ways of looking at things
that happen to us, that are harmful because they make us feel bad because they are not
based on facts or they distort reality.

For a description of each type of thinking error, look at the worksheet called Thinking
Errors.

Read and discuss each type of thought. Make sure the client understands each thought category.
One way to make sure is asking him/her to provide an example of each thought after discussing
each thinking style.

Part 4: Closure and discussion of homework

Do you have any questions or comments about what we talked about today?

Now we are going to discuss the assignment that you are going to complete during this week
before our next session.
Homework

(a) Mood Thermometer.

(b) Keep a record of your thoughts. Complete the List of Positive and Negative Thoughts. At the
end of each day read the list and mark each thought you had. Add up the total number of
positive and negative thoughts. See if there’s a relationship between the number of each type
of thought (positive or negative) and your mood.
SESSION 3

USING YOUR THOUGHTS TO CHANGE YOUR MOOD

PART 1: Review of the homework

Review or summarize briefly the following concepts discussed in Session 1 (promote the client’s
participation in this review):

 Daily Mood Scale

 Types of thoughts people who are depressed have.
 List of Positive and Negative Thoughts: What are some of the thoughts you had in the
past week?

PART 2: Increasing thoughts that improve your mood

Stop everything your are doing

When we feel nervous we can take a break and mentally give ourselves a time out. Let your
mind relax and take a deep breath. Pay attention to your body’s natural ability to relax and feel at
peace. Feeling at peace can give you energy.

You lead the client in a relaxation exercise after discussing this point. Pick the exercise you feel
most comfortable leading. You can use sounds or music to help relaxation.

Increase the number of positive thoughts in your mind

Make a list of good thoughts you have about yourself and about life in general. Provide the
adolescent with a blank sheet of paper to do this exercise, and discuss it afterwards.

Congratulate yourself mentally

Other people do not notice most of the things we do. Therefore, it is important for us to
acknowledge them and give ourselves credit for doing them. You can ask the client to identify a
reason to congratulate him/herself mentally.
Projection into the future

Imagine yourself in the future, at a time when things will be better. Ask the adolescent to
imagine his/her future in 1, 5 and 10 years. Encourage him/her to imagine it as detailed as
possible. The exercise can be oral or written.

PART 3: Decreasing thoughts that make us feel bad interrupt your thoughts

When a thought is ruining your mood, we can identify it and try to interrupt it. First, identify the
thought. Next, tell yourself: “This thought is ruining my mood, so I am going to change it or
substitute it for a positive one.”

Time to worry

Set aside "time to worry" each day so that you can concentrate completely on necessary thoughts
and leave the rest of the day free of worries. The "time to worry" can be 10 to 30 minutes each
day.

Laugh at your problems by exaggerating them

If you have a good sense of humor, try to laugh at your worries. If you feel you don’t have a
good sense of humor, try to do it any way you can. Sometimes this can take away the pain of
certain hardships. For example, you can ask the client what’s the most embarrassing that has
ever happened to him/her.

Consider the worst that could happen

 Often some of the fears we have about what could happen make us feel depressed and
they paralyze us.
 To help you stop making negative predictions and prepare yourself for what could
happen, it’s useful to ask yourself – What could happen if ____? Or what would really be
the worst thing that could happen if_____?
 Remember that the worst thing that could happen is only one of many possibilities and
just because it’s the worst doesn’t mean that is the most probable.
 It’s good to ask yourself whether you’re exaggerating what could happen. Maybe none
of the things you fear will happen, but if you consider the different possibilities you’ll be
better prepared.
 For example, you have failing grades in several classes. Your parents are pressuring you and
you’re afraid of flunking your grade. You could think – what is the worst that could happen if
I fail? One possibility is that you’ll have to take tutoring or repeat a class during the summer
and your parents will be upset. You would feel bad and possibly your parents would be upset
for some time, but you could handle it, and resides, you could review the material you didn’t
learn so well in order to get better grades next year.

PART 3: Being your own trainer

Just as we can help someone to do something difficult by coaching them or giving them
instructions, we can help ourselves by coaching ourselves. This is what we mean by learning to
feel better.

Practice time

Now let us think of some examples of how to use these ideas. Think about how to use the
examples with the thoughts you have had this week. You can discuss what strategies, of the ones
discussed in this session, he/she could use in particular situations.

PART 4: Closure and homework

Do you have any questions or comments about what we talked about today?

Now we are going to discuss the assignment that you are going to complete during this week
before our next session.

1. The Daily Mood Scale

2. List of Positive and Negative Thoughts
3. Practice some of the strategies we discussed to increase positive thoughts and decrease
negative ones
SESSION 4

HOW YOUR THOUGHTS AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 3 (promote adolescent
participation in this review):

 Mood Thermometer
 List of Positive and Negative Thoughts - What are some of the thoughts you had last
week?
 What strategies did you use to increase positive thoughts and decrease negative ones?

PART 2: Debating/disputing your negative thoughts – the A-B-C-D method.

When you feel depressed, ask yourself what you are thinking. Then try to talk back to the
thought that is bothering or hurting you.

A is the Activating event; what happened

B is the Belief or the thought that you are having; that is, what you tell yourself about
what is happening

C is the Consequence of your thought; that is, the feeling you have as a result of your
thought

D is the way in which you Dispute or talk back to your thought (this means that you
challenge negative thoughts and generate alternate positive thoughts)

In these examples, you can use the ABCD method in the following way (it’s better to use
examples from the client’s experiences):

A - My Dad didn’t come for me this weekend (this is a fact).

B - Some of the thoughts you might have about this fact are: “My dad doesn’t care about
me”, or “My Dad doesn’t want to spend time with me”

C - The consequence of thinking these thoughts is feeling mad, sad and disappointed.
 D - I can talk to these thoughts in the following way: "My Dad cancelled because of
problems he has with my Mom”, “My Dad has always shown me in other ways that even
loves me even if he can’t spend a lot of time with me.”

Example 2

A - I have an F in two classes and it’s already mid-semester.

B - I’m stupid, I can’t do anything right. I’m going to have to repeat the 10th grade. I’m never
going to be able to study or work at what I want.

C - I felt sad, frustrated and mad.

D - I still have the chance to find opportunities to pull up my grades, such as doing extra credit
work or finding a tutor. I might have to repeat the class during the summer, but it doesn’t mean I
won’t graduate, or be able to do what I want. I’m smart and there are some classes that are harder
for me than others.

Excercises with the ABCD method

When you feel depressed ask yourself what you’re thinking. Then try to talk back to the thought
that’s bothering you.

Use a situation that the adolescent has brought up in therapy to practice the ABCD method.

PART 3: Some thoughts that can contribute to feeling depressed

The following thoughts are thoughts that people with depression commonly have and can make
them feel worse.

Generate a discussion in which you and the adolescent change or modify the following thoughts
to more positive and flexible ones. Following each negative thought are examples of alternate
thoughts. One way of doing this exercise is reading each one out loud and modeling for the
participant how to change it to a more positive, flexible one. Afterwards you can ask the
adolescent to do the same with the next thought on the list.

“Everyone should love/like me.” “Not everyone has to like me.” “I have people who love me
very much.”
“I should do everything right all of the time” “I want to do things the best way possible. “I’m
going to do the best I can.” “I do lots of things right.”

“I am a bad person.” “I make mistakes just like everybody else, and that doesn’t mean I’m bad.”
“I can learn from my mistakes” “Everybody makes mistakes.”

“I will feel awful if things don’t happen the way I want them to.” “Things aren’t always going to
turn out the way I’d like.”

“I should worry about the bad things that can happen.” “There’s no point in worrying about
things I have no control over” “I don’t know what might happen in the future.”

“Nobody loves me.” “I might feel rejected right now but it doesn’t mean I don’t have people who
love me.”

“I’ll never be able to be happy.” “I feel unhappy right now, but things can get better.”

“I should feel bad when when people I care about are having a hard time.” “It’s important to
support the people I love when they’re having a hard time, but feeling bad won’t help solve their
problems.”

“I need everyone's approval to feel good about myself.” “I can feel good even though other
people don’t agree with the things I do.”

“I have to be popular and accepted by my friends to feel like I am worth something.” “I can’t
expect everyone to like me the important thing is to have good friends.”

“My family suffers because of me.” “There are problems in my family that I can’t control.”
“Blaming myself isn’t going to solve our problems.”

“It’s my responsibility to solve the people I love’s problems.” “It’s not my responsibility to solve
other people’s problems, but I can support them.” “I help with what I can.”

PART 4: Review of the session and closure

Ask the following direct questions:

What have you learnt?

Do you have any questions or comments about what we talked about today?
Let the participant respond and make any clarifications or corrections as need may be.

Homework

1. The Daily Mood Scale

2. List of Positive and Negative Thoughts
3. Use the A-B-C-D Method to debate or challenge your negative thoughts.
SESSION 5

HOW YOUR ACTIVITIES AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 4 (promote client
participation in this review):

 Daily Mood Scale

 List of Positive and Negative Thoughts
 The A-B-C-D Method

In this treatment we work with thoughts, activities and relationships to improve our mood or
how we feel. In the module we’ll be starting today we will be working with activities and how
they affect how we feel.

PART 2. The activities that we do affect our mood: through our activities we can tell how we
feel.

The facilitator may ask the following question then explain:

Do you stop doing things because you feel depressed? or Do you feel depressed because
you stop doing things?

The most probable answer is BOTH: The fewer things you do, the more depressed you
feel. The more depressed you feel, the fewer things you do. This is called a "VICIOUS
CYCLE."

To break the vicious cycle you can increase those activities that make you feel better.

These activities can be called "pleasant", "encouraging", "inspiring", etc. We call them
"pleasant."

PART 3: Pleasant activities do not have to be special activities (although they can be).

By pleasant activities we are referring mostly to everyday activities (i.e. listen to music, watch
TV, read a book, talk on the phone, surf the Internet).
Sometimes it is hard to think about what we consider pleasant, especially if we haven't done it in
a long time. When we are depressed, it is even harder to remember pleasant things. To help you
we use a List of Pleasant Activities. What activities do you enjoy? When you feel depressed, are
there things you stop doing?

For the next week, you will keep a daily record of the number of pleasant activities you do. Use
the List of Pleasant Activities by putting a mark next to each pleasant activity you do every day.
Personalize your list. If any of the activities do not apply to you, leave it blank or put a line
through it. You probably have never done this before in your life. Lots of people find this
exercise interesting and useful. This week you don’t have to do anything other than what you
usually do. Just identify the pleasant activities that you do each day of this week. By doing this,
you’ll learn something about how your daily activities affect how you feel.

PART 4: Sometimes obstacles get in the way of our doing certain pleasant activities.

What obstacles or things prevent you from doing pleasant activities?

Ask for specific examples of obstacles to doing pleasant activities. Let the client share as much
as possible.

Some obstacles to working with pleasant activities are:

 YOUR THOUGHTS:
 What kind of thoughts help you enjoy an activity?
 What thoughts make it hard for you to enjoy an activity?
 Have you ever enjoyed an activity that you thought you wouldn’t?
 PEOPLE:
 How have other people made it hard for you to enjoy a pleasant activity?

PART 5: Closure and discussing homework

Ask the client if they have any questions or seek any clarification.

Homework

1. Daily Mood Scale

2. At the end of each day, mark each of the activities on the List of Pleasant Activities that
you did that day. Count the total number of marks you have at the end of each day. Bring
the list to our next session
SESSION 6

HOW YOUR ACTIVITIES AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 5 (promote adolescent
participation in this review):

 Mood Thermometer
 List of Pleasant Activities
How did you feel keeping track of your activities?
How many did you do each day?

PART 2: More information on pleasant activities:

1. How can pleasant activities help you feel better?

You can make reference to the diagram that represents the interaction between our thoughts,
actions and feelings.
 It is not enough to say to yourself, "Feel better!" It is often easier to change the things
you do. If you change the things you do, you can also change the way you feel.
2. Remember that:
 Pleasant activities do not necessarily have to be special activities, although they can be
special. Pleasant activities are often ordinary activities that we enjoy.
 Some examples are watching the sun set, reading a book, talking to a friend,
play sports, going to a park, smelling a flower, drawing or painting, listening
to music.
 Pleasant activities can be different for different people. For example, some people find
reading a book while alone is a very pleasant activity. Other people can find being in a
noisy and crowded shopping center fun.
3. It is important to have an adequate number of pleasant activities in order to feel good.
 We feel our best when our activities are well-balanced between things we” have to do"
and things we "want to do." Since we have more control over the things we want to do, it
is important to keep these activities in mind and do them.
  What are some of the things you have to do? What things do you do because you enjoy
them? Do you have a good balance?
4. The problem with things that put demands on your time and the need for doing pleasant
activities.
 Often it is hard to create a balance between things we have to do and things we want
to do. One solution to deal with this problem is planning our time

Explore whether the participant keeps an agenda or date book of these weekly activities.
Afterwards present and discuss the advantages of using a Weekly Activities Schedule.
Practice using the worksheet titled Weekly Activities Schedule by asking him/her to write
down the activities he/she does on a daily basis and the time he/she does them.
Encourage him/her to use it during the week.

 Planning and programming your activities is a way to gain more control over your
life.
5. Doing pleasant activities without spending a lot of money.
Exercise: Make a list of pleasant activities that the adolescent can do that don’t cost a lot
6. Anticipating problems
Exercise: From the List of Pleasant Activities choose one that you would like to do. Let’s
think of things that might prevent you from doing that activity so that you can prepare for
possible problems and plan for solutions so that they don’t interfere with your activity.
Doing this exercise you should consider the following questions:
 How can you organize and plan your time?
 How can you use your thoughts to help you plan and enjoy this activity?
 What could be a potential obstacle to doing this activity?
 How can we manage this/these obstacle(s)?

PART 3: Discuss the homework

Do you have any questions or comments about what we talked about today?

Now we are going to discuss the assignment that you are going to complete during this week
before our next session.

1. Daily Mood Scale

2. At the end of each day, mark each of the activities on the List of Pleasant Activities that
you did that day. Count the total number of marks you have at the end of each day. Bring
the list to our next session.
3. Complete the Weekly Acitivites Schedule.
4. This week you’re going to carry out an experiment with yourself.
 You are going to make a Personal Contract. Pick a pleasant activity that you can
do this week and establish a reward for yourself if you do it.
 Complete the worksheet titled, "How much do you think you will enjoy your
pleasant activities? Pick 3 to 6 activities that you would like to do in the next few
weeks. Write how much (%) you think you’ll enjoy them. After doing them, write
down how much you really enjoyed them.
SESSION 7

HOW YOUR ACTIVITIES AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 6 (promote adolescent
participation in this review):

 Daily Mood Scale

 List of Pleasant Activities
 Weekly Activities Schedule
 Personal contract and Prediction of Pleasant Activities
What we hope you will learn from this experiment is:
 You don't need to wait until you "feel like doing something" to do it. You can
choose to do something and really do it.
 You can enjoy certain activities even if you thought they wouldn't be fun.
 You can influence your mood with your activities. The more you practice doing
this, the more control you will have over your mood.

PART 2: Creating your own plan for overcoming depression

One way is by establishing goals.

1. What are goals? How can reaching goals help you feel better? Ask these questions to
promote a discussion.
2. There are several types of goals:
 SHORT TERM GOALS - Things you’d like to do soon (say in the next 6 months)
 LONG TERM GOALS - Things you’d like to do at some point in your life
 LIFETIME GOALS - Your life philosophy. What do you care most about in life?
3. Identifying goals – what are your goals?
Ask the client to write down his short term, long term and lifetime goals on the worksheet
Personal Goals. Use one of the goals he/she wrote to discuss how to establish goals
using the following guides.
4. Setting clear, concrete goals:
 Set clear, concrete goals so that you can be sure of when you’ve reached them.

UNCLEAR GOALS CLEAR GOALS

(general) (specific/concrete)
Be less bored Go to the mall once a week
Be a good friend Spend three hours a week doing pleasant
things with your friends
Be a good musician Spend 4 hours a week practicing an
instrument
Get better grades Study for two hours every afternoon
 Which one of your goals can be clearer and more concrete?
5. Break down your big goals into smaller parts:
 Make sure that each part can be achieved without too much effort. If your goal is to
be a good baseball player, then you could start by finding out were the nearest
baseball park is and what times you can practice.
 Which one of your goals could you divide into smaller parts?
6. Setting realistic goals:
 It is often difficult to determine beforehand what’s realistic and what’s not.
What’s not realistic today can be realistic in the future. However, if you find you
can't meet most of your goals now, then they are probably not realistic for you at
this time.
 Do you think your goals are realistic?
Evaluate with the client whether he/she can reach his/her goal taking into
consideration his/her: abilities, resources, motivation, etc.
7. What are some of the obstacles that prevent you from achieving your goals?
After discussing the exercise, ask the adolescent to identify possible obstacles to
achieving his/her goals.
8. To make changes in our lives, sometimes we need to make changes in our goals:
 Things that are realistic might become unrealistic.
For example:
 An adolescent plays volleyball and she’d like to play in a major league. She hurts
her knee badly during a game, and she can’t keep playing that sport. However,
maybe she can become a volleyball coach or assistant coach.
 Things that were unrealistic might become realistic.
For example:
An adolescent wanted to be able to drive his mother’s car. His mother told him
that he still wasn’t old enough to do so. He felt like he would never get to drive,
he saw it as so far away. Finally he turned 16 and his mother let him drive under
her supervision.
Ask the participant if he/she can come up with another example.

If a change occurs in your life that requires a change in goals, then maybe you’ll have to:

- Enjoy activities in new ways

- Develop new interests, abilities and activities.
9. To help overcome depression:
 Establish realistic goals.
 Recognize the positive things you do to reach them.
 Congratulate and reward yourself mentally and in real life.

PART 3: Closure and discussing homework

Ask the client if they have any questions or seek any clarification.

Homework

1. Daily Mood Scale

2. Weekly Activities Schedule
3. Time management: Make a list of the goals you’d like to complete this week. Put them in
order of priority. Are you really sure that you want to do the last ones on your list?
Identify a plan to achieve the highest ones on your list.
SESSION 8

HOW YOUR ACTIVITIES AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 7 (promote client
participation in this review):

 Mood Thermometer
 Weekly Activities Schedule
 List of personal goals

PART 2: Depression and the healthy management of reality

Illustrate the difference between the objective and the subjective world.

We live in two worlds:

1. The objective world (the world outside, everything outside of us) For example, the
places, people and events around us that we can’t change (where we live, the school we
go to, who are parents are).
2. The subjective (internal) world (our internal world, what’s inside our minds) for
example, our thoughts, beliefs, wishes, feelings and dreams (how we perceive what we
do and what happens to us).

These two worlds are our reality. The key to feeling emotionally healthy is to learn how to
manage these two parts of our reality.

 The objective world, generally speaking, we can’t change, but we can learn ways to
manage it in a way that it doesn’t’ affect how we feel so much.

For example, you can’t change the fact that your parents are getting a divorce, but you
can change the way you react to it. You can isolate yourself, be mad at them, or think it’s
your fault. You can also find a friend to talk to, think that your parents are adults and they
must know why they made that decision, and try to do pleasant activities that can help
make you feel better. You can see the possible positive side to this, which could be that
they are happier and there is more peace at home.
  On the other hand, we can have more control over our subjective world. When people are
depressed, they often perceive their subjective world as the only reality.
For example, remember when we talked about thinking errors. If you don’t change your
negative thoughts, you might think they are the only reality and that will continue to
make you feel depressed.

No one completely controls these two worlds. However, you can learn to have more control
over your subjective world and identify ways to manage the objective world.

 When people are depressed they feel that have no control, that there’s nothing they can
do to feel better. However, things can2 always change and improve.

There are ways to feel you have more control and feel less depressed.

Alternatives

 Sometimes we find ourselves in situations in which it’s hard to make decisions because
we don’t see alternatives or we only see one. It can also happen that we feel we don’t
have any alternatives when things don’t happen the way we want them to. On these
occasions it helps to consider all the alternatives and not to focus on that fact that you
don’t have what you really wanted.
 The more alternatives you have, the more freedom you’ll have.
 Have you ever found yourself in situations such as these? If the client doesn’t provide an
example, you can present him/her with one of the following situations, asking them to
provide alternatives to them:
- A guy you don’t have romantic feelings for invites you to a party, but you enjoy his
company as a friend. You want to ask a guy you really like or hope that he asks you.
- Your friends invite you to go out, but your mom asked you to help your grandfather
cut the grass because he hasn’t felt well lately and can’t do it alone.

Thinking that the world is made up of chunks of time

It’s common when people feel depressed for them to think they’re always going to feel that way.
They can also think that their depression won’t go away unless something in the objective world
changes. If you see the world as little chunks of time that you decide what to do with, you can
feel more in control and take action to overcome your depression.

Be careful of telling yourself:

 “I can’t enjoy life until _______________”.

For example, if you tell yourself:

 “I can’t enjoy life until my depression goes away”, consider thinking – “I can feel better
every day if I do the things I have been learning.”
 "I won’t be happy until I have a boyfriend/girlfriend” – consider thinking – “I can enjoy
spending time with my friends and meeting new people.”

Have you ever had these kinds of thoughts?

“I can’t enjoy life until _______________.”

What can you do to change that type of thought to one such as:

“To enjoy my life I am going to _______________________.”

PART 3: Making your two worlds healthier for you.

Making your outside world healthier.

What things in your outside world are contributing to your depression?

What can you do about them now?

- Let’s talk about your alternatives. Mention two alternatives (concrete actions) that
you have to manage the outside world.
- Let’s talk about your time. How do you use your time to reach those alternatives?

Making your inside or internal world healthier.

What things in your internal world are contributing to your depression?

You can ask the client whether there are still negative thoughts that he/she has often, and work
with these thought in alternatives and time (below).

What can you do about them now?

 - Let’s talk about your alternatives. Mention two alternatives (concrete actions) that
you have to manage your internal world.
- Let’s talk about your time. Do you spend a lot of time thinking you want to
change the past or anticipating the future?

PART 4: Review of the activities

What did you learn?

 Pleasant activities and the way you manage your internal and outside worlds make help
make your time more satisfactory. When your time becomes more satisfactory, your life
will also and you will feel better. Integrate pleasant activities into your life plan. If
pleasant activities help you overcome your depression, they can also help you feel
healthier emotionally.
 The better you feel, the more you can help yourself and others.

Homework

1. Daily Mood Scale

2. Weekly Activities Schedule
SESSION 9

HOW YOUR RELATIONSHIPS AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 8 (promote client
participation in this review):

 Daily Mood Scale

 Weekly Activities Schedule
 Review how we understand depression according to CBT
 In this treatment we work with thoughts, activities and relationships (family, friends,
others) to improve your mood. In this module (the last 4 sessions) we will be working
with your relationships and how they affect how you feel.

PART 2: Let’s work with how your contact with other people affects your mood

Severe depression is associated with:

 Having less contact with others

 Feeling uncomfortable, shy or mad at others
 Being less assertive (not saying what you like/dislike or not knowing how to express your
feelings and preferences)
 Being more prone to feeling rejected, ignored, or criticized

Does depression cause people to be less sociable? Or does being less sociable make people to
get depressed?

The answer is probably that depression and lack of contact with other people influence one
another.

For example, a change of school can mean leaving a lot of friends behind. This can make
you feel sad. If when you feel sad you don’t make an effort at making new friends, your
sadness can become depression. Feeling depressed may make you feel less sociable,
which will make you even more depressed because you’re spending a lot of time sad and
lonely.
PART 3: The importance of social support

 The support we receive from being in contact with other people is important for our
health. The contacts we have with our family and friends create a kind of protective
social network or "social support network"
 The system or "social support network" refers to people who are close to us and with
whom you share important information or important moments of your life. These people
can be family, friends, neighbors, classmates and acquaintances. In general, the stronger
the social support we receive, the more we are able to confront difficult situations.

What is your social support network like?

Who are your friends? How often do you see them? What do you do? Who do you trust?

Exercise: Recreate your social support network using the diagram on the My Social Support
Network worksheet.

The client should write his/her name in the center circle and in each shape write the name of
someone in their network. In discussing this exercise, evaluate the quality and quantity of his/her
network and whether it should be expanded or strengthened.

Important principles to keep in mind

(i) If your social support network is too small, make it larger. Your network is too small
if there is no one you trust to talk about your personal matters, if you have no one to
go to if you need help, or if you have no friends or acquaintances to do things with.
(ii) If your network is adequate and of a good size, appreciate it and try to keep it strong.
In other words, don't let disagreements cause separations between you and the people
in your network. Frequent communication helps maintain friendships.

The four sessions this month will focus on how to enlarge and maintain your social support
network

PART 4: Keeping your social support network healthy

How can we maintain a healthy social support network?

Ask this open question to promote a discussion. Some examples can be: spending time with
people, showing people how you feel about them, being assertive, helping your friends and
family, working with negative thoughts that can be harmful to relationships

 Contact with others is very important, be it by phone or in person (talk, listen, go out, do
activities together).
 Some thoughts that can block this. For example:
- “They haven’t called me; it looks like they don’t care about me.”
- “I am not going to be the one to make the first move.”
- “They don’t like me.”
- “No one in my family understands me.”
- “My mom never listens.”
- “I can never forgive him/her.”

Meeting people

Ask the following open questions, promoting a discussion.

How do you make friends? What have your friends done to get closer to you? What does
a friendly or sociable person do?

The easiest way to meet other people is by doing an activity you like in the company of others.

When you enjoy something, it’s more likely that you’ll be in a good mood and that way it’ll be
easier to be sociable and friendly.

Even if you don’t find anyone in particular that you want to get to know better, you’ll be doing
something you enjoy and you won’t feel it was a waste of your time.

Since the main focus will be on the activity and not on meeting other people, it’s more likely that
you’ll feel less pressure than you’d feel if the only purpose was meeting new people. If there
were people you want to get to know better, it’s more probable that they’ll have things in
common with you.

Exercise: How and where can you meet people?

Promote a discussion or list places and ways you can meet new people and make friends.
Being assertive

What’s the difference between being passive, assertive and aggressive?

There are three ways we can act and communicate with others:

 Being passive means not expressing your feelings to others because you think they’ll be
annoyed, feel bad or because they are superior to you. You might feel you have to
“swallow” your feelings or you’ll be rejected.
 Being aggressive jeans treating others with hostility, anger and being insensitive to other
people’s needs and feelings because you feel yours are more important.
 Being assertive means being able to say positive and negative things without feeling bad.
You don’t always have to say what you think, but it’s important to feel that you have that
option. You can say things in a nice way that can help resolve situations and maintain the
relationship healthy.

PART 5: Closure and discussing homework

Ask the participant if he/she has any questions or points that they need clarification.

Homework

1. Daily Mood Scale

2. Use the Weekly Activities Schedule to write down the types of contacts you had with
people each day. Write a plus sign (+) if they were positive and a minus sign (-) if they
were negative
SESSION 10

HOW YOUR RELATIONSHIPS AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 9 (promote client
participation in this review):

 Daily Mood Scale

 Weekly Activities Schedule – Contacts with others
 Social support network and how to maintain and strengthen it

Introduce the purpose of the session.

In this session we are going to explore how your thoughts, actions and feelings influence
your relationships and how your relationships affect these three areas. Before talking
about how these three areas are affected by your relationships, it’s important to evaluate
first how they are when you are alone.

When you’re alone, what are your thoughts like?

When you’re alone, what are your actions like?

When you’re alone, what are your feelings like?

PART 2: Your thoughts

What thoughts do you have when you are with other people?

 Thoughts that prevent you from making friends.

Ask for examples.
Some examples: “Will they like me? I don’t like him/her, What if they reject or
ignore me? I don’t know what to say.”
 Thoughts that help you feel comfortable with other people.
Ask for examples.
One way to feel better is to shift the focus of attention from you to the other person and think
about how he/she feels. Think about how you feel when you’re going to meet new people. Other
people probably feel the same way.

Some examples: “I’ve never talked to him/her so I don’t know what he/she is like. I’ve
got nothing to lose by trying. Maybe he/she will enjoy talking to me.”

PART 3: Your expectations

What can you expect from other people?

What can others expect from you?

You can explain this concept using parent-child relationships and/or friendships. You can ask
the adolescent to share experiences that will help in the discussion.

 If your expectations are too high, you’ll be disappointed and maybe you’ll become
frustrated.
 If your expectations are too low, you won’t expect anything from the relationship and
you might lose the chance to develop good relationships. Also, if you expect little from
people, you’re not giving them the chance to show you what they can really offer.

PART 4: Your actions/behavior

How do you approach others?

What impression do you think you give off to others?

Present the following information and discuss by relating to the client’s experience.

 Your face: Do you smile often? Do you make eye contact?

 Your body: Do you look tired or worn out?
 Your appearance: Is it appropriate for the time and place?
 Your speech: Is it too slow or too soft to hear you? Do you speak with anger or irritation?
Do you raise your voice?
 Your conversation: Do you show interest in what other people say, or do you ignore or
criticize them?
  Your attitude: Do you complain a lot? Are you in a bad mood? Do you offend others with
your attitude?

PART 5: Your feelings

How do your feelings affect your relationships?

Different emotions can influence the way you relate to others. There are times when we
experience negative emotions (i.e. anger, sadness) that have nothing to do with the person we’re
relating to. However, we let these feelings affect the relationship. This is way it’s important to be
able to identify and manage our feelings in a healthy way.

What feelings do you have when you’re with others?

Identifying our feelings when we’re with other people can help us evaluate the quality of our
relationship.

For this, it’s important to:

- Recognize how your feel and why you’re feeling that way
- Communicate in an assertive or appropriate way what you feel
- Practice the difference between being passive, assertive or aggressive: Assertiveness
which is being able to share positive and negative feelings clearly and comfortably (even
if you think the other person won’t like what you’re saying). Changing your point of view
can help you to be more assertive instead of being passive. For example, if you frequently
think, "I don't want to make anyone feel bad," try to think, "Saying what I think can help
us communicate better and resolve the situation. At least I can let people know what I
think."

PART 6: Review and closure

 The purpose of examining your thoughts, actions and feelings is that you can identify
how these three areas are influencing your relationship with others, and consider what
you need to improve to have healthier relationships.
 You can change your mood if you work on improving your relationships. What areas do
you think you can improve?
  Summarize for the adolescent what you discussed in these sessions in relation to these
three areas, his/her experience and relationships.

Homework

Daily Mood Scale

SESSION 11

HOW YOUR RELATIONSHIPS AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 10 (promote

adolescent participation in this review):

 Daily Mood Scale

 Improving your relationships can help make you feel better.

PART 2: Examine the adolescent’s thoughts, feelings and actions in relation to a person with
whom he/she has identified interpersonal difficulties. Explore a problematic situation that
happened recently with that person. Use this relationship as material to work with this section

When you’re with __________________________

 What do you think?

 How do you act?
 How do you feel?

Learning to be assertive and practicing in your mind

Exercise:

Ask the client to think about a situation with a person with whom he/she has difficulty in
being assertive. Provide the following instructions:

 Image the situation as if it were a photograph.

 Imagine the action beginning as if it were a movie.
 Imagine telling that person something in an assertive way.
 Imagine the response you get from that person.

PART 3: Communication skills.

Apply the following communication skills the situation discussed in the previous exercise.

Active listening
When you are talking to someone, listen to what they are saying instead of thinking about you
are going to say back or respond. If you’re thinking about what you’re going to answer, you
might miss part of what the person is telling you. People often argue about what somebody said
without knowing if that was what the person really wanted to say or express.

To improve your active listening and communication skills:

 Repeat what the other person said in your own words so you can be sure you
understood him/her correctly. For example, “I understand that you’re
saying____________.”
 Ask the person directly what he/she meant to say. For example, What did you mean by
__________?”
 When we become mad with someone, instead of attacking them, it’s more effective to
say what you think and/or feel in relation to what they are doing, or their actions.
Instead of saying – “You (are/always/never)…” It’s better to say – “I feel ________/I
think________.” When we attack people they generally become defensive and aren’t
going to listen to what we really want to tell them.
- Examples of verbalizations where you attack the other person: “You’re unfair.”
“You never do what I want.”
- Alternatives: “When you scold me before listening to what I have to say, I feel
frustrated.” “When you say no, I feel like you don’t care about me and don’t want
me to have any fun.” “I feel that you’re not listening.”
Exercise:

Step 1: State the fact or event and what bothered you about it.

Step 2: State how you feel.

Step 3: Say what you think. “When you __________(yell at me) I feel
_______(anxious) because it makes me think______________________.” (you
don’t want to see me)

 Find the right moment to talk. The best times aren’t when the person is doing something,
or there isn’t enough time to talk or if you’re in the middle of an argument.
  Consider your non-verbal language (gestures, facial expressions, posture, etc.) Non-
verbal language is 80% of communication.
 Consider the tone of your voice
 Follow the example of assertive people you know and ask them for suggestions (i.e.,
family, friends, teachers).

PART 4: You can decide to change

Before being with other people

 Thinking differently: To change your feelings towards others, you can decide beforehand
the kind of thoughts you want to have when you’re with them.
 Acting differently: If you want to change your behavior when you’re with others, decide
beforehand how you would like to act when you are around them.

After being with other people

Learn from your experiences: think about the feelings you had while you were with them.
How did you feel when you left? Can you define what made you feel good or bad?

PART 5: Closure and discussing the homework

Ask the participant this direct question:

Do you have any questions about what we have discussed today?

Homework

1. Daily Mood Scale

2. Practice being assertive during this week. Pick a simple situation in which you can
practice.
SESSION 12

HOW YOUR RELATIONSHIPS AFFECT YOUR MOOD

PART 1: Review

Review or summarize briefly the following concepts discussed in Session 11 (promote client
participation in this review):

 Daily Mood Scale

 Assertiveness exercise
 Up until now, you have learned to think act and feel healthier. Sometimes in our lives
things can happen that overwhelm us. Sometimes depression starts at these times. If you
use the strategies you’ve learned here, it’s less likely that you become depressed again or
that you remain depressed for a long time.

PART 2: Contact with others is important for you mood because they can___________:

 Share pleasant experiences with you

 Help you reach your goals
 Provide you with company and a sense of security
 Provide you with valuable information about yourself, your strengths and areas to
improve

PART 3: It’s healthy to maintain relationships with others. However, relationships need constant
attention. Nothing that is alive is static, it’s always changing. When relationships don’t work out,
it doesn’t necessarily mean that something is wrong with you or with the other person. It’s
helpful to consider the following questions:

 Do you both want the same thing from the relationship?

 Do you have similar interests?
 Are you capable of telling each other what you think and feel freely?
 Do you have to make big changes or can you be yourself in the relationship?
 Is this relationship good for you? And for the other person?
 Is this relationship abusive?

Remember you always have the option to end a relationship that is not good for you.
PART 4: Relationships can help improve your life.

What kind of friends can help you feel good? Improve your life?

Your social environment can help you be a better person. You are a valuable person. You have
good qualities and strengths. People can help you feel like a good person, as valuable and with
good self-esteem. Pick environments where you can meet people that can help, not harm you.
You can also be a good influence on other people.

PART 5: Closure

When you finish this material for Session 12, discuss with the participant the following:

1. Tell him/her that you’re finished with the material in the manual.
2. You can generate a brief discussion about how he/she felt with the manual and during the
sessions.
3. You can also evaluate how the adolescent feels in terms of his/her depression.
4. Explain that during the last session you will be talking about how you’ve observed
him/her in therapy and how he/she felt during the process.
5. Also explain that during the final session you will be offering recommendations about
strategies to prevent relapses and to continue improving his/her mood.
CLOSING SESSION

In this feedback and closing session, meet with the client and discuss the following points with
him/her.

1. Offer the adolescent information about his/her participation and progress throughout
therapy.
2. Ask him/her for feedback about his/her experience in therapy. You can ask about what
the adolescent liked most and least, what helped the most, etc.
3. Make a plan to manage possible relapses and discuss strategies to prevent them.
4. Offer recommendations in terms of referral to other types of therapy or services if
needed.
5. Offer post-treatment recommendations.
 Make appropriate referrals (if needed).
 Offer general recommendations on:
- How to help and support the adolescent in continuing to get better
- Possible signs of relapse and steps to follow if the client suspects that he is
relapsing
6. Closure and goodbye