Cognitive Behavioral Therapy (CBT) Guide for Case Managers

CLIENT WORKBOOK

Michelle Friedman-Yakoobian Ph.D.

Jennifer Gottlieb Ph.D.
Lois Hollow ARNP, BC
Narsimha Pinninti M.D.
Corinne Cather Ph.D.

2007

© 2007, The General Hospital Corporation. Do not reproduce without

consent of authors.

CBT Client Manual 8-10-07

 Use of this Treatment Manual and Training Information

We hope that you find our treatment manual and client workbook to be helpful in your
work with your clients. Although it is acceptable to make copies of the client handouts
for use in your clinical practice, please do not reproduce this document in its entirety or
use this manual without permission from the authors. Although portions of this treatment
manual can be used on their own, we have designed this manual to be used in conjunction
with in-person staff trainings provided by the authors, in order to create a better
understanding of the CBT techniques presented. Currently, we offer three levels of
training described below. An important objective for the provision of these trainings is
for us to evaluate the manual in terms of its user-friendliness and its effectiveness in
training mental health staff and improving client care and outcomes.

Intensity of training Expected Outcome

Level A: One day training: Didactic • Gain understanding of use of Cognitive
in the morning followed by watching Model with people with severe mental
a video and exercise in afternoon. illness.

Competencies and skills formally • Learn one CBT technique.

assessed.

Level B: Training per level A • Gain more extensive knowledge of

followed by group supervision every cognitive model.
two weeks discussing individual
cases and interventions, lasting 6 • Ability to apply a variety of CBT
months. techniques in practice.

Competencies and skills formally • Improved satisfaction of clients.

assessed.
• Improved engagement of clients.
Client satisfaction and engagement
level formally assessed.

Level C: Training for two full days • Gain extensive understanding of

together or split, plus individual cognitive model.
supervision of one hour per case
manager every two weeks and group • Demonstrate proficiency in use of CBT
supervision once a month, lasting 6 – techniques with clients.
12 months. Supervision will include
discussion of video/audiotapes of • Improved satisfaction of clients.
client sessions.
• Improved client outcomes: Engagement,
Staff competencies and skills Symptoms, Functioning, Community
formally assessed. tenure, Satisfaction.

CBT Client Manual 8-10-07 ii

Client satisfaction, symptoms, and
functioning formally assessed.

We appreciate your feedback on this manual. Please feel free to contact us with any
questions or comments. To request a manual, or to inquire about our trainings, please
contact the authors below:

Narsimha Pinninti, M.D. Michelle Friedman-Yakoobian, Ph.D.

UMDNJ—School of Osteopathic Medicine Massachusetts Mental Health Center
Steininger Behavioral Care Services, Inc. Beth Israel Deaconess Medical Center
19 East Ormand Ave 180 Morton Street
Cherry Hill, NJ 08034 Jamaica Plain, MA 02130
Phone: (856) 428-1300 Phone: (617) 626-9357
Email: [Link]@[Link] Email: mfriedm3@[Link]

Lois Hollow, ARNP, BC Corinne Cather, Ph.D.

WestBridge Community Services Schizophrenia Program of the
1361 Elm St. Suite 207 Massachusetts General Hospital
Manchester, NH 03101 Freedom Trail Clinic
Phone: (603) 634-4446 25 Staniford Street
Email: lhollow@[Link] Boston, MA 02114
Phone: (617) 912-7800
Jennifer Gottlieb, Ph.D. Email: ccather@[Link]
Schizophrenia Program of the
Massachusetts General Hospital
Freedom Trail Clinic
25 Staniford Street
Boston, MA 02114
Phone: (617) 912-7833
Email: jgottlieb2@[Link]

CBT Client Manual 8-10-07 iii

 Table of Contents:

PART ONE: INTRODUCTION ………………………………………….………...1-7

IA. COGNITIVE BEHAVIORAL THERAPY……………………………………….2

Introduction Handout 1A: What is CBT and the Cognitive Model…………..2-4

IB. SETTING THERAPY GOALS….…………………………………………………5

Introduction Handout 1B: Setting Goals for CBT…………..………………..5-7

PART TWO: HANDOUTS FOR PROBLEMS 1-20………………………………….8

I. NON-ADHERENCE TO MEDICATION…………………………………………9

Handout 1:Facts About Medication…………………….……………..……...9-13

Exercise 1A: Weighing the benefits and drawbacks of medication……14

Exercise 1B: Why do some people stop taking their medicine? ………15

Exercise 1C: Medication troubleshooting……………………………16-18

II. NON-ADHERENCE TO PROGRAM OR PHYSICAN APPOINTMENTS………19

Handout 2: Understanding the “Stress-Vulnerability Model”……………..…19-22

Exercise 2A: Calm Breathing…………………………………………..23

Exercise 2B: Scheduling Pleasant and Productive Activities……...…24-26

III. ALCOHOL AND SUBSTANCE ABUSE………………………………………..27

Handout 3: Information about Drugs and Alcohol…………………………...27-30

Exercise 3A: Benefits and Drawbacks of Using Alcohol or Drugs….31-32

IV. PARANOIA AND DELUSIONS…………………………………………………33

Handout 4: Information about Psychosis: Paranoia and Delusions………….33-37

Exercise 4A: ABCD Theory of Dealing with Distressing Thoughts…38-41

V. HALLUCINATIONS……………………………………………………………..42

Handout 5: Information about Psychosis: Hallucinations……………………42-45

CBT Client Manual 8-10-07 iv

 Exercise 5A: Coping with Voices…………...……………...………..46-49

Exercise 5B: Thought Record for Hearing Voices………………..…50-51

VI. DISORGANIZED COMMUNICATION

Exercise 6A: Improving Communication with Others…………..…..52-56

VII. NEGATIVE SYMPTOMS……………………………………………………….57

Handout 7: Understanding Negative Symptoms...……………………….....57-61

VIII. ANGER AND HOSTILITY……………………………………………………..62

Handout 8: Dealing with Anger ………….………..………………………..62-64

Exercise 8A: Anger Record………………………..…...…………...65-66

IX. DEPRESSION AND SUICIDAL IDEATION…………………………………67

Handout 9: Facts about Depression…………………………………………67-69

Exercise 9A: Thought Record…………………………..……………70-71

Exercise 9B: Positive Self Talk………...……………………………72-73

Handout 10: Coping with Suicidal Thoughts……...………………………....74-75

Exercise 10A: Suicide Prevention Plan………………………………76-77

X. TRAUMA AND PAST VICTIMIZATION……... ……………………………....78

Handout 11: Facts about Traumatic Experiences…………………………….78-80

XI. CONFLICT WITH FAMILY MEMBERS………………………………………..81

Handout 12: Including Your Family in Your Mental Health Treatment….…81-84

Resources for Family Members………………...…………………………….83-84

XII. REPEATED HOSPITALIZATIONS, XIII DEALING WITH STRESSORS:

PROBLEM SOLVING…………………………………..…………………..85

Handout 13: Solving Problems and Achieving Goals………...…………….85-88

Exercise13A: Problem-Solving / Goal Setting Guide……………….89-90

CBT Client Manual 8-10-07 v

XIV. VICTIMIZATION………………………………………………………………..91

Handout 14: Facts about Exploitation and Victimization……………………91-93

Exercise 14A: Preventing Exploitation and Victimization…….....….94-95

XV. HIGH RISK BEHAVIORS……………………………………………………..96

Handout 15: Reducing Your Risk of Infectious Diseases…………….……...96-97

XVI. SEXUALLY INAPPROPRIATE BEHAVIORS, XVII. UNREALISTIC

EXPECTATIONS FOR CASE MANAGEMENT SERVICES, AND XVIII.
MISTRUST OF THE MENTAL HEALTH SYSTEM AND CASE MANAGERS…98

Handout 16: What to Expect from Your Treatment Team……………..….....98-100

Exercise 16A: Know Your Treatment Team and What They Do…101-102

XVII. PROMOTING COMMUNICATION WITH TREATMENT TEAM…………103

Handout 17: Facts about Communicating with Doctors.………………….103-106

Exercise17A: Improving Communication with your Doctors.…...107-109

XVIII. RELAPSE PREVENTION…………………………………………………...110

Handout 18: Staying Well and Reducing Relapse………………….……...110-112

Exercise 18A: Wellness/Relapse Prevention Plan…………….....113-114

PART TWO: ADDITIONAL HANDOUTS FOR MULTIPLE PROBLEMS…...115-140

Appendix Handout 1: Facts about Anxiety……………………...………..116-120

Appendix Exercise 1: ABCD Theory of Feeling Nervous..………121-125

Exercise 2: Making a Decision: Pro/Cons Matrix…………….....……......126-128

Exercise 3: Using a Coping Card ..……………………….……………….129-130

Exercise 4: General Thought Record Form………………………………131-134

Exercise 5: Mark’s Story about Medication and Day Treatment……..……135

Exercise 6: Suzanne’s Story about her Symptoms….…………………...136-137

Exercise 7: Emma’s Experience with Distressing Thoughts ……………....138

CBT Client Manual 8-10-07 vi

 Part 1: Introduction

CBT Client Manual 8-10-07

 Introduction Handout 1A: What is CBT and the Cognitive Model?

CBT, which stands for “Cognitive Behavioral Therapy,” is a type of counseling that
helps people better understand their own thinking, feelings, and actions. Cognitive is
another word for thinking, or the thoughts or mental images we have. Behavioral refers
to our actions, what we do. CBT was originally developed to treat depression, but it is
now used to treat a variety of other conditions, including schizophrenia, schizoaffective
disorder, and bipolar disorder. CBT is also used to help people cope with a variety of
medical conditions like breast cancer and fibromyalgia.

Once people understand how they think, how they feel, and what they do, CBT can help
people learn to recognize how some of the ways they think and things that they do may
be making life more difficult or getting in the way of their goals. CBT can help a person
to learn strategies to improve day to day living. For example, CBT can help you work on
feeling more comfortable interacting with others, coping with feeling depressed or
anxious or worried, getting out and doing more activities you used to like, and better
dealing with stress or other symptoms.

CBT can help people understand how they think, feel, and what they do.
CBT can also help people improve day to day living, and cope with difficult emotions
and other symptoms.

An important part of CBT is that it highlights that our thinking, our feelings, and our
actions are ALL related to each other. This means that the way we think about a certain
situation has a big effect on how we feel, which then has a big effect on what we choose
to do or not do about that situation. This idea, called the Cognitive Model, looks like
this:

Thoughts

Behaviors Feelings

CBT Client Manual 8-10-07 2

Thinking about things differently can have a huge impact on your feelings and actions.
Here’s an example:

Situation: It is raining for the 7th day in a row.

Thought you have: “This rain is terrible, it is ruining everything.”
Feeling(s) you have: frustrated, sad, hopeless
What you do: stay home from day treatment and miss the group outing

Now here is another example with the same situation but the thought you have about the
situation is different:

Situation: It is raining for the 7th day in a row.

Thought you have: “The rain is really good for the plants and flowers, even though I do
not like it very much.”
Feeling(s) you have: Acceptance and hopefulness
What you do: go about your daily activities, and even admire the flowers on your way

Notice that although it is raining in both scenarios, the way the person thinks about the
rain very much influences how they feel (sad in the first example versus accepting and
hopeful in the second) and THEN also makes a difference in how they end up spending
their day (avoiding positive activities versus engaging in their day).

How does CBT work?

CBT is probably somewhat different than other types of therapy you may have
participated in before. Here’s how:

• CBT is a fairly short-term type of therapy

• CBT focuses more on current problems and stress and less on things that
happened in your childhood or in the distant past.
• You and the therapist work as a team, where the therapist is like a coach, listening
to your problems, giving you feedback, helping you learn about your thinking
patterns. What you want to get out of CBT is discussed a great deal and you and
the therapist make these kinds of decisions together.
• A big goal of CBT is to have you be able to eventually become your own coach,
based on everything you have learned and tried out during the therapy.

What to expect with CBT:

• You and the therapist discuss your goals (like wanting to get a part time job) and
what kinds of things get in the way of your goals (like having paranoid thoughts
about the employer, the voices telling you not to fill out the application).
• CBT involves trying things out that are new, such as trying to think about some of
your beliefs differently, doing a new activity, or handling stress in a way that is
different from how you may have handled it in the past.

CBT Client Manual 8-10-07 3

 • CBT almost always involves trying things out on your own between your therapy
meetings. This is important because this helps you get closer to your goals. Also,
the more you practice, the more comfortable new things get.
• You and your therapist will be spending a lot of time checking in with each other.
It will be important to share how you think the CBT is going. The two of you can
work on addressing problems as they come up.

Research studies have shown that CBT is a therapy that can be very effective.
It can help you make the changes in your everyday life that you want to make!

CBT Client Manual 8-10-07 4

 Introduction Handout 1B: Setting Goals for CBT

Your CBT therapist will help you to set some goals for your work together by doing a
“needs assessment” with you. This involves your therapist asking you a number of
questions about your mood, symptoms you are experiencing or have recently
experienced, stressful situations that you are dealing with, and your wishes and goals for
the future. You and your therapist will then decide on what goals you want to work on
together.

The following list of common problems that many people work on in CBT. These can
help you start thinking about what you would like to work on with your therapist. On the
list below, please circle those that sound like a good fit for you. You can also fill in some
problems or goals that you would like to work on at the end of the list.

Potential Goal Targets for CBT:

(adapted from Cather et al., 2003, fCBT manual)

I don’t have enough friends

I spend time with people who are not good for me.
I don’t know what to do with my free time
I don’t have enough hobbies
I don’t have a good job
I don’t socialize enough
I stay home too much
I am bored a lot
I don’t like where I live or my living situation
I have trouble interviewing for jobs
I have trouble starting and keeping up conversations
I don’t have a boyfriend/ girlfriend
I would like to go back to school but don’t know how to get started on it
I am nervous around other people
I am not very independent
I don’t do any of my own food or clothes shopping
I don’t take good care of myself
I am worried about my health
I have bad habits that I would like to change (e.g., smoking, drinking alcohol)
I don’t spend enough time with my family

CBT Client Manual 8-10-07 5

I would like more control over my finances
I get into frequent arguments with my family
I feel uncomfortable taking public transportation
I hear voices that bother me
Other _______________________________________
Other________________________________________

Setting personal goals can sometimes be overwhelming. One thing that can help is to
look at goals based on their time frame: Short-term goals are for the next few weeks to 6
months, medium-term goals are between 6 months to two years, and long-term goals are
beyond two years. For example, someone who has not worked in 10 years might choose
“get back to working in a paid job” as a medium or long-term goal and “join an
employment-skills program” as a short-term goal.

After you and your therapist have completed the Needs Assessment and you have
discussed the potential goals that you circled above, your therapist can help you decide
which short, medium, and long-term goals to work on first.

Goals to Work on First:

The two medium or long-term goals that I want to start working on first are:

1) _____________________________________________________________

2) _____________________________________________________________

Two short-term goals that I want to start working on are:

1) _____________________________________________________________

2) _____________________________________________________________

Now that you have identified which goals to work on, it can be helpful to consider the
advantages and disadvantages of seriously working on these goals. A useful tool for
making a decision is called the “Payoff Matrix.” With your therapist’s help, please
complete the Payoff Matrix by filling in the possible advantages and disadvantages of
working on your goals.

CBT Client Manual 8-10-07 6

Advantages of working on: Disadvantages of working on:

______________________________(goal) ______________________________(goal)

Advantages of not working on: Disadvantages of not working on:

______________________________(goal) ______________________________(goal)

CBT Client Manual 8-10-07 7

 Part II: Handouts for Problems 1-20

CBT Client Manual 8-10-07 8

 Information Handout 1: Facts about Medication

Most people who are experiencing psychotic symptoms (eg: hearing voices, seeing
things, having beliefs that are not based on reality) are prescribed one or more
medications called antipsychotics. These medicines help reduce psychotic symptoms and
decrease the likelihood of relapse. They may also help with problems associated with
psychosis like anxiety, depression, concentration, and sleep problems. There are two
main types of antipsychotics: older (first generation) and newer (second generation)
antipsychotics.

Sometimes, antipsychotics are not effective and additional medications are prescribed to
control psychotic symptoms or to help with depression, anxiety, or mood swings. These
medicines are called antidepressants, mood stabilizers or anti-anxiety medications. Many
people find that taking these medications provides a great deal of relief from the
symptoms and helps them function better. Below are some examples of each type of
medication:

Lists of commonly used medications:

Antipsychotics: Antidepressants: Mood Stabilizers: Anti-anxiety

Clozaril Prozac Lithium medications:
Zyprexa Paxil Depakote Ativan
Risperdal Zoloft Tegretol Xanax
Abilify Lexapro Neurontin Klonopin
Seroquel Wellbutrin Lamictal Valium
Geodon Celexa (Some antipsychotics also
Haldol (older) can work as mood
Prolixin (older) stabilizers)
Thorazine
(older)

Common medications for psychotic symptoms are antipsychotics.

Antidepressants and mood stabilizers are also used to help.
Taking medications can provide a lot of relief from distressing symptoms.

How can the medicines be taken?

Most of the time, the medications are taken by mouth in a pill or liquid form. Sometimes,
though, they can be injected into your body. These injectable forms generally last longer
than the pill form. Injections are given every two to four weeks, depending on the
medication strength and dose that is needed to control your symptoms.

How do these medications work?

CBT Client Manual 8-10-07 9

These medications work by affecting normal chemicals in the brain. Most simply put,
psychiatric symptoms are caused by having too little or too much of certain chemicals in
the brain. These chemicals are also called neurotransmitters (e.g., dopamine). These
chemicals help us to perform different mental functions like thinking clearly,
distinguishing reality from unreality, feeling motivated to do things, etc. The medication
affects specific neurotransmitters, such as dopamine, serotonin, and/or norepinephrine.
The effect of medication on these brain chemicals is what decreases symptoms like
hallucinations, delusions, disorganized thinking, depression, and anxiety.

Medications work by affecting brain chemicals called neurotransmitters.

Why should I take medications?

• Medications can reduce the severity of distressing symptoms that you have.
• Medications can help you think more clearly and feel better.
• Medications lower the chances of relapses (symptoms getting worse)
• Medications can help keep you out of the hospital.
• Most people who take medication find that it increases their chances of
accomplishing their life goals.

What’s the downside of taking medication?

Side effects:

Even though the goal of medication is to help people feel better, some people experience
side effects from taking these medications. Side effects are unwanted effects of the drug.
Below are some examples of side effects that some people experience. Check off
whether or not you have experienced any of these side effects when taking medications:

Tiredness † Yes † No

Stiff muscles † Yes † No

Dry mouth † Yes † No

Having trouble sitting still † Yes † No

Dizziness † Yes † No

Increased appetite or weight gain † Yes † No

Reduced appetite or weight loss † Yes † No

CBT Client Manual 8-10-07 10

 Low sexual interest or sexual † Yes † No
dysfunction
Twitches or abnormal movements † Yes † No

Nausea, diarrhea, or constipation † Yes † No

Important things to remember about side effects:

• Side effects do not happen to most people who take medication.

• All of them do not usually happen to one person.
• It is impossible for a doctor to predict which medications are going to give which
side effects to certain individuals. It is important that you and your doctor talk
about the possible side effects of a medication before you start taking it.
• Your doctor can change your medication to one that is less likely to cause side
effects or can recommend or prescribe something to reduce the side effect.
Someone who is very concerned about weight gain, for example, might prefer a
medication that is less likely to cause weight gain.
• Certain side effects can get better over time, so even if you experience difficulties
when you first start taking the medication, they might go away after taking the
medication for a few days or weeks.

Medications can sometimes cause undesirable side effects.

Some side effects go away after you have taken the medication for a little
while or you can take a side effect medication.

Deciding which medication to take should be based on a conversation with

your doctor.

Other downsides of taking medication:

• Some people have distressing thoughts about medication: For example “Taking
medication means “I am weak,” “I am not in control,” “I will become dependent
on the medications” or “I am sick.”
• Some people feel annoyed about taking medications because their family
members are always asking whether or not they took their medication and feel as
if they are being treating like a child.
• If you are experiencing any of these thoughts and feelings about taking
medications, it can be helpful to talk about them with your doctor, therapist, or
case manager. It can also be helpful to talk to other clients who are doing well.

What can get in the way of taking my medication every day?

CBT Client Manual 8-10-07 11

Taking medication every day is not as easy as it seems. It can be difficult to remember to
take them, it can be easy to run out of pills if you forget to plan ahead, and it can seem
like it is not worth spending money on prescriptions. The side effects can sometimes feel
really uncomfortable too. Below is a list of some things that can get in the way of taking
medication every day and some ideas to help. Check off any that have affected you
either recently or in the past:
Barrier to Taking Experienced What can help:
Medication this?
I have forgotten to † Yes † No ƒ Use a daily medication organizer box labeled
take them. with the days of the week.
ƒ Link medication-taking with an activity that
you do every day (e.g., brushing your teeth,
drinking you morning coffee).
ƒ Talk with your doctor about what to do if you
realize that you have forgotten to take a dose of
your medication.
I ran out of my † Yes † No ƒ Write a note on your medication bottle to
medication before I remind you to call for a refill when you have
refilled my less than 5 days of medication left.
prescription. ƒ Ask your case manager or a family member to
help remind you to re-order your prescriptions.
o Call your pharmacy right away to re-
order the medication.
o Call your doctor or clinic and ask if they
might be able to provide you with a
sample of medication to get you by until
your prescription is filled.
I got confused about † Yes † No ƒ Ask your doctor to write down your medication
what medications I instructions
was supposed to take ƒ Use a daily medication organizer box labeled
and how much. with the days of the week. You can fill it up
once a week and then you just need to
remember to take the pills that are in the box for
that day.
It did not seem † Yes † No ƒ Discuss your feelings with your doctor
worth it to spend my ƒ Consider the advantages and disadvantages of
money on taking medication
prescriptions. ƒ Talk with your case manager to see if there are
some options for helping to fit money for
prescriptions into your budget.
I stopped taking my † Yes † No ƒ Discuss the side effects with your doctor.
medication because I He/she may be able to help.
did not like the side
effects.

CBT Client Manual 8-10-07 12

I stopped taking my † Yes † No ƒ Keep in mind that medications are given to
medication because I control symptoms but also to prevent symptoms
felt better and did from coming back For example, people with
not think I needed it. high blood pressure are given medications even
when their blood pressure is normal to prevent
it from getting high.
ƒ Discuss the potential advantages and risks of
stopping medication with your doctor.
ƒ Review the times you stopped the medicine in
the past. Were things better for you when you
were off or on the medicine?
ƒ Talk to a trusted family member or friend and
ask them whether they think you seem to be
better off when you are on or off the medicine.

Taking medications can be a challenge sometimes.

Talking it over with your doctor and being honest about your experience can be really
helpful.

It can be unhelpful and even dangerous to stop taking your medications on your own.

CBT Client Manual 8-10-07 13

 Exercise 1A: Weighing the Benefits and Drawbacks of Taking Medication
Many people who take psychiatric medications have a lot of thoughts about the benefits
and drawbacks of taking medication. It can be helpful to discuss both your positive and
negative thoughts about medication with your case manager. When thinking about the
benefits and drawbacks of medication, consider how medication impacts: a) Your
thoughts, b) Your feelings, c) Your sleep patterns, d) How you feel and act around other
people, and e) Your ability to get things done. Try to think of both short term and long-
term effects.

Benefits of taking my medication: Drawbacks of taking my medication:

Short-term________________________ Short-term________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

Long-Term________________________ Long-Term________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

1. Ask yourself an important question: Does taking medication help you to get further
in your life and accomplish your life goals?
_______________________________________________________________________

2. Now ask a trusted relative or friend who cares about you and wants what is best for
you: Do you think I function better when I am on medicine or off it?
________________________________________________________________________

3. Do the benefits outweigh the drawbacks or do the drawbacks outweigh the benefits?
________________________________________________________________________

4. Some things that I can do to help minimize the drawbacks of taking medication are:
________________________________________________________________________
________________________________________________________________________

CBT Client Manual 8-10-07 14

 Exercise 1B: Why do some people stop taking their medicine?

Taking medications exactly as they are prescribed is one of the most important things a
person can do to help them recover from mental illness. However, many people stop
taking their medicines against the advice of their doctor, even though medications are the
single most effective form of treatment currently available. Consider the following
scenario:
After Antonio came home from the hospital, he was feeling much better—more
like his old self. He no longer heard angry voices yelling at him, and he was able
to concentrate and think more clearly. Antonio’s doctor told him his symptoms
were caused by schizophrenia—a brain illness, and that he would need to take
medication for a long time—possibly the rest of his life. However, when Antonio
began to feel better and his symptoms went away, he wondered if maybe the
trouble he was having before was just caused by stress. He began to think that
maybe he didn’t need to take the medications anymore. Besides, it was a pain
remembering to take the medications and they often left him feeling sleepy.

What are some reasons that Antonio wanted to stop taking his medication?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

What might be some drawbacks of stopping the medication for Antonio?

________________________________________________________________________

________________________________________________________________________

What could Antonio do instead of stopping his medication on his own?

________________________________________________________________________

________________________________________________________________________

Have you ever stopped (or thought about stopping) your medicine or changed the dose
without telling your doctor? What were some of your reasons for doing this?

________________________________________________________________________

________________________________________________________________________

CBT Client Manual 8-10-07 15

 Exercise 1C: Medication Troubleshooting Plan

Taking medication every day is not as easy as it seems. It can be difficult to remember to
take them, it can be easy to run out of pills if you forget to plan ahead, and it can seem
like it is not worth spending money on prescriptions. The side effects can sometimes feel
really uncomfortable too. It can be really helpful to talk with your case manager about
things that have gotten in the way of taking medications in the past, and what you can do
to overcome or prevent barriers to taking your medications in the future. Below is a list
of some possible barriers to taking medications. Please indicate whether or not you have
experienced any of these and fill in examples of any barriers that you encountered that
are not on the list:

Barrier to Taking Medication Experienced this?

I have forgotten to take them. † Yes † No

I ran out of my medication before I refilled my † Yes † No

prescription.
I got confused about what medications I was † Yes † No
supposed to take and how much.
It did not seem worth it to spend my money on † Yes † No
prescriptions.
I stopped taking my medication because I did not † Yes † No
like the side effects.
I stopped taking my medication because I felt † Yes † No
better and did not think I needed it.
Other: † Yes † No
______________________________________

______________________________________

Other: † Yes † No
______________________________________

______________________________________

Action Plan:

Now that you have identified potential barriers to taking your medications as prescribed,
you and your case manager can come up with an action plan (by making a Coping Card)
and avoid these barriers, dealing with them if they occur. Below is an example of how to
make a coping card and a blank where you will practice by making your own:

CBT Client Manual 8-10-07 16

Barrier: I sometimes forget to take my medication.
What I can do to prevent it:
1. Always take my medication right before I brush my teeth in the morning (I never
forget to brush my teeth so this is a good activity with which to link taking my
medication)
2. Keep my medication organized in a daily box labeled with days of the week (this
helps me remember how much to take and it is easy to check whether or not I took it
today)
3. Keep my medication right next to my toothbrush (this way I will see it whenever I
brush my teeth so it will help me remember to take it)
What I can do if this barrier occurs:

1. Talk to my doctor about what I should do when I forget.

2. For my prescriptions, my doctor has recommended the following:
ƒ Take my medication as soon as I remember if it is still the same day.
ƒ If I do not remember until the next day, I will just take the next day’s medication.
(This is what my doctor recommended).
ƒ If I start to experience unpleasant symptoms after missing a dose of medication, call
my doctor to let him/her know and get advice for what to do.

Below, fill in your own action plans for dealing with a barrier to taking your medications.

Barrier #1: __________________________________________

What I can do to prevent it:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

What I can do if this barrier occurs:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

CBT Client Manual 8-10-07 17

Barrier #2: __________________________________________

What I can do to prevent it:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

What I can do if this barrier occurs:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

Barrier #3: __________________________________________

What I can do to prevent it:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

What I can do if this barrier occurs:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

CBT Client Manual 8-10-07 18

 Information Handout 2:
Understanding the “Stress-Vulnerability Model”of Psychosis

Usually, symptoms of illnesses tend to fluctuate, or go up and down over time. This
means that there are periods of time where symptoms are more severe, and times when
they are less severe. For example, people with asthma sometimes find that their
symptoms tend to be worse in the summer and better in the winter. Someone with a bad
back may experience more pain when it is raining and less in dry weather. The same is
true for people who have mental illnesses. There are times in life when the symptoms
seem really distressing, and other times when they may not be as bad. This “up and
down” is related to something called the “stress-vulnerability model.” The stress-
vulnerability model helps explain how different factors affect the development and the
course of mental illness.

What does “Stress-Vulnerability” mean?

“Vulnerability” refers to the degree to which a particular individual is susceptible to a

particular illness. People can have a vulnerability to physical problems like diabetes or to
certain types of psychiatric disorders, like depression or schizophrenia.

It is very important to understand and recognize that everyone has some degree of
vulnerability to various physical or psychiatric illnesses. For example, the chance of
anyone developing schizophrenia is 1 in 100. The vulnerability is higher if someone has a
family member with the illness.

Biological Vulnerability

Biological Vulnerability means that the vulnerability to the illness comes from a
combination of genetic (genes from your parents and family members that get passed
down to you), physical (like complications during the mother’s pregnancy), and
environmental (like the time of year of one’s birth) factors.

Symptoms of mental illness fluctuate over time.

Everyone has some type of vulnerability for a physical or mental illness.

People can have vulnerability to have certain types of psychiatric disorders

because it can run in their genes.

Stress

“Stress” is a pretty common word in everyone’s life, and in this case it refers to
something in your environment that is new or a change that forces a person to adjust or
adapt.

CBT Client Manual 8-10-07 19

Here are some examples of things in life that can cause stress (there are many others):

In your relationships with others:

• Not getting along with family or friends
• Living with people who are critical or unkind

In your health care or treatment:

• Having a medication change
• Starting to work with a new staff member, participating in a new therapy group.

In your day to day living:

• Moving to a new apartment
• Poverty; having to pay lots of bills

When someone has biological vulnerability to a mental illness, the mental illness may
develop on its own or may develop when something causes stress in life. Stress can also
make symptoms get worse over time or can cause a relapse. It looks something like this:

Biological Stress
vulnerability +

Development of mental illness

or
Increased symptoms and
Relapse

Can you do something to reduce your changes of developing illness or having a

relapse?

Some things that affect your likelihood of developing illness are not under your control
(for example, you can’t change your genes). However, there are some things that you
can do to help reduce your biological vulnerability and stress level (and this can help
reduce your chances of developing illness or having a relapse).

CBT Client Manual 8-10-07 20

Factors that affect biological vulnerability:

1. Medications: Taking your medication as prescribed helps prevent relapses and

works in your body to make the relapses less severe.

2. Drugs and Alcohol: Do not use alcohol or drugs because they can directly work in
your body to make you more vulnerable to symptoms and can make your medications
not work as well.

Taking medications decreases your biological vulnerability.

Using alcohol and drugs increases your biological vulnerability.

Factors that affect stress:

1. Using positive coping skills

Examples:

1. Relaxation techniques like deep breathing (See Client Exercise 2A CALM

breathing)
2. Using problem-solving skills to help figure out the best possible solution to a
problem (see Information Handout 12 and Exercise 12A for more information
on Problem Solving).
3. Using positive self-talk by saying to yourself, “You can get through this” or
“You are trying really hard, that’s important.” (See Client Exercise 9B,
“Positive Self-talk”)
4. Rewarding yourself for handling stressful things well

2. Using social support

Examples:

1. Talking to a friend or family member

2. Talking or spending time with peer.
3. Seeing your Case Manager more often
4. Seeing your Clergyperson
5. Participate in a support group at a day treatment program.

3. Do meaningful activities and keep a weekly schedule

Examples:

1. Go to day treatment and keep your appointments

CBT Client Manual 8-10-07 21

 2. Do volunteer work
3. Spend time with friends or family with whom you get along well
4. Join a peer support group
5. Exercise
6. Read
7. Take some classes or enroll in school
8. Do artwork

It’smore
For important to remember
information that although
on Medication youplease
adherence, can’tsee
always prevent
Handout stressful
X, “Facts events
about
from happening, you can work on how to react better
Medication” and Handout Y, “Medication Adherence Exercise.” to those events so that you
feel better and reduce the effect of stress.

For more strategies for coping with stress, please see Exercise 12A, “Problem Solving
Exercise.”

For more strategies for preventing an increase in symptoms or a relapse, please see
Information Handout 19 and Exercise 19A, “Creating a Personalized Relapse Plan.”

CBT Client Manual 8-10-07 22

 EXERCISE 2A: Calm Breathing

Learning to be in touch with your breathing can help make you relax and feel CALM.
Practice this a few times with your case manager and then use this CALM Breathing to
calm yourself whenever you need to. Here are the steps to CALM breathing:

• Inhale
o Inhale slowly and deeply, filling your chest with air, counting four
seconds to yourself 'One and two and three and four'. The count will give
you an easy, even pace. Breathe as fully as you can without discomfort.
Imagine your chest slowly filling with air, feeling you chest muscles
lifting.
• Hold your breath
o When you have inhaled fully, hold your breath for a few seconds if you
can. This should be just a comfortable pause.
• Exhale
o Exhale slowly – repeating the word C-A-L-M to yourself. Let the air out
through your mouth or nose (whatever is most comfortable) remembering
to say C-A-L-M slowly to yourself. Let out as much air as you can, down
to the lower part of the lungs. Feel yourself relaxing as you do. Feel your
shoulders and chest letting go. As you exhale, think of the tension flowing
out of you and think of yourself being CALM.
o Do not worry if you do not do this perfectly. It may seem a bit difficult to
stay with at first, but just keep going and practice. The important thing to
remember is to go slow to relax your breathing rate.
o Repeat for ten cycles if you can. Repeat CALM to yourself as your exhale
slowly and notice how you feel after the exercise. Discuss how you feel
with your case manager.
o You may feel a CALM feeling like warmth radiating from your chest
throughout your body. This is a relaxed feeling to strive for.

CBT Client Manual 8-10-07 23

 Exercise 2B: Scheduling Pleasant and Productive Activities:

Even though people sometimes think that cutting down on activities is a way to decrease
stress and feel better, doing too few activities can actually make stress and depression
worse. This is because doing too little can lead to boredom, which is a major cause of
stress and depression. One of the best ways to combat depression is to increase
participation in activities that are pleasant and productive. Pleasant activities are those
that you currently enjoy or have enjoyed in the past. Productive activities are those that
make you feel like you have accomplished something meaningful. Examples of
productive activities can include learning a new skill, exercising, or helping a friend.
Some activities are both pleasant and productive. For example, you might join a yoga
class and find that you enjoy it and also feel proud of yourself for exercising!

What are some activities you currently do or have done in the past that are pleasant or
enjoyable (e.g., going for a walk, watching a movie, cooking dinner with a friend)?

1. _______________________________________________

2. _______________________________________________

3. _______________________________________________

What are some activities you currently do or have done in the past that are productive
(e.g., doing a household chore, volunteering, helping a family member)?

1. _______________________________________________

2. _______________________________________________

3. _______________________________________________

If you have been feeling depressed or unmotivated for a while, you might find that it has
been a long time since you have done things that are pleasant or productive. This is
because many people react to stress or depression by cutting back on pleasant and
productive activities. For example, a person might stay home rather than attending a peer
support group because he feels stressed and tired and does not “feel up to it.” However,
research shows that cutting back on activities and isolating from other people can make
stress and depression worse. This is because activities provide pleasure, a sense of
connection with the world and others, improve confidence, and give life a sense of
meaning and purpose. A starting point might be to practice doing something pleasant or
productive every day of the week.
Boredom can be a cause for stress and depression.
One strategy for alleviating stress and depression is to practice doing
something pleasant or productive every day.

CBT Client Manual 8-10-07 24

 Pleasant and/or Productive Activities

Below is a list of some pleasant and productive activities. Put a check by those that you
currently do and star those that you do not currently do, but would like to try.

1. Individual Activities (At Home)* 2. Individual Activities (Outside Home)*

Soak in the tub Go to a movie
Read magazines or newspapers Go for a walk
Listen to music Sit in the sun
Think about past trips Go to a pet store and look for the pets
Straighten up my room Go swimming
Cook Go to the beach
Repair something that needs fixing Fly a kite
Have a quiet evening Drive
Take care of my plants Garden
Play with a pet Go to the beauty parlor/barbershop
Doodle Go to a play or concert
Exercise (e.g., run in place, do push-ups) Walk in the woods or on the beach
Think about some things to buy Buy or borrow a book
Sing around the house Buy a special coffee
Paint Get a massage
Play a musical instrument Visit a museum
Make a gift for someone
Watch a funny movie 3. Activities with Others (At home)
Sew Talk with family
Daydream Play cards or another game
Make lists Invite a friend to watch a video with you
Take pictures Bake sweets to share with a friend or relative
Write in a diary Call a friend
Dance
Meditate 4. Activities With Others (Outside home)
Do a crossword puzzle or su doku Go to a support group
Surf the internet Practice religion
Do yoga Have lunch with a friend
Do a jigsaw puzzle Go on a date
Play a video game Go camping
Make a “to-do” list Play a sport
Write a letter or send an email Participate in a club
* Many of the individual activities can also be done together with a friend or family member

Two pleasant and/or productive activities that I will try in the next week are:

1. _______________________________________________

2. _______________________________________________

CBT Client Manual 8-10-07 25

 Daily Schedule

One way to practice adding pleasant and productive activities into your daily life is to
plan a daily schedule that includes some pleasant and productive activities. Below, fill
out a schedule for your week that includes both things you have to do as well as some
pleasant or meaningful activities. Be sure not to put too many things on your schedule so
that you can fit everything in. As you go about your day, keep track of your actual
activities and rate (on a 1-10 scale, 10 being the best) how pleasant or productive the
activity was for you. Try doing this schedule for four weeks and add a new activity each
week. You can make copies of this schedule or use the weekly schedule form instead.

Time Planned Activity Actual Activity How it felt

7-8 AM Pleasant 0-10 _____
Productive 0-10 _____
8-9 AM Pleasant 0-10 _____
Productive 0-10 _____
9-10 AM Pleasant 0-10 _____
Productive 0-10 _____
10-11 AM Pleasant 0-10 _____
Productive 0-10 _____
11-12 Noon Pleasant 0-10 _____
Productive 0-10 _____
12-1 PM Pleasant 0-10 _____
Productive 0-10 _____
1-2 PM Pleasant 0-10 _____
Productive 0-10 _____
2-3 PM Pleasant 0-10 _____
Productive 0-10 _____
3-4 PM Pleasant 0-10 _____
Productive 0-10 _____
4-5 PM Pleasant 0-10 _____
Productive 0-10 _____
5-6 PM Pleasant 0-10 _____
Productive 0-10 _____
6-7 PM Pleasant 0-10 _____
Productive 0-10 _____
7-8 PM Pleasant 0-10 _____
Productive 0-10 _____
8-9 PM Pleasant 0-10 _____
Productive 0-10 _____
9-10 PM Pleasant 0-10 _____
Productive 0-10 _____

CBT Client Manual 8-10-07 26

 Information Handout 3: Information about Drugs and Alcohol

Alcohol and some drugs are also known as psychoactive substances because they can
change the way that a person perceives the world, thinks and feels, and what they do.
Some common psychoactive substances are alcohol, marijuana, cocaine, and
methamphetamines. Because psychoactive substances are addictive, many people have
struggled with not being able to stop using these substances once they have started.

Psychoactive substances are drugs that affect the mind.

The most commonly used substances are alcohol,

marijuana, cocaine, and methamphetamines.

Why do people use alcohol or drugs?

You or someone you know may have used drugs or alcohol for one or more of these
reasons (Check off below which of the following reasons you or someone you know has
used substances):

___ To feel better socializing

___ To feel less anxious around others
___ As a way to spend time with others
___ To feel accepted by others as “normal”
___ Due to peer pressure

___ As self-medication (reducing the unpleasant effects of symptoms)

To try to decrease:
___ Depression
___ Anxiety
___ Sleep problems
___ Nervousness or being jittery
___ Hallucinations
___ Side effects of medication
___ Tension
___ Lack of interest in activities

___ Because of habit or routine that is difficult to break

___ To increase pleasure in life

___ To relieve cravings or withdrawal symptoms

___ To overcome boredom

___ To numb painful feelings from life stressors and problems.

CBT Client Manual 8-10-07 27

___ Other reasons? List these below:

_____________________________________________

_____________________________________________

_____________________________________________

Drugs and alcohol can make symptoms worse.

They also can make your medication less effective or contribute to

other unhealthy behaviors.

People with mental illness are highly sensitive to substances.

Consequences of using drugs and alcohol:

Substance use can cause a variety of consequences. These are some common ones that
people with mental illness tend to experience:

Worsening of your illness in following ways:

• Increase in distressful symptoms
• Relapse and needing to be hospitalized
• Experiencing depression and having increased risk of suicide
• Becoming more irritable or angry and having violence problems

Problems in relationships:
• Not participating in as many activities as you used to; withdrawing
• Having more conflict with family or friends
• Losing your housing (not being able to pay rent, or getting evicted)

Financial and legal problems:

• Spending too much money
• Getting in trouble with the law

Risk of being victimized:

• Being in more risky or dangerous situations
• Becoming a target for predators

Health problems:
• Serious health problems (e.g. heart attack or stroke from cocaine)
• Accidental death from overdose of drugs or contaminated drugs
• Premature death

CBT Client Manual 8-10-07 28

 There are a range of consequences of substance use relating to:

Symptoms
Relationships
Physical health
Personal safety
Daily living and activities
Legal issues

What happens when a person with a mental illness uses alcohol and/or drugs?

It can be especially dangerous to use drugs and alcohol if you have a psychiatric
condition like schizophrenia or depression. There are several reasons for this:

• These substances can directly affect the brain chemicals that are responsible for
your illness, which can make your symptoms worse.

• These substances can make your prescribed medication less effective in helping
you.

• Using substances makes it more likely that you will engage in other unhealthy
behaviors (for example, getting less sleep, eating a less healthy diet, not showing
up for work or treatment, not remembering medication as consistently) and these
behaviors can contribute to having a relapse.

• People with mental illness are “super-sensitive” to the effects of drugs and alcohol
(because of their biological vulnerability). This means that they are more likely to
experience extreme effects from even a very small amount of a substance. In
other words, while others can have a couple of beers and feel OK, a person with a
mental illness is more likely to become very drunk and to experience lots of
negative effects such as symptoms getting worse.

How can a person stay away from drugs and alcohol?

Having a mental illness can make it especially challenging to avoid substances, as

described above. There are many temptations and it can be difficult to cope with distress
without using drugs or alcohol. It is important to discuss these challenges with a doctor
or therapist or case manager. Below are some steps that can help you to stop using
alcohol and drugs:

1. Be honest with yourself:

Nothing can be accomplished unless you are honest with yourself about your drug and
alcohol use and take the necessary steps to deal with it.

CBT Client Manual 8-10-07 29

2. Enroll in a treatment program:

Enrolling in a treatment program can help you interact with other people who share
similar problems. Also a treatment program can help you understand the reasons you use
alcohol and drugs and to learn important skills for dealing with life problems.

3. Going to an AA or NA group:

It has been shown that people who regularly go to an AA or NA support group improve
their odds of staying sober.

4. Talk to your doctor about medications to reduce cravings.

There are a number of medications now available that can help reduce the cravings for
alcohol and drugs and they can help strengthen your coping strategies to deal with
substance use.

Condition Medications
Alcohol abuse Campral
Buspar
Revia
Opiate abuse Suboxone
Methadone
Revia
Naltrexone pellets

What if I don’t want to stop using alcohol and/or drugs right now?

Although you may have been told by others that you should stay away from drugs and
alcohol, you yourself may not have noticed any problems that have come up from using
substances. If this is the case, it still can be important to educate yourself about the effects
of drugs and alcohol (e.g., by reviewing this information with your case manager). It is
also important to keep an open mind about looking at whether alcohol or drugs may be
interfering with your physical or mental health, relationships with others, and/or your life
goals for yourself. (See Exercise 3A, Weighing the Benefits and Drawbacks of Using
Alcohol or Drugs to examine your personal pros and cons of substance use).

Having a mental illness can make it especially hard to avoid substances.

Talking with a professional about temptations can help.

There are many programs available especially tailored to help people with
mental illness who are struggling with alcohol and drug use.

CBT Client Manual 8-10-07 30

 Exercise 3A: Weighing the Benefits and Drawbacks of Using Alcohol or Drugs

Use of alcohol and drugs is very common in individuals with psychiatric problems.
People use drugs for a variety of reasons like coping with boredom, negative thoughts
and feelings, peer influence or wanting to feel high (see Information Sheet Information
about Drugs and Alcohol for more detail about this topic). Many people who have used
alcohol or drugs in the past or currently have a lot of thoughts about the benefits and
drawbacks of taking alcohol or drugs. It can be helpful to discuss both your positive and
negative thoughts about drugs and alcohol with your case manager. Examine the benefits
and drawbacks on different aspects of your life like relationships, work, financial
situation, physical and psychological health etc. Use the grid below to write in lists of
personal benefits and drawbacks to using (and not using) drugs and alcohol.

Benefits of using drugs or alcohol: Drawbacks of using drugs or alcohol:

IiiI
Short-term (Immediate)_____________ Short-term (Immediate)_____________
__________________________________ __________________________________
__________________________________ __________________________________
_________________________________ _________________________________

Long-term_________________________ Long-term_________________________
_________________________________ _________________________________
__________________________________ __________________________________
__________________________________ __________________________________

Benefits of NOT using drugs or alcohol: Drawbacks of NOT using drugs or alcohol:

Short-term________________________ Short-term________________________
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________

Long-term_________________________ Long-term_________________________
__________________________________ __________________________________
_________________________________ __________________________________
__________________________________ __________________________________

CBT Client Manual 8-10-07 31

Now work on answering the following questions using the information you
generated above (remember, there is no right or wrong answer per se, but be sure to
use the list above to help guide how you respond to these questions):

1. Do the benefits of USING drugs or alcohol outweigh the drawbacks of using drugs or
alcohol? Or do the drawbacks of using drugs or alcohol outweigh the benefits?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. Which lasts longer: the benefits of using or drawbacks from using substances? In what
ways?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. Which helps you get closer to your life goals: using substances or not using
substances? In what ways?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

4. If you think about your personal values, which is more in keeping with these values:
using drugs and alcohol or not using drugs and alcohol? Why?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

CBT Client Manual 8-10-07 32

 Information Handout 4: Information about Psychosis: Paranoia and Delusions

Psychosis is a term that is often misunderstood. It is a real medical condition that affects
the mind and can cause confusion or a loss of contact with reality. Psychosis causes your
mind to play tricks on you. Symptoms of psychosis include delusions (having strong
unusual beliefs that other people do not share), hallucinations (hearing, seeing, feeling, or
smelling things that are not really there), and very disorganized speech and behavior.
More details about having paranoia and delusions are described below. (For more
information about hallucinations, please see Information Handout 5, “Information about
Psychosis: Hallucinations”).

Examples of common types of delusional beliefs:

Experience Examples
Paranoia Feeling convinced that family, government
agencies, or others are trying to bother or
harm you even though this is not true.

E.g., Josh is 38 years old and for six years,

he has believed that the CIA is trying to get
rid of him. Wherever he goes he sees
people in black cars that he believes are
CIA men. In reality, the CIA is not after
Josh and the people in black cars are not
part of the CIA.

Referential Thinking Believing that words, colors, or other

things in the environment have special
meaning related to you or that the radio,
TV, or music is about you.

Eg: Kathy believes that the songs Michael

Jackson sings are about her. She never met
Michael Jackson in person.

Grandiose Delusions: Believing that you have special talents or

powers that others do not have or that you
have a special connection to people in
power.

Eg: Kenny is 67 and believes that he owns

AMTRACK even though his monthly
income from SSD is $700.

CBT Client Manual 8-10-07 33

 Romantic delusions: Believing that someone important is in love
with you even though there is no evidence
that this is true and the person may not
know you personally.

Eg: George believes he is engaged to

Oprah Winfrey. He has never met her in
person.

Religious delusions: Beliefs that you are a messiah or chosen

person and have a special mission.

Eg: Thamon has been in a psychiatric

hospital multiple times on an involuntary
basis. He believes himself to be a messiah
and that he was hospitalized so that he
could save the lost souls in the hospital.

Delusions of control: Beliefs that someone is controlling your

body.

Eg: Pam believes that her actions are being

controlled by her neighbor who uses a
satellite to control her every move.

Thought Broadcasting Feeling like your thoughts are being

broadcast outside of your head for others to
hear.

E.g.: Gina believes that her thoughts are

broadcast over her school’s loudspeaker.

Thought Insertion Feeling like thoughts have been inserted

inside your head or like your thoughts are
not your own.

E.g.: Jessie believes that aliens are

planting pornographic images in her mind.

Mind Reading Thinking that other people can read your

mind or that you can read other people’s
minds.

E.g.: Jenny avoids taking the subway

because she believes the other passengers
can read her mind.

CBT Client Manual 8-10-07 34

Who can develop psychotic symptoms?

Anyone can develop psychotic symptoms because the human brain has a vulnerability to
develop psychosis. However the degree of vulnerability can vary among different
individuals. Having a psychiatric condition can make you more vulnerable to developing
delusions, but paranoia and delusions can occur in people who do not have a psychiatric
condition as well.

Low-level paranoid thoughts are very common. Some examples include:

You walk into a group meeting late and everyone laughs as they look at you. You
believe they might have been talking about you before you walked in.

You’re walking on an isolated road at night and you see a shadow behind a bush. You
think someone might be hiding behind the bush.

Some situations that can cause delusional thinking in someone who does not have a
large vulnerability for developing a psychiatric condition:

1. Sleep deprivation: A research study found that medical students who were not
allowed to sleep for four or five days became paranoid and started to hallucinate.

2. Medical conditions: Conditions like low thyroid can cause paranoia. Also, the
effects of severe medical infections like pneumonia might bring on some paranoia or
delusions.

3. Medications: Some medications can cause paranoia eg: steroids used for asthma
(note: antipsychotic medications do not cause delusional thinking).

4. Illicit drugs: When people take certain types of drugs, like methamphetamines,
cocaine, crack, or hallucinogens (e.g., acid), the effects are similar to psychotic
symptoms.

5. Extreme-stress situations: In high-stress situations, such as when people are taken

as hostages or are in solitary confinement, they might develop paranoid thinking or
unusual beliefs.

Paranoia and delusions are common, often disturbing symptoms.

These symptoms also occur in people who do not have a psychiatric condition.

Having these symptoms can make it hard to tell fantasy from reality.

CBT Client Manual 8-10-07 35

What causes paranoia and delusions?

The exact cause of paranoia and delusions is still fairly unknown. However, researchers
think that it has to do with a combination of problems with the way the brain is
functioning. Some specific information about the cause of paranoia and delusions is as
follows:

1. Too much dopamine:

• Dopamine is a chemical in the brain called a neurotransmitter that influences
emotions, thoughts, and behavior. Medications that decrease dopamine levels tend
to help reduce psychotic symptoms. Therefore, too much dopamine in certain parts
of the brain may be responsible for psychotic symptoms.

2. Biases (Problems in thinking):

• Certain biases (errors in thinking) are thought to lead to delusions:
o Personalizing bias: Tendency to interpret neutral situations personally
(e.g., A friend doesn’t return your phone call and you assume it is
because she is mad at you)
o Intention bias: Attributing bad intentions to people’s behaviors
(e.g., A stranger brushes up against you as he walks by and you
assume he is trying to mess with you)
o External bias: Attributing things that happen to you to outside sources.
(e.g., You fail a test and assume it is because the professor made the
test too hard rather than because you did not study enough)

3. Difficulty in accurately reading emotions:

• People who develop paranoia are more likely to view neutral facial
expressions as being threatening,
• This can lead to believing that someone is angry with you or wants to
harm you even though they don’t.

4. Stress:
• For people who have a vulnerability to psychosis, stress can be a trigger for
experiencing paranoia or delusions in the first place.
• Stress can also play a role in how and when paranoia or delusions get worse.

Paranoia and delusions are caused in part by a chemical imbalance in the brain.

Dopamine and problems in thinking may cause paranoia and delusions.

Life stress can contribute to an increase in these symptoms.

CBT Client Manual 8-10-07 36

What are the consequences of paranoia and delusions:

Paranoia and delusions can cause a great deal of anxiety and distress for people. They can
become so overwhelming in their intensity that a person cannot concentrate on things.
Delusional beliefs can lead people to do things that disrupt their social relationships,
interfere with self-care tasks, or even get in the way of being able to attend to personal
safety.

Because paranoia can cause people to avoid things that they view as suspicious,
threatening, harmful, or dangerous, it can cause a great deal of anxiety. For more
information on anxiety and avoiding things because of anxiety, see Information Handout
22, “Facts about Anxiety.”

How can paranoia and delusions be treated?

1. Medication
• Antipsychotic medications are very important to control the frequency and
severity of psychotic symptoms.
• For more information about medication, see Information Handout 1, “Facts about
Medication.”

2. Cognitive Behavioral Therapy (CBT):

• CBT can be help people to better understand their symptoms and develop new
coping skills to deal with symptoms and improve daily functioning.

3. Avoiding alcohol and street drugs:

• It is important to avoid street drugs, as they can make paranoia and delusions
worsen and feel more disturbing over time.
• Even though drugs and alcohol may help people feel less anxious and paranoid in
the moment, the longer term effects are usually harmful.

There is effective treatment for paranoia and delusions.

Taking medications, like antipsychotics, is very helpful.

CBT is a useful treatment to help people understand and cope with symptoms.

CBT Client Manual 8-10-07 37

 Exercise 4A: A-B-C-D Theory of Dealing with Distressing Thoughts

Our beliefs or attitudes about events create our emotional reactions to different situations.
This means that how we think about a certain thing that happened makes us feel a certain
way. That is why two people who experience the same event may have very different
reactions to it and feel differently about it. You can see this when you use the ABCD
method.

A: “Activating experience:” What happened (can be an action or event).

B: “Beliefs about experience:” Thoughts you have about what happened.
C: “emotional Consequences:” Your emotions based on the beliefs about the event or
incident.
D: “what you Do:” How you react based on your beliefs and related emotions.

For example:
Mary and Janet receive an invitation for the same party. Mary is outgoing and loves
parties. Janet has social anxiety. Below is how they react to the invitation
A: Activating experience
Receiving an invitation to a
party

Mary’s reaction Janet’s reaction

B: Beliefs about experience B: Beliefs about experience

“This is great! It will be fun to “They just invited me because
see my friends at the party.” they want to make fun of me”
“I will make a fool of myself”
“It is better not to go”

C: emotional Consequences C: emotional Consequences

Happy, excited about the party Scared, nervous, anxious

D. What you Do D. What you Do

Go to the party and have a good Avoid the party, stay home, and
time. feel bad for being a whimp.

CBT Client Manual 8-10-07 38

 Part II: Alternative Beliefs Exercise:

As you can see by the scenario with Mary and Janet, there are a number of different ways
that a person can interpret a situation—and these different interpretations can lead to
different emotional reactions. The thoughts that lead to different emotional reactions are
like fuel to the fire of emotions. An effective way to change unpleasant emotional
reactions and change your behavior is to work on changing the thoughts that power the
emotions.

We can reduce the amount of distress that we experience by considering alternate ways of
thinking about situations that come up in daily life. It’s important to understand that
changing the way one thinks about things is not easy because you have probably been
thinking this way for a long time. Changing your thinking is a skill that you can work on
and develop. Below, you can practice this skill by coming up with alternative beliefs
about a few different regular day-to-day situations.

For example: What are at least three different ways that a person could interpret each
of the following situations?

1. You pass by a friend in the hallway and say “hello”—but he keeps walking and does
not say “hello” back.
Possible interpretation of event Likely emotional response

Example: “Maybe he didn’t see me.” Disappointed but Calm

2. Someone calls you on the phone and doesn’t leave a message.

Possible interpretation of event Likely emotional response

CBT Client Manual 8-10-07 39

3. You get onto the bus and sit across from two girls you don’t know. They start
whispering to each other and laughing.
Possible interpretation of event Likely emotional response

The more you practice coming up with alternative reasons why something may have
happened, the more you can feel in control of how you react to things in your life that
may bother you.

Here are some other common scenarios to try out:

1. Your case manager did not come as promised.
2. You didn’t receive your disability check in the mail.
3. You can’t find your wallet.
4. You pass by a truck that has a word that seems significant to you written on it.

NOW: Write in a situation that happened to you this week and the possible ways of
interpreting that event:

Event: _____________________________________________________________

Possible interpretation of event Likely emotional response

CBT Client Manual 8-10-07 40

Try some more:

Write in a situation that happened to you this week and the possible ways of
interpreting that event:

Event: _____________________________________________________________

Possible interpretation of event Likely emotional response

Event: _____________________________________________________________

Possible interpretation of event Likely emotional response

It is important to work with your case manager to come up with an alternative perspective
on these events. This will give the paranoia & delusional thinking less power, sending it
away. When you practice changing your way of thinking about situations, you will be on
your way to having more pleasurable feelings.

CBT Client Manual 8-10-07 41

 Information Handout 5: Information about Psychosis: Hallucinations
Hallucinations involve hearing, seeing, feeling, or smelling things that other people do
not. Hallucinations can happen as a part of psychosis (a medical condition that can cause
your mind to play tricks on you). Hallucinations can also occur in normally functioning
individuals (who do not have a psychiatric condition) and in certain stressful conditions
like bereavement or sensory deprivation. Most often hallucinations are the auditory type
(hearing things or voices). However, there are several different types of hallucinations.

What are some examples of hallucinations?

Symptom Examples
Hearing things that other people don’t hear • Doors slamming, people talking or
singing, whistling noises

Seeing things that other people don’t see • Shadows or people at one’s bedside

Hearing a voice that tells you what to do or • “You are a loser;” “Everybody hates
criticizes you you;” “Don’t go to the party;” “Don’t
get on the bus;” “Shove that
pedestrian”

Hearing a voice that tracks your actions • “You are stepping off the train;”
during the day “You are cooking some soup”

Feeling things inside your body or on your • Sensation of others doing something
skin that aren’t there to your body; feeling people touch
you.

Smelling things that aren’t really there • Smoke, peppermint, feces

Tasting things that you aren’t eating at the • Cigarettes, alcohol, metal
time

How common is hearing voices?

Hearing voices is very common. It is important to remember that the human brain has a
vulnerability to have psychotic symptoms like hearing voices or sensing things that aren’t
really there. This means that under certain conditions or in certain situations, almost
everyone (whether they have a psychiatric condition or not) could hear voices. Some
situations in which a person can hear voices include:

1. Normal individuals: Some individuals who do not have a psychiatric condition and
are fully functioning in society hear voices.

CBT Client Manual 8-10-07 42

2. Sleep deprivation: Studies have found that when people are deprived of sleep for
periods of time or when they are in “sensory deprivation” chambers, they often hear
voices.

3. Certain Stressful situations: Individuals who are subjected to high-stress situations,

like when people are taken as hostages or are in solitary confinement, also tend to
hear voices or have physical sensations (e.g., someone touching you) that aren’t there.
Severe medical infections like pneumonia might bring on hallucinations or other
psychotic symptoms.

4. Medical conditions: There are also some medical conditions, which can cause
hallucinations, like some types of epilepsy (Temporal Lobe Epilepsy) and certain
vision problems (called Charles Bonnet Syndrome).

5. Medications: Some medications (such as certain medications that treat Attention

Deficit Disorder or Parkinson’s disease) can cause hallucinations as a side effect or
toxic effect. It is important to note, however, that antipsychotic medicines do not
produce hallucinations as a side effect.

6. Illicit drugs: Finally, certain types of drugs, like methamphetamines or hallucinogens

(e.g., acid), could produce the experience of hearing voices.

Hallucinations are common, often disturbing symptoms.

Hearing voices is the most common type of hallucination

These symptoms also occur in people who do not have a psychiatric condition.

Certain medical conditions and/or drug use can also cause hallucinations.

What causes hallucinations?

The exact cause of hallucinations is still fairly unknown. However, researchers think that
it has to do with a combination of problems with the way the brain is functioning. Some
specific information about the cause of hallucinations is as follows:

1. Too much dopamine:

• Dopamine: is a chemical in the brain called a neurotransmitter that influences
emotions, thoughts, and behavior. More dopamine is thought to be responsible for
psychotic symptoms like voices. Antipsychotic medication reduces the level of
dopamine in the brain.

CBT Client Manual 8-10-07 43

2. Attention difficulties:
• Due to irregularities in the brain, some people have trouble paying attention when
there are many things going on at once (like when you are in crowded mall and
there are lots of people talking and walking around, music playing, food smells,
etc).
• Voices may occur when a person has “sensory overload” (e.g., when too many
things are going on at once in the immediate environment).

3. Trouble separating internal events from external events:

• Some people, because of brain irregularities have trouble recognizing whether a
thought they are having is coming from themselves or from another person or
voice.
• For example, if you hear the sentence, “You are stupid” in your head, some
people have trouble determining if they are saying that to themselves (as a
thought they are having) or whether someone else is saying it to them in their
head (like a voice).
• It is often the case that people will have a thought in their head but mistake it for
the statement of another person. This is experienced as hearing voices.

4. Feeling judged or criticized by others:

• Some people feel like other people (people they know and also people in general)
are judging them, criticizing them, or intruding upon them. As a result, they may
feel extra sensitive or vulnerable (like they can be easily upset, hurt, or put in
danger). They may also feel helpless, like they can’t do anything about it.
• When people who have a biological vulnerability to psychosis AND they have
these kinds of beliefs, voices can develop.

5. Stress:
• Just like other symptoms that are discussed in this handbook, researchers have
found that for people who have a vulnerability to psychosis, stress can be a trigger
for experiencing hallucinations in the first place.
• Stress can also play a role in how and when hallucinations get worse. In high
stress times, voices may get louder, more frequent, or more hostile.

Hallucinations are caused in part by a chemical imbalance in the brain.

Dopamine and attention problems may cause voices.

Life stress can contribute to an increase in psychotic symptoms.

Consequences and Reactions to Voices:

Some people who hear voices are able to carry on with their life without any difficulties.
Some people even find the voices to be comforting and feel they provide them with

CBT Client Manual 8-10-07 44

company. However, many people find that there are times when the voices are very
distressing and can make it difficult for to concentrate on tasks at hand. Some people
may feel compelled to follow commands made by the voices and may even hurt
themselves or try to hurt others in response to the voices. If a person is in danger of
harming themselves or others, the person may need to go to the hospital to stay in a safe
environment for a period of time. (See above for more information on stress, and see
Information Handout 2 “Information about the Stress-Vulnerability Model). For more
information about relapse and how to prevent it, see Information Handout 19: “Staying
Well and Reducing Relapses.”

What can you do to help deal with hallucinations?

There are treatments available that can help decrease hallucinations and help people cope
with them.

1. Medications:
• Antipsychotic medications can help to control the frequency and severity of
hallucinations. Sometimes mood-stabilizing medications and/or antidepressant
medications are used as well.

2. Cognitive Behavioral Therapy (CBT):

• CBT can help you to learn to deal with voices in a variety of ways. First, it can
help you to learn about your personal triggers for increases in hallucinations (like
not getting enough sleep, staying at home all day, using alcohol, feeling stressed
out by finances, etc.) and strategies for avoiding these triggers.
• CBT can also help you learn better coping skills to deal with hallucinations and to
challenge and change distressing beliefs that you might have about the voices.
That is, many people who experience a lot of distress associated with their voices
have some of the following mistaken beliefs: “Voices mean that I am crazy.”
“Voices are all powerful and I am powerless against them.” “People around me
know that I am hearing voices.”

3. Avoiding alcohol and drugs:

• Avoiding street drugs and alcohol can reduce the likelihood of hallucinations.

For more information on how to cope with voices, see Exercise 5A , “Coping with
Voices.”

There is effective treatment for hallucinations.

Taking antipsychotic medications is very important.

Learning to understand and cope with hallucinations makes a difference.

CBT Client Manual 8-10-07 45

 Exercise 5A: Coping with Voices

The following is a four-step process to help you gain better control over the voices so that
you can function and get on with your life despite them:

Step 1: Rate the voices and Identify when and how they interfere with your life:

The very first step for gaining control is to understand the situations that trigger and
maintain the voices. For example, some common triggers are negative emotions like
depressed mood, anxiety, anger, or even boredom. A new experience or a stressful event
can make the voices become more frequent or louder. Sometimes the voices may be
related to the time of the day or the situation you are in. Exercise handout 5B, “Thought
Record for Voices” can help you to begin learning about the situations that trigger you to
hear voices. Below are some strategies to more closely examine how to cope with voices.

When dealing with voices, it can be helpful to rate them on a scale from 0 to 10 and to
notice at what number they interfere with your activities. For example:

Jason hears voices several times a day. He used to see his voices as being either present
or absent, without being able to notice variations in how loud or disabling they were. His
therapist taught him to rate his voices on a scale from 0-10, with 10 being the loudest
voices he ever heard. This helped Jason realize that the voices varied in how lout they
were. Also, Jason realized that the voices did not really interfere with his life until they
reached a seven. He and his therapist developed a plan to ignore them when they were
lower than seven and to use specific coping skills when they were seven or above.

Rate the voices you hear on a 0 to 10 scale with 10 being the loudest.

My voices are usually at:_________

They interfere with my life when they reach a score of:_________

Now list some ways that the voices interfere with your life. Think about your own life
and think about how hearing the voices or your reaction to the voices has interfered with
some aspect of your day-to-day living.

I have noticed that the voices have interfered with my life in the following three
ways:

1. _______________________________________________________

2. _______________________________________________________

3. _______________________________________________________

CBT Client Manual 8-10-07 46

Step 2: Examining how you have coped with the voices in the past:

Most people have their own methods of coping with the voices. Some methods are
helpful, and some are not helpful, and may even have distressing consequences. Let’s
examine some things that you may have tried yourself in the past:

The last time I heard voices, three things I did that were helpful were (e.g.,
listened to headphones, told myself I was in control):

1. _____________________________________________________

2. _____________________________________________________

3. _____________________________________________________

Sometimes, despite our best efforts, some of the ways we try to cope don’t turn out as
well as we thought. It’s important to remind ourselves of what we tried before that didn’t
help or made things worse, so we remember not to use that coping strategy in the future:

When I have heard voices in the past, two things I did that were not helpful were
(e.g., screamed out loud, paced, gritted my teeth):

1._____________________________________________________

2. _____________________________________________________
Step
WhatIII:did
Identifying
you see asnew
the ways
problemto cope
withwith
eachthe
of voices:
these coping strategies (e.g., it
made me angrier or the voices got worse)?
It’s always good to learn new ways to cope. In general, two good ways to deal with
voices are to engage in activities that 1) give some pleasure or satisfaction and 2) distract
1._____________________________________________________
you from the voices. It’s important to understand that certain activities may reduce the
voices to some extent but may not completely eliminate them.
2. _____________________________________________________

CBT Client Manual 8-10-07 47

Step 3: Identifying new ways to cope with the voices:

In general, two good ways to deal with voices are to engage in activities that 1) give some
pleasure or satisfaction and 2) distract you from the voices. Below is a long list of
different ways that people who hear voices cope with them to make them less bothersome
and stressful.

1. In the list below, CIRCLE all of the ideas that you have tried in the past.

2. Put a *STAR * next to 5 ideas that you have never tried before that you think you
could try out the next time you hear voices.

Ignore them Paint or draw or doodle

Hum or sing a song out loud Sleep
Listen to music out loud Call a friend to get advice or for support
Watch TV Call a friend just to chat
Go for a walk or do another activity you Call a family member who is supportive
like to do of you
Go to a movie Exercise
Surf the internet Do your laundry
Write in a diary or journal Read the newspaper or a magazine
Start reading a new book Put on headphones and listen to music
Send an email Treat yourself to a snack
Read magazines or newspapers Rent a funny movie
Repair something that needs fixing Check your thoughts about your voices
Check in with your therapist or case Attend a therapy group
manager or doctor
Go to your day treatment center or Play cards
clubhouse
Do a crossword puzzle Play a video game
Attend a peer support group Take a shower or a bath
Do a jigsaw puzzle Make sure you have been taking your
medications

CBT Client Manual 8-10-07 48

Step 4: Make a plan to practice new ways to cope with the voices in the future:

It can be helpful to make a plan ahead of time to deal with voices. That way, when you start
to notice the voices and become stressed out, you can immediately start to follow the plan
for how to cope with them.

Pick three things that you will do next time you hear voices. One of them should be
something that you tried before that was helpful. Two of them should be new things that
you starred from the list above.

Rate your voices on the scale of 0 to 10 before starting the activity and then after
completing the activity. This was you will find out how effective any particular
activity is.

The next time I hear voices, I will try the following:

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

Once you have a list of different activities that are effective, make a note of them and
utilize them as necessary.

CBT Client Manual 8-10-07 49

 Exercise 5B: Thought Record for Hearing Voices

Using this chart will help you to keep track of the voices that you hear in order to better understand the triggers for voices and
ways that are effective for dealing with them. When you hear voices, write down the date and time that you heard it, what you
were doing at the time, what the voice said, how you felt during or afterwards, and what you said or did in response. Then, on
your own, or with the help of your case manager, come up with another way you could have coped to help plan for next time.

There’s an example to help you learn how to use the thought record.

Date/Time What were you doing What did the How did you feel What did you say What else could
when you heard the voice? voice say? after hearing the or do in response? you have said to
(SITUATIONAL voice? (BEHAVIORS) yourself in
TRIGGERS) (EMOTIONS) response? What
else could you
have done?
Thursday At home, getting ready to “You shouldn’t Scared, anxious, I yelled at the 1. I could have
evening go to the day treatment even bother stupid, sad voices really loud said, “they are
holiday dinner. going. Everyone and my landlord just telling me
there hates you downstairs came something, that
anyway. If you go, up and was upset. doesn’t mean I
something bad have to listen.”
will happen.” I decided not to go 2. Called my mom
to the party and I 3. Gone to the
stayed home party anyway.

CBT Client Manual 8-10-07 50

 Thought Record for Hearing Voices

Date/Time What were you doing What did the How did you feel What did you say What else could
when you heard the voice? voice say? after hearing the or do in response? you have said to
(SITUATIONAL voice? (BEHAVIORS) yourself in
TRIGGERS) (EMOTIONS) response? What
else could you
have done?

CBT Client Manual 8-10-07 51

 Exercise 6A: Improving Communication with Others

Communicating with other people helps us to strengthen and maintain our relationships and to
get things done. Communicating effectively with other people is a skill that has to be learned.

Characteristics of effective communication: The following are some of the characteristics of

effective communication.

1. Choose the Right Time: For example, do not try to talk something important to your mom
as she is about to walk out of the door.

2. Choose the Right Place: For example, do not try to talk about yourself with your case
manager in the corridor as other people are passing by.

3. Prepare the other person: For example, use a statement like “I have an important thing to
discuss about my health,” or, “Do you have 10 minutes?”

4. Get feedback about your communication: For example, ask a question like, “Did I express
my problem clearly?” This can inform you about the clarity of your communication and give
you a chance to clarify any misunderstandings.

5. Summarize: To avoid misunderstandings, summarize what you understand to make sure the
other person agrees. For example, “I understand that we both will be meeting here next week
at 10AM.”

Barriers to effective communication: Some of the barriers are:

1. Thoughts that are jumbled and confused can make it difficult to communicate in a way that is
understandable to others.

2. Emotions like anxiety, worry, and anger can affect how well you communicate with other
people.

3. Choosing wrong place or time can distract the other person and make you less effective.
Observe the person’s body language to see if they are interested or not.

Communication has different skills:

Below you will find some communication skills that will help with talking to other people.
Choose a skill that you think would be beneficial to learn. Then, go through the steps of each
skill, making sure you understand each one. Ask your case manager, a friend, or a relative to
help you practice this skill, using the particular difficulty that you want to work on as the
example. Have that person pretend to be someone you would need or want to talk to in daily life,

CBT Client Manual 8-10-07 52

while you go through the steps of the skill and practice the steps of the skill. This is what is
called a “role play.”

Practice, practice, practice! The more role-plays you do, the easier it will be to use these skills
when you are interacting with other people.

For additional skills for improving communication, please see Information Handout 18, “
Exercise18A “How to Improve Communication with your Doctors”

*Note: all skills are taken from Bellack, et al (1997) Social skills training for schizophrenia: A
step-by-step guide. NY: Guilford.

1. Starting a Conversation:

Steps of the Skill:

1. Choose the right time and place.

2. Introduce yourself or greet the person you wish to talk with.

• Examples of greetings: “Hello” or “How are you doing,” “Good morning”

3. Make small talk

• Examples of small talk are the weather, sports, local news, where you are at the moment
(e.g. day treatment, the park, the bus stop, etc)
• Topics to avoid when you don’t know someone well: politics, religion, and very personal
information

4. Judge if the other person is listening and wants to talk.

• Some things to observe to help you judge this include:

ƒ Is the person answering with just one word answers or longer sentences?
ƒ Is the person looking at you or looking away or at their watch?
ƒ Is the person facing you or facing the other direction?

Name three situations in your life where using this skill would be useful:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

CBT Client Manual 8-10-07 53

2. Staying on the Topic Set by Another Person:

Steps of the Skill:

1. Decide what the topic is by listening to the person who is speaking.

2. If you still do not understand what the topic is after listening, ask the person.

3. Say things related to the topic.

Name three situations in your life where using this skill would be useful:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

3. Making Requests:

Steps of the Skill:

1. Look at the person.

2. Say exactly what you would like the person to do.

3. Tell the person how it would make you feel.

In making your request, use phrases like:
“I would like you to ______”
“I would really appreciate it if you would _______”
“It’s very important to me that you help me with ________”

Name three situations in your life where using this skill would be useful:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

CBT Client Manual 8-10-07 54

4. Getting your Point Across:

Steps of the Skill:

1. Decide on the main point you want to get across.

2. Speak in short sentences and stay on the topic. Do not introduce another topic.

3. Pause to let the other person speak or ask questions.

4. Answer any questions.

Name three situations in your life where using this skill would be useful:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

5. Listening to Others:

Steps of the Skill:

1. Maintain eye contact.

2. Nod your head.
3. Say, “uh-huh,” or “okay” or “I see.”
4. Repeat what the other person said.

Example:
Psychiatrist: “Take this medication once a day in the morning.”
Client: “Okay, once a day.”
Psychiatrist: “Make sure you take it with food as well.”
Client: “With food, uh-huh.”

Name three situations in your life where using this skill would be useful:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

CBT Client Manual 8-10-07 55

6. What to Do When You Do Not Understand What a Person is Saying:

Steps of the Skill:

1. Tell the person that you are confused or that you did not understand what was said.
2. Ask the person to repeat or explain what was just said.
3. Ask further questions if you still do not understand.

Name three situations in your life where using this skill would be useful:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

CBT Client Manual 8-10-07 56

 Information Handout 7: Understanding Negative Symptoms

There are two broad types of symptoms that are common in schizophrenia: positive symptoms
and negative symptoms. Positive symptoms are often referred to as psychotic symptoms and are
described in Information Handout 5 “Information about Psychosis: Hallucinations” and
Information Handout 4, “Information about Psychosis: Paranoia and Delusions.”

Negative symptoms can be understood as the absence of certain thoughts, emotions, or

motivation to do things. These may be things that used to be easier for you before your illness
symptoms started, but now you may feel like something is “missing” that was not before. Having
negative symptoms can be really difficult for people.

If you have negative symptoms, you may have experienced any or all of the following:
(Check off items on the list below that you have experienced)

___ Apathy (low motivation)

Examples:

___ Not having the “get up and go” that other people seem to have

___ Feeling like you don’t care about doing different activities

___ Not really having an opinion when asked by someone

___ Having trouble completing daily living tasks like keeping the house
clean, bathing regularly, doing laundry, keeping your room in order

Sam is an outgoing 20-year-old college student who used to wake up early nearly every day,
exercise, and go to class. He enjoyed basketball, drawing, and meeting up with friends.
During the second year of college, Sam started hearing voices and had difficulty keeping up
with his studies due to the stress. He also found himself having trouble getting daily tasks
completed, like showering or cleaning up his apartment. Instead of getting up early like he
used to, Sam had difficulty getting out of bed at all. He stopped joining his friends at their
weekly lunch meetings and stopped participating in most activities. When someone asked his
opinion about what he wanted to do, he found himself thinking, “I don’t care; it doesn’t
matter.”

___ Flattened affect

Examples:

___ Speaking without much emotion in your voice

CBT Client Manual 8-10-07 57

 ___ Having other people tell you that you sound “monotone”

___ Not showing a lot of emotion on your face

Julie is a 36-year-old waitress who had trouble keeping her job after she started to
experience symptoms of schizophrenia. Although, after a leave of absence from work, she
was able to return to her job at the restaurant, she noticed that she didn’t feel quite the same.
Julie found that she now had trouble demonstrating that she was having a certain emotion.
For example, she could tell that she was feeling frustrated or angry or even pleased at
certain times, but she just couldn’t show those emotions anymore. It was like she had
forgotten how to smile or use facial expressions. She also noticed that when she talked or
expressed an opinion, or when she was helping customers, her voice came out “monotone” –
like there was little emotion to it. Other people tended to notice too, and mentioned to Julie
that she sounded different than before, that she was “somber” or “emotionless.”

___ Loss of pleasure

Examples:

___ Not being interested in doing activities that you used to enjoy

___ When you do activities that are supposed to be fun, having the
experience of not enjoying it as much as you think you should.

Mark is a 34-year-old man who was in the hospital a few years ago because he was
hearing voices and feeling really paranoid. Those symptoms got better over time since he
has been taking medication and going to therapy. However, Mark felt like he was not
interested in doing any of the things he used to like to do before he was in the hospital.
For example, Mark used to be on the bowling team at the local bowling alley and always
looked forward to the weekly practices and the weekend tournaments. He also used to
enjoy going over to his brother’s house to watch football and spend time with his two-
year old niece. Mark knew that these activities used to be fun for him and he knew that
other people in his life still enjoyed them. But, he never felt like doing these things
anymore, and his family often had to encourage him to leave the house.. When he pushed
himself to visit his family or go to a movie, he never had the kind of fun that he used to.

___ Poverty of Speech (Low amount of speech)

Examples:

___ Not feeling able to engage in lengthy conversations with others.

___ Usually staying quiet when in a group of people.

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 ___ Answering questions from other people in few words and not giving
a lot of detail in your answer.

Lucia is a 42 year old woman with schizophrenia who does a pretty good job keeping up with
daily tasks. She has no problem going to the grocery store to do her weekly shopping, using
the bus, and she never misses a doctor or therapy appointment. Lucia remains very close
with her family and has dinner with her parents, grandmother, and younger siblings at least
twice a week. Although she feels glad to be at these dinners, she feels like she doesn’t have
much to say when she is there. In fact, she usually just quietly eats her dinner and helps with
the dishes afterwards, despite the lively conversation that her family has around the table.
The same holds true at her day treatment program. Lucia stays quiet during the group
lunches and outings. She finds that it is difficult and tiring to be in a long conversation with
another person. When her family members question her about why she doesn’t talk much or
give details when asked a question, Lucia can’t really come up with an answer. It is a
stressful, confusing problem.

___ Asociality

Examples:

___ Not being interested in spending time with other people.

___ Avoiding being in social settings or interacting with others.

___ Not looking forward to spending time with people you care about
(such as family or friends)

___ When you do spend time with other people, even if it is with people you
care about, you find you don’t enjoy it.

Bernard is a 28-year-old man who lives in a supportive housing complex. He had a first
psychotic episode when he was 21. Although he used to be a fairly social guy (he had some
roommates, a girlfriend, and spent lots of time with his family), he has found recently that he
doesn’t tend to interact with other people hardly at all. Bernard has a part-time job at the
grocery store, and performs quite well at his work. On the job, however, he generally avoids
interacting with his co-workers. He just feels like being with other people is kind of a
“drag.” He very much cares about his family (Bernard lives nearby his parents and he has a
twin brother and younger sister), but he never finds himself truly looking forward to their
weekly visits. And even when they take him to his favorite Italian restaurant and they all play
Monopoly (this used to be Bernard’s favorite board game), he finds he doesn’t really have
fun and enjoy their company that much.

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Misunderstanding of Negative Symptoms

Sometimes, people in your life might not realize that what you are experiencing is negative
symptoms. Oftentimes, people mistakenly think you are being “lazy” or “slow” or “boring”
because of your reduced activity or lack of emotions. Even the most well-meaning family
members and friends can misunderstand these symptoms and think that you are not participating
in activities or laughing along with the group on purpose. It is important to understand that these
symptoms are not your fault and that they are a part of the illness.

How Negative Symptoms Interfere in Your Life

Sometimes it is difficult for people who have negative symptoms to realize that they have them,
or that the negative symptoms cause problems. However, having negative symptoms usually
does significantly interfere in a person’s life. Many times, the negative symptoms are very
distressing and prevent people from meeting their life goals and/or enjoying things that they used
to. It is also the case that people have certain hopeless thoughts or ideas about participating in
activities (e.g., “It won’t be fun” or “I won’t know what to say at the party”) that maintain the
negative symptoms.

Here are some examples of how specific negative symptoms are related to having distressing
thoughts or emotions:

Negative Symptom Thoughts Emotions

Apathy “I can’t do anything right” Hopelessness

“I might as well not try

because I will fail”
Poverty of Speech “I don’t know what to say” Nervousness

“I can’t think of anything

interesting to talk about”

Treatment of Negative Symptoms

1. Medication:

Negative symptoms can be treated in two ways. One is by taking medication prescribed by your
doctor, which can often help you to feel more energetic or motivated. However, be sure to keep
track of the effects of your medication. Sometimes side effects of medication can slow you down
or make your face appear less expressive. In these instances, it is important to work with your
doctor to adjust the medication.

CBT Client Manual 8-10-07 60

2. CBT (Cognitive Behavioral Therapy):

Another type of treatment for negative symptoms is CBT (Cognitive Behavioral Therapy). In
CBT, your therapist can help you understand your symptoms better and help you figure out how
to try new things to lessen the impact of the negative symptoms. For example, CBT can:

1. Help you to figure out which negative symptoms you have and how those specific symptoms
may be getting in the way of your life goals (e.g., You want to get a part-time job but feel
uncomfortable making small talk with co-workers so you haven’t tried to look for any jobs).

2. Help you to remember some of the activities you used to enjoy (like bowling, or going to
museums) and help you plan how to start doing them again, little by little.

3. Help you to identify what kinds of thoughts you are having that might get in the way of you
doing those activities (e.g., “It will probably be boring”) or spending time with others (e.g.,
“No one will want to go anywhere with me”).

4. Help you to plan out how you are going to handle certain social situations that seem stressful
to you (like figuring out how to start a phone conversation with a relative or what you will
talk about at the day treatment annual picnic).

5. Help you to build up your social skills by practicing them with your therapist. This way, you
will learn more skills and feel more comfortable when you are interacting with others in your
daily life.

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 Information Handout 8: Dealing with Anger

Anger is a normal human emotion that all people have. However, we all differ in the frequency
and the intensity of our anger. When anger causes a problem for a person, it is usually because
the person expresses their anger inappropriately or because the anger is out of proportion to the
situation.

Anger is a normal emotion that everyone has from time to time. Some people
tend to become angry more easily than others.

Our reactions and effects of anger:

Some people feel good and strong when they are angry and other people feel very uncomfortable
when they are angry. Some people react to anger by becoming very quiet and withdrawing from
a situation. Other people react to anger by yelling or saying hurtful things. These behaviors can
have serious consequences that cause problems for the person in their personal life or work.
Acting without thinking when angry can even wind up causing a person to have legal problems
or to get arrested. After the anger has passed, many people find that they feel guilty and
ashamed of the things they did when they were angry.

What can I do to avoid “acting without thinking” when I get angry?

Learning to deal with anger is a coping skill that we all can learn. Two common ways of
approaching anger are a) Using distraction techniques to deal with anger. b) Examining and
changing the thoughts that power the anger. The following are some coping methods to deal
with anger. Try each of the following strategies and see what works best for you. The important
thing to remember is that the more you practice, the better you get at strengthening the skill.

Distraction techniques:

ƒ Take a time out: Walk away from the situation and take a break. Give yourself some time
to calm down before coming back. If you are in the midst of a difficult discussion with
another person, you can say “I need to take a break now so I can think things through.”

ƒ Count to 10 slowly: This can help you take a quick mental break and help you to avoid
saying or doing something that you will feel guilty about later on. Count slowly to yourself
and concentrate on the counting.

ƒ Take a few slow, deep breaths: When you get angry, your breathing will tend to get
shallower and quicker—which can lead you to feel dizzy, disoriented, and often more angry.
Taking a few slow, deep breaths (and closing your eyes, if possible) can help you to calm
down a bit so that you can think more clearly and feel more in control of the situation.

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ƒ Think of someone you love: Bringing the image of someone you love (such as a child) or
another happy memory that can help you to feel less angry.

ƒ Go for a walk or a run: Exercise can be a great way to burn off extra energy when you are
feeling angry so that you can calm and think more clearly about how to deal with the difficult
situation that you are in.

What can I do to help me better control my anger in the long run?

Practicing the following strategies can help you feel less angry and more in control of your
behaviors when frustrating situations occur:

ƒ Recognize and change the thoughts that power anger by completing anger records:
Anger records help you to identify the various distortions in your thoughts that power anger.
You can work with your case manager or therapist to work on changing these thoughts. (See
the Anger Record handout included in this manual).

Justin had angry outbursts since childhood leading to multiple expulsions from school
and later on losing jobs and girl friends. By doing anger records Justin learned that
situations that made him feel powerless provoked these angry outbursts. Along with his
case manager, he examined these situations and found that there are things he could do
in these situations. That removed the sense of powerlessness and his angry outburst
reduced in intensity and frequency.

ƒ Recognizing early warning signs and learn assertive communication: Anger is easier to
control when it is small (a spark) as opposed to an inferno. Recognizing anger as it develops
and learning to ask for what you need in difficult situations can help you to feel more in
control when frustrating situations come up. It can be especially helpful to practice role-
playing these kinds of situations with your case manager. (also see the handout, “Strategies
for Communicating Effectively” for some strategies for asking for what you need).

ƒ Avoid alcohol and drugs: All of us are much more likely to act impulsively when under the
influence of alcohol or drugs. This is because alcohol and drugs lower inhibitions and can
interfere with thinking clearly when frustrating events happen. Avoiding alcohol and drugs
can help you stay more in control of your daily life and less vulnerable to anger or impulsive
acts.

ƒ Take your prescribed medications: Symptoms, such as anxiety, depression, and paranoia,
can make you more vulnerable to out-of-control anger. Therefore, taking your medications
exactly as prescribed can help you to stay in control and be able to deal effectively with
difficult situations.

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ƒ Reward yourself for making positive changes in handling anger: Be sure to recognize
and give yourself a pat on the back when you are able to use these strategies successfully to
handle anger appropriately.

CBT Client Manual 8-10-07 64

 Exercise 8A: Anger Record

This is a chart to help you keep track of your anger episodes. By filling out this form each time you experience an anger
episode, you can learn some new strategies to help you stay in control when you get angry and to reduce the negative
consequences of your anger.
Date/ What is the situation the Anger What thoughts and What did I do when I What was the What else could I
Time surrounded my anger? intensity images went through got angry? consequence of my have done in this
(1-100) my mind? actions? situation that could
have improved the
outcome?

CBT Client Manual 8-10-07 65

 Here is an example of how someone might fill out this form:
Date/ What is the situation the Anger What thoughts and What did I do when I What was the What else could I
Time surrounded my anger? intensity images went through got angry? consequence of my have done in this
(1-100) my mind? actions? situation that could
have improved the
outcome?
Thurs I was waiting on line at 60 This isn’t fair. I pushed the other The other customer I could have said,
9 AM the coffee shop and person out of the way complained to the “excuse me, but I
someone skipped me I am always getting and said “It’s my manager and he asked think I was next.”
when it was my turn to pushed around. turn—you can’t push me to leave the store.
order. me around like this. I I could have taken a
People think they can have the same rights I never got to have my deep breath or counted
treat me badly because as anyone else! ” coffee. to 10 before
I don’t have a lot of responding so that my
money. anger would be better
controlled.
I have to do something
about this.

CBT Client Manual 8-10-07 66

 Information Handout 9: Facts about Depression

What is depression and how do I know if I have depression?

Major depression is a psychiatric disorder that causes a person to feel depressed or down nearly
every day for a period of at least two weeks. It is important to know that depression is different
than having a bad day or having the blues. Depression causes significant distress and interferes
with a person’s day-to-day functioning so that they are not able to go about their daily activities
as they did before.

Depression is a psychiatric illness that causes a person to feel down or

depressed for a period of at least two weeks.

Depression is different from having the blues or a stressful couple of

days. It really interferes with your daily life.

Common symptoms of depression:

You may have experienced any or all of these symptoms if you have struggled with depression.
Read through the following list with your case manager and check off any of the following
symptoms that you have experienced in the past month.

___ Depressed mood: feeling down or low most of the time

___ Decreased interest in doing things or not enjoying things when you do them

___ Feeling worthless, helpless, hopeless about the future

___ Feeling overly guilty about things you have done or not done

___ Having thoughts of wanting to die or end your life

___ Having a bigger or a smaller appetite; losing or gaining a significant amount of weight

___ Sleeping too much or not sleeping enough (e.g., having insomnia)

___ Having trouble concentrating or paying attention

___ Having low energy or fatigue and not doing as much as you used to

___ Feeling agitated or easily annoyed

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 ___ Feeling restless, like you can’t sit still

___ Having trouble making decisions

___ Other symptoms: _____________________________________________

_____________________________________________

Sometimes people who have another psychiatric condition, like schizophrenia, will have
symptoms of depression in addition to other symptoms they have (such as hearing voices or
trouble thinking clearly). This can make it very hard to cope. It is important to be aware of
whether you are experiencing symptoms of depression and then let your doctor or counselor or
psychologist or case manager know.

Breaking the Depression Cycle

Medication:
• There are effective medications available to treat depression. Have a conversation with your
doctor about your medication options.

CBT:
• CBT (Cognitive Behavioral Therapy) can also be very useful to help break the cycle.
Learning what patterns have kept the depression going can help you to try to change those
patterns.

• For example, if you find yourself sleeping a lot and not having motivation to do activities
that you used to enjoy, CBT techniques can assist with developing a daily schedule and
accomplishing tasks little by little until you find you can take more on. CBT can also help
you challenge some of the negative thoughts you may be saying to yourself (for example,
“I’m a loser and worthless”) and have you practice telling yourself more accurate helpful
things (for example, “Even though I might be having a hard time right now, I am a good
person and important to my family”).

Coping Skills to Deal with Depression

Activity scheduling for low energy: When you have low energy and don’t enjoy your usual
activities, you tend not to engage in activities. This only makes you more depressed. The way to
deal with low motivation and energy is to make a schedule of things to do ahead of time.

(For more information, see handout: “Scheduling Pleasant Activities”)

Changing unhelpful thoughts: According to CBT, unhelpful (or “maladaptive”) ways of

thinking can cause depressive symptoms and keep them around. Examining ones’ thoughts and
changing the inaccurate or unhelpful ones can help control depressive symptoms. Usually this is

CBT Client Manual 8-10-07 68

done along with your therapist but can also be done alone. It takes practice but can make a big
difference over time. A “thought record,” as shown below, can be used to keep track of the
negative thoughts and help you change them. This exercise shows that you can change the
severity of depression by examining what you are saying to yourself, challenging those negative
thoughts, and replacing them with thoughts that are more helpful and productive.

Medications prescribed can help with symptoms of depression.

CBT is also very useful in helping people “break the cycle” of

depression.

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 Exercise 9A: Thought Record Example
Date/ Situation that made my What thoughts and Depression What alternate responses Depression intensity
Time depressed mood worse? images went through intensity (1-100) can I come up with?
my mind?
In bed thinking about [Link] is too much of 70 1. It is an effort but I can 50
going to day program effort. do it.
[Link] there does not 2.I will better after
change my depression. spending the day in
[Link] will help program.
me. 3. Isolating myself makes
4. I will stay in bed me more depressed.
4. I will push myself to go.

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 Blank Thought Record

Fill out this form each time to feel your depression/ mood getting worse.
Date/ Situation that made my What thoughts and Depression What alternate responses Depression intensity
Time depressed mood worse? images went through intensity (1-100) can I come up with?
my mind?

CBT Client Manual 8-10-07 71

 Exercise 9B: Positive Self Talk

It is common to carry on an internal conversation with yourself during the day. Most of us do
this without even realizing it is going on. What we say to ourselves is very powerful and can
serve to either motivate us to succeed or have positive feelings (if we are saying positive things
to ourselves) or to have negative feelings about ourselves (if we are internally saying negative
things to ourselves). Understanding what your internal dialog is will help you become more
aware of your internal thoughts. One thing to remember is that POSITIVE thoughts are much
more powerful than negative ones. In the exercise below you will identify some of your negative
self talk and replace it with more powerful POSITIVE self-talk.

Try this exercise to identify your self talk by looking at the example below. In the first column,
is a list some things you may think about during the day. In the second column, is an example of
some of the things you may say to yourself presently about this topic:

Topic or Thought subject Self-Talk

(example) walking to the store (example) Walking to the store is too hard

Now look at the self-talk. If your goal is to get more exercise, this self talk will not support your
goal.

Look at the example below and notice how the self talk supports the goal of getting more
exercise:

Topic or Thought subject Self-Talk

(example) walking to the store (example) Walking to the store is good exercise
for me

Now try a few for yourself. Write down things that you think about during the day, your current
thoughts about it, and some new positive self-talk that can help you think more positively about
things:

Topic or Thought subject Old thought New Positive Self-Talk

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Try some more:

Topic or Thought subject Old thought New Positive Self-Talk

Positive self-talk takes practice and it is worth it! You will find yourself automatically replacing
those weaker negative thoughts with more powerful POSITIVE thoughts as you consciously
bring your attention here. This may seem unnatural at first, but soon you will get used to it and
see positive results. Think of this exercise as re-training your brain. Enjoy your workout!

CBT Client Manual 8-10-07 73

 Information Handout 10: Coping with Suicidal Thoughts

Suicidal ideas are fairly common and one estimate says that one in two people entertain suicidal
thoughts at some point in their life. However, suicidal thoughts are more common in people who
experience mental illnesses, such as depression, bipolar disorder, and schizophrenia. These
thoughts are also common for people who do not have a mental illness but have experienced a
major loss, such as the death of a loved one. If you have had these thoughts, you are not alone.
When you are feeling suicidal, an important thing to remember is that suicide is a
permanent response to a temporary problem. When you are feeling extremely depressed or
suicidal, problems do not seem temporary – they seem overwhelming. You feel like things will
never get better. But most things do get better, if you wait them out, and get help for the feelings
you are experiencing.

Many people feel hopeless at times and have thoughts of ending their life.

Most things do get better, if you wait them out and seek help and support.

What should I do if I am currently feeling suicidal?

Some people who are experiencing depression have suicidal thoughts much of the time—but
have developed strategies to cope without acting on them. However, if you have recently
experienced an increase in thoughts of ending your life and are currently at risk for
hurting yourself, it is important to get help immediately. The following are sources of help:

1) Call your therapist or doctor ______________________________________

(doctor’s name and phone #)
2) Call 911 or the following emergency number ___________________________

3) Call a support hotline: 1-800-273-TALK (8255) or 1-800-784-2433 (1-800-SUICIDE)

*The above information can be put onto a coping card and placed where your telephone. (See
Coping Card, Client Exercise X).

What about if I am not suicidal but I have urges to harm myself in other ways?

Some people who are not feeling suicidal find themselves having urges to hurt themselves in
ways that are potentially dangerous. For example, some people may cut or burn themselves on
purpose, because they find that this seems to help them cope with uncomfortable feelings that
they experience. If you experience these kinds of urges, it is important to talk with your case
manager and doctor about them, so they can help you to come up with some more effective, and
less dangerous, ways to cope with these feelings.

CBT Client Manual 8-10-07 74

What can I do to help me cope with suicidal feelings?

If you are not currently suicidal, but have felt this way in the past or have attempted suicide in
the past, it is can be helpful to come up with a suicide prevention plan to help you if you start to
feel suicidal again. This is something you can work on with your case manager.

• Part I: Warning Signs. Part I of the suicide prevention plan involves identifying warning
signs, symptoms, and behaviors you might experience if you were starting to become
suicidal. These can include signs that you would recognize yourself, or those that your
doctor, family, or friends might be able to help you recognize. For example, a warning sign
might be that you stop going to your doctor’s appointments and start to spend a lot of time in
your room. Another common warning sign is having thoughts that the future is hopeless and
that things will never get better.

• Part II: SAFE Plan. Part II of the plan involves identifying a SAFE plan—these are actions
that you will take to stay safe if you experience warning signs. There are four categories of
actions in the SAFE plan:

ƒ 1) Safeguarding your home environment (e.g., removing knives or pills that

might be tempting to use),

ƒ 2) Activities to cope with negative feelings and distract yourself from thoughts of
suicide,

ƒ 3) Asking for support from Family, Friends or your treatment team, and

ƒ 4) Going to the Emergency room or crisis center.

• Part III: Supportive People. Part III provides places to write in the names and numbers of
those people who you will ask to help you to carry out your safety plan. This can include
members of your family, friends, neighbors, and members of your treatment team.

CBT Client Manual 8-10-07 75

 Exercise 10A : Suicide Prevention Plan:

Part I. Warning Signs

Some warning signs that I am becoming suicidal that I will notice might be:
_________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
Some warning signs that other people might notice might be:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Part II. SAFE Plan

Below is a list of actions you can take to get help if you are experiencing hopelessness and thoughts
about suicide. These actions are divided into four categories Circle all those that you will do if you
start to become suicidal.

S: Safeguard

1. Get rid of all dangerous weapons in your home

2. Do not keep large quantities of pills in your home (ask a friend, relative, or your doctor to hold
onto your extra medication)

A: Activities

1. Make a list of reasons to live: The list should include people who care about you, a list of your
positive qualities (both those that you see in yourself and those a friend would say about you),
your accomplishments both big and small, your dreams in life, and your spiritual beliefs about
life and death.

2. Make a special effort to participate in activities that are potentially pleasant and rewarding. (Make
and follow a schedule for participating in these activities every day)

3. Avoid isolating.

F: Family, friend, and counselor support

1. Call a family member or friend and ask for support.

2. Call my doctor, therapist, and/or case manager

3. Call a support hotline 1-800-273-TALK (8255) or 1-800-784-2433 (1-800-SUICIDE)

E: Emergency action

1. If none of the above works and you are in real danger of hurting yourself, call 911 or go to a local
emergency room or crisis center.
CBT Client Manual 8-10-07 76
Part II Continued: Safe Plan

Below is a list of actions other people can take to help you if you are feeling hopeless and suicidal.

1. Provide support to you by listening to your feelings

2. Help get your mind off things for awhile by participating in a pleasant activity with you

3. Help you to get rid of dangerous weapons or extra pills by storing them for you.

4. Help you to make an appointment with your doctor or therapist

5. Help you to make a list of reasons to live.

6. Ask you to sign a safety contract.

7. Take you to the hospital (if necessary).

8. Other ___________________________________________________________________

9. Other ___________________________________________________________________

10. Other ___________________________________________________________________

Part III. People to help carry out safety plan.

Below, list names and numbers of family, friends, neighbors, or clinicians that you will ask to help
you with your safety plan. Also, write down which items (numbers from the list above) you would
like each person to help with.

NAME PHONE NUMBER WHAT THEY SHOULD DO

Psychiatrist name and phone number: _______________________________________________

Case manager name and phone number: _____________________________________________

Other clinician name and phone number: _____________________________________________

CBT Client Manual 8-10-07 77

 Information Handout 11: Facts about Traumatic Experiences

Unfortunately, horrible things can happen to people. When a person had something happen to
them in the past that caused extreme fear, physical or emotional pain, threat, and/or danger, he or
she is said to have experienced a “traumatic event.” These events can occur in childhood,
adolescence, or adulthood.

“Traumatic events” cause extreme fear, physical or emotional pain,

and/or threat to a person’s life

Some examples of traumatic events are:

• Being hit, punched, or beaten as a child.

• Being punished very harshly as a child (e.g., not being fed, not being allowed to leave
the house, attend school, or interact with other children for an extended period of time).
• Being forced to engage in sexual activities as a child, teenager, or adult.
• Being in a romantic relationship as a teenager or adult where you were threatened,
emotionally or verbally abused, or forced to engage in sexual activity.
• Being involved in any kind of life-threatening emergency like a fire, a flood, or a natural
disaster.
• Being mugged, robbed, raped, sexually assaulted, or threatened with a weapon by a
stranger or someone you knew.

What might happen to a person after experiencing a traumatic event?

Even though the event may have happened a very long time ago, if it was traumatic, it will
sometimes “stick with” a person. It is not unusual to still think about the event or have strong
negative emotions related to it, even if it happened when you were very young. While not
everyone who has experienced a traumatic event has painful memories or other distressing
symptoms, many people do. Identifying symptoms that are common reactions to trauma can be a
first step in healing from the incident. Common symptoms are:

1. Trying not to think about the event, but having bits and pieces of the memories come
back to your mind.
2. Having nightmares about the incident.
3. Noticing that certain things in daily life are strong reminders of the incident (for example,
a person who was robbed in a park may start to feel afraid or anxious upon walking past a
park).
4. Avoiding people, places or things that are reminders of the event (for example, avoiding
spending time with a friend who was with a person the night he/she was raped).
5. Not wanting to tell anyone or talk about the event.

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 6. Getting very nervous, upset, or anxious when talking about things related to the event.
7. Feeling depressed, having difficulty imagining one’s life in the future, or feeling nothing
at all (“emotionally numb”).
8. Being “jumpy” or getting startled by loud noises easily.
9. Feeling constantly “on guard”, like the person has to “watch his/her back” all the time.
10. Not feeling comfortable spending time with other people; being socially isolated.
11. Thinking things like, “I am always going to be unsafe now,” “The world is a dangerous
place,” “I can’t trust anyone” or “It’s my fault that I was raped.”

There are often unpleasant symptoms that go along with having experienced a
traumatic event.

These symptoms can really get in the way of leading the life that a person
wants for him/herself.

What you can do if you have experienced a traumatic event in the past:

Even though remembering or talking about the event can cause a lot of distress, it is very
important to let someone know that this has happened to you. The first thing to do is to tell your
case manager. You do not have to go into details about the incident if you feel uncomfortable at
first. Here are some other things you can do to cope:

• Request “talk therapy” from your mental health clinic. If it is available, your case
manager can help put you on a wait list for individual or group therapy. The therapist
can help you talk more easily about what happened and learn skills to cope with
difficult thoughts and feelings.
• Learn “calm breathing.” This breathing techniques helps to dispel stress and tension
from the body. When we are stressed or anxious, it is common to breathe in a shallow
manner, sometimes even holding our breath. (See Calm Breathing, patient exercise
2A) Practice this skill with your case manager.
• Participate in “relaxation training.” This involves learning and practicing breathing
exercises and muscle relaxation that can help you feel less anxious or scared in certain
moments (for example, when things remind you of the trauma or when you are talking
about it). Ask your case manager to teach you how to do this.
• If you find yourself getting extremely anxious a lot of the time, talking to your
psychiatrist can be helpful. He/she may be able to prescribe a medication to take to
help you feel calmer.
• Learn and practice other ways to soothe yourself when you feel anxious or have
memories about the traumatic event. Bring up a memory that is pleasant and makes
you feel safe into your mind. Call a trusted friend, take a walk, take a bath, listen to

CBT Client Manual 8-10-07 79

 soft music, have some tea, etc. Think ahead of time about what is relaxing for you so
you can do it immediately when you get distressed.
• Stay away from drugs and alcohol. Although drinking or getting high may make you
feel better in the moment, drugs and alcohol usually interfere with a person’s ability to
learn more helpful coping skills and to function as a parent, spouse, employee, or
student.

If a traumatic situation is occurring NOW in your life, DEFINITELY

tell your case manager IMMEDIATELY.

You want to prevent dangerous situations from happening to you and

PROTECT YOURSELF!

CBT Client Manual 8-10-07 80

 Information Handout 12: Including Your Family in Your Mental Health Treatment

Family members and trusted friends can play an important role in helping a person to
recover from mental illness and to achieve personal goals. However, working jointly with your
family may require somewhat of an adjustment for everyone. You might be giving up some of
your privacy and independence, while the family members might need to spend some of their
extra time on your treatment and/or take on some tasks to help you.

Family members can play an important role in helping a person to recover from
mental illness and to achieve personal goals.

What are some advantages of including my family in my mental health treatment?

Your case manager may ask to meet your family at some point. Including your family in your
mental health treatment can have several advantages, including:

1. Family member can become more understanding: If your relative learns more about
your treatment and your experiences, he/she is likely to be more understanding and
helpful to you. Many clients find that it is frustrating when relatives don’t seem to
understand what they have gone through and why it might be important to take small
steps towards goals and avoid taking on too many new responsibilities at once.

2. Family members can information to help treatment providers to make good

decisions: Family members who have known you for a long time can help you to inform
your clinicians about medicines and other treatments that have worked for you in the
past. They can also provide important information related to noticing warning signs of
your illness.

3. Family members can help organize things and keep track of appointments:
Supportive family members can help you keep track of appointments and organize your
life, especially when things become stressful.

4. Family members can support you in working toward life goals: They can help you to
try new coping strategies that you learn in cognitive behavioral therapy, and provide
encouragement to help keep you motivated to work hard on your goals.

5. Participating in treatment can help family members feel better about themselves:
Your relative may be feeling upset or guilty about the difficulties that you have
experienced because of your mental illness—getting support and learning about your
symptoms and ways they can be helpful to you can help family members to feel better.

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 Research shows that when relatives participate in a program to learn about
symptoms of mental illness and strategies for being supportive, clients tend to
have fewer relapses and hospitalizations.

What are some ways that my family can participate in my mental health treatment?

There are a number of ways that your family can learn to help support your recovery from
mental illness. You can discuss with your case manager which of these resources may be the
most helpful for you and your family. Some examples are:

ƒ Family meetings: It can sometimes be useful to invite your family to come with you to an
appointment with your case manager, therapist, or psychiatrist. If you are concerned about
some private information, you can ask the physician or therapist not to share it with your
family members.

ƒ Family therapy: Often, it can be helpful to meet together your family member(s) with a
family therapist on a weekly or every-other-week basis. A family therapist can provide
important information to you and to your family about symptoms and treatments. A family
therapist can also educate you and your family members about ways to reduce symptoms,
prevent hospitalizations, and enhance your independence and progress towards your goals.
Family therapy focuses on improving a family’s ability to solve problems, communicate
better, and reduce stress. Talk to your case manager about whether family therapy is
available at the clinic where you get treatment to learn more about this option.

ƒ Participating in a consumer advocacy group. Another way that your relatives can learn
skills for helping to support your recovery is to participate in a consumer advocacy and
education program, such as the National Alliance for Mental Illness (NAMI). NAMI is an
organization that provides education and support to individuals who experience mental
illness and their families. There are chapters of NAMI all around the country. To find a
nearby chapter, you and your relatives can look on their website, [Link].

ƒ Reading about mental illness and strategies for supporting recovery. Your case manager or
doctor may be able to recommend some books and websites to your family that can provide
some information about mental illness and strategies for helping to support your recovery
(see attached reading list).

What can I do if my family is critical and unsupportive of me?

If you are dissatisfied with how your family members treat you, your case manager can help you
to address this with your family. When family members are critical and unsupportive, this is
often due to a lack of understanding of mental illness or unrealistic expectations they may have
for the person who has been affected by symptoms. Your case manager might recommend some
resources for your family to help them to learn about your illness and how they can best support
you in your recovery.

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ADDITIONAL RESOURCES FOR FAMILY MEMBERS:

Books
FOR INFORMATION/SUPPORT:
• Amador, X. (2000). I am Not Sick. I Don’t Need Help! Helping the seriously mentally ill
accept treatment. Peconic: Vida Press.
• Dickens, R. & Marsh, D. (Eds.). (1994). Anguished Voices: Siblings and Adult Children of
Persons with Psychiatric Disabilities. Boston: Center for Psychiatric Rehabilitation, Sargent
College of Allied Health Professions.
• Gottesman, I.I. (1990). Schizophrenia Genesis: The Origins of Madness. New York:
Henry Holt and Company.
• Keefe, R.S.E. & Harvey, P.D. (1994). Understanding Schizophrenia. New York: Free
Press.
• Marsh, D.T. & Dickens, R. (1997) How to Cope with Mental Illness in Your Family: A self
care guide for siblings, offspring, and parents. New York: Jeremy P. Tarcher/ Putnam.
• Mueser, K.T. & Gingerich, S. (1994). Coping with Schizophrenia: A Manual for Families,
Consumers, and Providers. New Harbinger Publications.
• Mueser, K.T., & Gingerich, S. (2006). The Complete Family Guide to Schizophrenia.
Guilford Publications.
• Temes, R. (2002). Getting Your Life Back Together When You Have Schizophrenia. New
Harbinger Publications.
• Torrey, E.F. (1995). Surviving Schizophrenia: A Manual for Families, Consumers, and
Providers. New York: Harper Collins Publishers, Inc.
• Woolis, R. (1992). When Someone You Love Has a Mental Illness: A Handbook for
Families and Friends. New York: Jeremy P. Tarcher/ Putnam.
FOR TEENAGERS:
• Friedman, M. (2000). Everything You Need to Know about Schizophrenia. New York:
The Rosen Publishing Group.
AUTOBIOGRAPHIES:
• Schiller, L., & Bennett, A. (1996). The Quiet Room : A Journey Out of the Torment of
Madness. New York: Warner Books Inc.
• Simon, C. (1997). Mad House: Growing up in the Shadow of Mentally Ill Siblings. New
York: Penguin Books.
• Olson, L.S. (1994). He Was Still My Daddy. Portland: Ogden House Publishing Co.

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 • Sexton, L.G. (1994). Searching for Mercy Street: My Journey Back to My Mother. Boston:
Little Brown & Co.
Websites
FOR GENERAL INFORMATION:
[Link]
[Link] (Medscape Schizophrenia Resource Center)
[Link] (National Alliance for the Mentally Ill)
[Link] (The Schizophrenia Homepage)
[Link] (Schizophrenia Digest)
[Link] (Information in 8 different languages)
[Link] (Early Psychosis Prevention and Education Centre, Australia)
[Link] (“Basic Facts about
Schizophrenia” – British Columbia Schizophrenia Society)
[Link] (“Schizophrenia: A Handbook For
Families” – British Columbia Schizophrenia Society)
[Link] (National Institute of Mental Health)
[Link] (National Alliance for Research on Schizophrenia and Depression)
[Link]
[Link]
[Link] (MGH Blum Patient and Family Learning Center)
FOR MEDICATION INFORMATION:
[Link]
[Link]
FREE VIDEO PRESENTATIONS AVAILABLE ONLINE:
[Link]
[Link]

CBT Client Manual 8-10-07 84

 Information Handout 13: Solving Problems and Achieving Goals

One way to decrease stress in daily life and to make progress on personal goals is to learn
skills for effective problem solving. The following Problem-Solving exercise can be used to
help you come up with new ideas and a new way to work on achieving a goal. The more you
practice this strategy, the better you will become at solving problems and achieving goals.

Practicing a problem-solving strategy can help decrease stress and deal with
daily problems and accomplish life goals.

Steps for Problem Solving:

There are several steps in effective problem solving and following these steps is likely to help
you to solve problem more effectively. When you are doing problem solving, it is best to write
things down, because following these steps can be a lot to remember.

1) Clearly identify the problem or goal,

2) Brainstorm about all possible solutions,
3) Consider the pros and cons of each possible solution,
4) Pick the best solution or combination of solutions,
5) Make a specific plan to carry out the solution you chose. (This may include
identifying people that you need to help you carry out the plan)
6) Evaluate whether or not the solution worked.

Step 1: Clearly Identify the Problem or Goal

The first step for tackling a problem or achieving a goal is to clearly define the problem that you
are trying to solve or the goal that you are hoping to achieve. Some examples of problems or
goals that you can work on using this problem-solving exercise include:

1. I do not have enough money to pay all my bills.

2. My doctor says I need to lose weight in order to reduce my risk for heart disease.
3. I do not socialize enough.
4. I would like to get a job.
5. I do not like where I live.

Step 2: Brainstorm about Possible Solutions

The next step is to come up with as many possible solutions to the problem or goal as possible.
Write down any and all possible solutions that come to mind (don’t worry yet about considering
whether or not they will work). You will be evaluating the pros and cons of each idea later on.
For example, if the problem you decide to work on is “I do not have enough money to pay all my
bills,” your list of possible solutions might look like this:

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Possible solutions:
1. Get a job
2. Borrow money from my sister
3. Try to win the lottery
4. Cut down on cigarette smoking (save money by not buying as many cigarettes)
5. Buy groceries and make food at home rather than eating out.
6. Ask my case manager for help with making a plan to pay off my debt.

Step 3: Consider the Pros and Cons of Each Possible Solution

Once you have made a list of all the possible solutions you can think of, it is time to evaluate the
pros (advantages) and cons (disadvantages) of each possible solution. Using the example, “I do
not have enough money to pay my bills,” this step might look like this:

Possible solution Pros Cons

1. Get a job ƒ Could earn money to help ƒ Haven’t worked for a long
with bills time and don’t have much
ƒ Might enjoy working and help experience
keep me from being bored ƒ Last job was really stressful
ƒ Working can help with self- ƒ Don’t think I could find a job
esteem soon enough to help with my
bills
2. Borrow money ƒ Could help me get bills paid ƒ She might be irritated with me
from my sister this month. for needing money again.
ƒ My sister has helped me with ƒ Haven’t been able to pay her
money before. back money I borrowed
before.
3. Try to win the ƒ Could help me get rich quick ƒ If I don’t win, I will be in
lottery if I win. even more debt.
ƒ My chances of winning are
very low.
4. Cut down on ƒ Could help me save money ƒ Will be hard to do.
cigarette ƒ Could improve my health. ƒ I have tried to do this before
smoking to save and found it too hard to keep
money it up.
5. Buy groceries ƒ Eating at home is cheaper ƒ Requires extra effort to go to
and make food than eating out. the store, buy food, and cook.
at home rather ƒ The food I make at home is ƒ I don’t like to cook or clean
than eating out often healthier. up after cooking.
6. Ask my case ƒ He might have some good ƒ He may ask me to make some
manager for ideas about what to do. changes in my spending that
help with ƒ He has helped me with are hard to make (e.g. stop
making a plan managing my money before. smoking and stop buying
to pay off my lottery tickets)
debt ƒ It’s hard for me to ask for
help.

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Step 4: Pick the Best Solution or Combination of Solutions

Once you have considered the pros and cons of each possible solution, you are ready to pick a
solution to try. You might choose just one of the options or decide to try a combination of
several of the options. For example, for the situation described above, a person might choose the
following solution:

Solution chosen: Talk to my case manager for ideas and cook at home instead of
eating out.

Step 5: Make a Specific Plan to Carry Out the Solution you Chose

Now that you have chosen a solution to try, it is important to make a specific plan for carrying
out this solution. The plan should address the following important questions:

1. Tasks. What specifically will you do to carry out the plan?

2. Time-frame. When will different parts of the plan be accomplished?
3. Resources. Are any special resources needed to carry out the plan (e.g., money, skills,
information?) Who can you ask for help in order to carry out this plan?
4. Possible obstacles. What could possibly interfere with successfully carrying out the plan?
How could these obstacles be avoided or dealt with if they occur?

For our example, the specific plan might look like this:

Tasks: I will ask my case manager for help with my debt. I will make a list of
groceries to buy and go to the supermarket to buy the ingredients.

Time-frame: Talk to my case manager: Wednesday, during our appointment.

Make list: By tomorrow afternoon
Go shopping: Wednesday afternoon, after my appointments

Resources: I can call my sister to see if she has some recipes for low-cost meals
that are easy to make at home. I will need to save the $40 left from
my check this month in order to buy groceries.

Possible I might not feel like going grocery shopping on Wednesday afternoon
obstacles: and be tempted to eat out instead. Therefore, I will tell my case
manager about my plan and ask him to remind me that it is important to
carry out my plan.

I might be tempted to buy lottery tickets today and spend the money I
need for groceries. Therefore, I will avoid going to the place where I
usually buy lottery tickets.

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Step 6: Evaluate Whether or Not the Solution Worked.

The final step for effective problem solving is to evaluate whether or not the solution you chose
and carried out worked. If the solution did not work, it can be helpful to determine what got in
the way and whether or not it might be helpful to try again or to choose a different solution to
try.

Practicing Problem-Solving

The form on the following pages can be used to help you practice problem-solving on your own.
The more you practice this, the better you will get at tackling problems and achieving goals.
You can practice problem-solving on your own or with the help of a friend, family member, or
clinician.

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 Exercise 13A: Problem-Solving / Goal Setting Guide:

1) What is the problem or goal that you want to work on? (Be as specific as possible)

_____________________________________________________________________________

_____________________________________________________________________________

2) Brainstorm about all possible solutions and write them in on the table below. DO NOT
evaluate these until Step 3.

3) Consider the pros and cons of each possible solution (write these in on the table below).

Possible Solutions Pros (Advantages) Cons (Disadvantages)

(brainstorming)

CBT Client Manual 8-10-07 89

4. After evaluating the pros and cons of each possible solution, I have decided that the best
solution, or combination of solutions is:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

5. My plan for carrying out this solution is as follows:

Tasks: What specific

tasks will I do?

Time-frame: When will

each task be done?

Resources: What do I
need to carry out the plan?

Possible obstacles:
What might get in the
way? How can I avoid
these obstacles or deal
with them if they happen?

6. Evaluation: Did my plan work? If not, what obstacles came up? Should I try again? Should
I choose another solution?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

CBT Client Manual 8-10-07 90

 Information Handout 14: Facts about Exploitation and Victimization

Unfortunately, it is sometimes the case that other people in our lives do not have our best
interests at heart, even if they say that they do. Sometimes other people may try to talk you into
doing things that are not good for you. And sometimes, because you may want to have certain
individuals in your life, it is hard to notice when others are taking advantage of you. Even when
you do notice, it is also sometimes difficult to stop the situation from continuing. “Exploitation”
is when someone is taking advantage of another person. In its most serious form, (for example,
sexual, physical, or emotional abuse), is called “victimization.”

How can you tell if you are being taken advantage of, exploited, or victimized?

It can be difficult to know when someone may be trying to take advantage of you.

Here are some clues to watch out for -- if an acquaintance, neighbor, friend, family member,
boyfriend or girlfriend repeatedly does the following:

Day to Day Situations:

• Frequently asks to borrow or use your things (like your phone to make long distance
calls, your TV, or other possessions) and does not return the items and/or does not return
the favor.

• Always asks or expects to borrow your car or have you drive them somewhere and does
not pitch in for gas.

• Always requests to borrow or simply takes some of your money (or a portion of your SSI
check) and does not pay you back.

• Frequently asks you for cigarettes but never returns the favor.

• Stays at your apartment for several days or longer without asking if it is ok or offering to
pay rent or contribute to groceries. Sometimes this is an even tougher situation if your
landlord does not allow more than one person per apartment.

More Serious Situations:

• Often asks you to drive them to or go to hang out in unsafe neighborhoods, even though
you know this may be a dangerous situation.

• Frequently requests that you to drive them to or go with them to bars, even though you
have told them that you are working on not using alcohol.

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 • Requests that you drive them, accompany them, or run an errand for them to buy drugs,
or do other illegal things for or with them.

Victimization (Very Dangerous) Situations:

• Asks or forces you to engage in sex when you don’t want to.

• Threatens you verbally, physically, or sexually when you don’t do what they request.

**Note: These are very serious situations. Please see Information Handout 10 “Facts about
Traumatic Experiences” for more information on these types of situations and how to handle
them.

What are some things you can do to prevent being taken advantage of, exploited, or
victimized?

Although the situations described above can be very difficult emotionally as well as dangerous,
there are some things that you can do to stop these situations from occurring again or prevent
them from happening in the first place.

Here are some tips to be aware of:

1. Stay away from drugs and alcohol. When people use substances, their judgment becomes
clouded. After using drugs or alcohol, saying no to others becomes more difficult, and
people place themselves more readily in possibly dangerous situations. Also, if others
notice that someone is intoxicated or high, they may be more likely to try to take
advantage of that person, because that person is more vulnerable in that state of mind.

2. Stay away from unsafe neighborhoods. Oftentimes, people who hang around in
unsafe neighborhoods do not have your best interests at heart. This can create many
dangerous situations. It is safest to always be aware of your surroundings.

3. Practice improving your social skills around saying “no.” Learning to be assertive and
planning out ahead of time what you will say if someone asks you to do something that you
know is unhealthy, illegal, or dangerous is a very important skill. It requires some practice
though. See accompanying Exercise 13B, entitled “Preventing Exploitation and
Victimization.” Practice these skills often so that when difficult situations come up, you will
feel more in control and know how to handle them.

4. Follow your treatment plan. It is very important to keep up with your medications, day
treatment program, and psychotherapy. Sometimes, having untreated psychotic symptoms
can lead to losing important things, like your apartment, which can lead to homelessness.

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 Being homeless or spending too much time on the streets is a big risk factor for
victimization.

5. Stay in touch with your treatment team. Let your case manager know if any of the
situations described above have been happening to you recently. Your case manager can help
you make a plan to prevent these types of situations from happening, and can help prevent
some of the negative consequences (like financial or housing problems).

6. Talk to a trusted individual if you feel you are being taken advantage of, exploited, or
victimized. Always tell a trusted friend or family member, your therapist, psychiatrist, and/or
case manager if you feel you are in an uncomfortable or possibly dangerous situation. It is
important to not keep these incidents a secret, even if you feel ashamed or embarrassed. A
trusted person in your life can help you figure out how to handle these situations and prevent
them from continuing to happen or from getting worse.
.

CBT Client Manual 8-10-07 93

 Exercise 14A: Preventing Exploitation and Victimization

As described in the information Handout 14 entitled, “Facts about Exploitation and

Victimization,” there are unfortunately situations that come up in life where people ask you
to things and don’t have your best interests at heart. There are a variety of effective ways to
handle these situations. One important way is to practice improving your assertiveness skills.
Learning to say “NO” with confidence can help get you out of many negative situations. If
you anticipate a situation in your life that involves someone trying to take advantage of you,
you can plan out ahead of time exactly what you will say to prevent that from happening.
This makes it easier to use this skill “in the moment.”

PART I. Learning the skill “Refusing Requests from Others”*

*adapted from Bellack, et al (1997), Social Skills Training for Schizophrenia: A Step by Step
Guide

Steps of the Skill:

1. Look at the person. Speak firmly and calmly.

2. Tell the person you cannot do what he or she asked. Use a phrase such as “I’m
sorry but I cannot _____”
3. Give a reason if it seems necessary.

Example:
Neighbor: “Hey, I need a ride to Johnnie’s Bar downtown. I’m meeting some people
there in 15 minutes. Why don’t you drive me then you can come in and
hang out for a little while.”
Client: “I’m sorry but I cannot do that. It is not a good idea for me to go to bars since
I got sober two years ago.”
Neighbor: “It’s no big deal, but whatever. Why don’t you just give me a ride over
there then and drop me off.”
Client: “I’m sorry but I cannot do that either. Even being near a bar is hard for me.”
Neighbor: “I’ll pay for the gas.”
Client: “Again, I’m sorry but I can’t do that. It’s just not something I feel I can do.”
Neighbor: “Alright, man, that’s cool.”

*This can be a difficult skill, especially if the person making the request is persistent or a
good friend of yours. But it will get easier over time. So practice, practice, practice!!! Asking
a trusted friend or your case manager to help you work on this skill can be very helpful.

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PART II. Identifying and working on changing “exploitation” situations

1. Have there been any situations in your life where you felt you may have been taken advantage
of? Have other people suggested that someone was taking advantage of you, even if you didn’t
think so? If so, describe the situation below.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. How did you handle the situation? How did it turn out?

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. Was there anything you wished you had done differently? If so, what?

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

4. Are there any situations currently where you feel you are being taken advantage of that you
would like to change? Choose one and describe it below:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

5. How might you address this situation with this person? Practice using the steps of the skill,
“Refusing Requests.”

1) Look at the person. Speak firmly and calmly.

2) Tell the person you cannot do what he or she asked. Use a phrase such as “I’m sorry
but I cannot __________.”
3) Give a reason if it seems necessary.

6. Practice the skill with a trusted friend or your case manager.

CBT Client Manual 8-10-07 95

 Information Handout 15: Reducing Your Risk of Infectious Diseases from
High-Risk Behaviors

Infectious diseases are illnesses that are easily spread from one person to another. People who
experience mental illness and engage in high-risk behaviors (such as using drugs and having
unprotected sex) are at higher risk for developing three kinds of infectious diseases that are
caused by viruses. These include: the hepatitis B virus, the hepatitis C virus, and human
immunodeficiency virus (HIV). These diseases are spread by contact with contaminated blood or
other body fluids (like semen). Each of these diseases is serious, and can cause serious health
problems or even death. This handout explains 1) How to avoid contact with these viruses, 2)
Whether a person should be tested for these diseases, and 3) If someone has a disease, how to
avoid spreading it to others.

Hepatitis B, hepatitis C, and HIV are viruses that are spread by contaminated
blood or body fluids.

What is hepatitis B and C?

Hepatitis B and C are diseases that hurt the liver. The liver is the part of the body that filters out
toxic materials. A person needs a healthy liver in order to live. When a person has hepatitis, the
liver becomes sick or inflamed, and can lead to more serious problems, including cirrhosis
(permanent scarring of the liver that reduces blood flow), liver failure (the liver is unable to
function) and liver cancer (cancer cells attack the liver).

What is HIV?

The human immunodeficiency virus (HIV) attacks and destroys special white blood cells in the
body, called T-cells, that are important for the body’s ability to fight off infections. When HIV
destroys these cells, the body cannot fight off infections, so infections that would normally be
minor (such as a mild cold) become very serious and can cause a person to become sick and even
die. Acquired immunodeficiency syndrome (AIDS) is the disease that someone gets after HIV
has destroyed the immune system and the body can no longer fight off infections.

How can I avoid contact with hepatitis B, C, and HIV?

All three of these viruses pass from one person to another through exposure to infected blood or
other body fluids. Some ways that people get exposed to contaminated blood or body fluids can
include the following:

• Sharing injection needles with other people.

• Sharing a straw with others when snorting cocaine, amphetamine, or heroin.
• Having sex without a condom with many partners or with people they don’t know well.
• Having body piercings or tattoos with improperly sterilized needles.

CBT Client Manual 8-10-07 96

• Using a razor, toothbrush, or nail clippers that has been used by someone with the infection
• Having a blood transfusion, hemodialysis, or organ transplant before 1992 (for hepatitis) or
1985 (for HIV)
• Being born to a mother with the infection

Some important ways to avoid contact with these viruses include:

• Avoid using street drugs. If you do use street drugs, do not share needles (for injecting) or
straws (for snorting) with another person.
• Avoid having sex with multiple partners or people you do not know well. Use a condom
unless you and your partner have recently tested negative for these viruses.
• Avoid getting a tattoo or body piercing unless you can be certain that a sterilized needle is
being used.

There are several precautions a person can take to avoid contact with hepatitis B,
hepatitis C, and HIV.

Should I get tested for any of these viruses?

A blood test can be used to tell whether a person has hepatitis B, hepatitis C, or HIV. Most
people who contract these viruses do not develop symptoms right away, but getting early
treatment can help to decrease the effects of these viruses on health. Therefore, it is a good idea
to get tested if you have been exposed to any of the risky situations listed above.

If I have one of these diseases, what can I do to prevent spreading it to others?

If you have one of these illnesses, it is important to meet with a medical care provider as soon as
possible to discuss your treatment options. Also, good self care can help a person to stay well.
This includes taking all your medications as prescribed, getting enough rest, eating healthy
foods, and avoiding using alcohol or street drugs.

In addition, to avoid spreading the infection to other people, it is important to avoid engaging in
behaviors that can lead to your body fluids coming in contact with others. This can include:

• Not sharing needles with other people

• If you have to share needles with others, make sure that you immerse them in bleach for 30
seconds at least three times.
• Always use a latex condom when engaging in sexual relations.
• Do not share personal items (razor, toothbrush, nail clippers) with others.

If you have contracted one of these viruses, it is important to avoid engaging in

behaviors that can lead to your body fluids coming in contact with others.

CBT Client Manual 8-10-07 97

 Information Handout 16: What to Expect from Your Mental Health Treatment

Mental health treatment is extremely important for helping you feel well and keep up with things
in your daily life. However, getting what you need and understanding the mental health system
can often be difficult. This is because there are so many professionals involved, so much
paperwork, and often, getting services (like housing, vocational rehabilitation, food stamps,
Social Security Insurance, etc.) takes a lot longer than you would like.

This can often lead to frustration – both for the client and the professionals who are helping the
client. Understanding what each mental health professional is able to do to help you (see
Exercise 16A, “Know Your Treatment Team and What They Do”) can make it easier to figure
out who the right person is to ask for help with which particular type of problem. This can also
help you learn what is reasonable to expect from the mental health system in general, and from
your case manager. This way, you can advocate for yourself and you will not become
disappointed by having expectations that don’t match with what is possible. Finally, it can be
very helpful to know what your role in your care is, and what is expected of you.

The more clear you are about what you can expect from mental health care and what your case
manager and other mental health professionals can expect from you, the more smoothly your
care will go! Also, you will likely feel more satisfied with the services you are receiving if you
keep in mind the following:

You Can Expect that Your Case Manager will:

1. Be prompt for your appointments, and keep scheduled appointments on a regular basis. If
he/she is going to be late for an appointment or needs to cancel a scheduled appointment, he/she
should let you know as soon as possible and apologize for any inconvenience.

2. Treat you with courtesy and respect, and behave in a professional manner.

3. Keep your records and personal information strictly confidential. (However, important
information related to helping you reach your treatment goals may be shared with your treatment
team. If there is an emergency situation, some personal information may be shared with other
professionals in order to keep you or someone else safe). Your case manager should discuss
confidentiality with you.

4. Help with parts of your life within his/her area of expertise (e.g., setting up housing, financial
benefits, other government services, helping with applications, coordinating care with other
providers in mental health system, etc.).

5. Refer you to other providers when you need help with things outside his/her areas of expertise
(e.g., psychotherapy, job training, medication issues, physical health issues, etc.).

6. Help you to make important decisions in a collaborative manner.

CBT Client Manual 8-10-07 98

7. Encourage independence as you are ready for it.

8. Be honest and forthcoming with feedback to you.

Your Case Manager (and other Mental Health Staff) will Expect You to:

1. Make every possible effort to attend all appointments and to be ready on time (avoid canceling
at the last minute or not showing up without calling). If you are going to be late for an
appointment or need to cancel a scheduled appointment, you should let your case manager know
as soon as possible.

2. Treat him/her with courtesy and respect.

3. Be patient and understanding that the staff members have many clients to help, and this means
they might not always be able to get back to you immediately when you ask for help with a
particular problem. Case managers need to divide their attention and services among many
clients.

4. Cooperate with them to help you to achieve your goals. (Sometimes, this might mean trying
out a suggestion that your case manager makes about a new way of solving a problem. This may
be hard at first, but it will get easier as you practice.)

5. Be as honest as possible (e.g., regarding symptoms, medication adherence, substance use,

daily activities).

6. Remember that your relationship with your case manager and other staff is a professional one
(see below for more details on this).

What Is Not A Part of the Client-Staff Relationships:

Although case managers care about their clients and are there to listen and help, there are certain
things that are not a part of the client-staff relationship. In general, clients and case managers will
not:

1. Engage in socializing outside of tasks related to case management. This means they will
generally not go out to dinner, to the movies, go to a bar, or have a drink.

2. Engage in any kind of romantic or sexual relationship.

3. Clients will not contact their case managers (or other staff) at their home phone numbers
(unless specifically told to do so by staff) or go to the staff member’s home.

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4. Give each other gifts. While it is important to express appreciation for one and other, a card or
letter is probably the best way to do it. Clients and case managers generally should avoid
spending money on each other.

5. Case managers generally will not tell you what to do. Rather, they will offer suggestions and
professional recommendations, and help you problem-solve solutions. Ultimately, it is your
choice whether to do one thing or another.

Extra Things to Remember:

*** Sometimes the client and case-manager relationship does not always feel comfortable or go
smoothly. This is natural. The important part is to talk to your case manager if something about
the mental health system or your relationship with him/her is bothering you. Usually, you can
both work together to make things better. (See patient exercise 6A, Communication skills).

*** Clients have the right to request to change their case manager (or other staff member) if they
feel that things aren’t working out and talking it over with the staff member has not been helpful.
It is important to understand, however, that depending on the clinic, changes cannot always be
made if there are not enough staff to go around. It is also important to note that a change like this
can usually be honored only one time. Keep in mind that trying to overuse this privilege usually
won’t work. The best thing to do is to try to work things out with the staff member first, before
requesting the change.

*** The lists above are general guidelines. This means that rules may vary from clinic to clinic.
The best way to make sure that you and your case manager are “on the same page” is to sit down
with him/her, go through this information sheet, and add any additional rules or guidelines that
apply specifically to your mental health system.

*** It usually takes time to get aspects of your mental health treatment ironed out. Be patient and
hang in there! If you follow the above guidelines, things will usually work out for the best!

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 Exercise 16A: Know Your Treatment Team and What They Do

Because mental health treatment can sometimes be complicated, there are many different people
in the field who have different specialties. You have likely been in contact with different
professionals, each of whom has worked with you on different types of issues. For example, your
psychiatrist helps you with medication, your individual therapist helps you work on relationship
stress, your group leader helps you learn better communication skills, and your case manager
helps you obtain Social Security and other benefits and things to improve your daily living.

Each of these individuals has expertise in distinct areas. With so many mental health
professionals around, it can sometimes be difficult to keep track of who to ask about what. This
is understandable. However, learning whom to go to with different issues can make things less
stressful for you and the person working with you. And it can probably help get your questions
answered more quickly and more accurately too!

Below is a chart that will help you keep track of which treater is responsible for which area in
your life. Take some time to fill out this information with your case manager. That way, when
you have a question about something that comes up and aren’t sure who to ask, you can check
this sheet and figure it out. You will also have a list of phone numbers for each person, so you
won’t have to worry about forgetting how to get in touch with them.

Keep this handy sheet in a place where you can get to it easily and remember where it is!
See attached page:

CBT Client Manual 8-10-07 101

 Know Your Treatment Team!

If I have a question I should talk to: And I can reach him/her

about..... at:

Medications and/or side My Psychiatrist:

effects, my dosage
___________________

Making or changing an The Receptionist:

appointment to see my
psychiatrist ___________________

Having to miss group Group or Day Treatment

Staff:

___________________

Issues related to family Therapist:

problems or my past or
other “psychological” ___________________
questions

Health benefits, SSI, other Case manager:

government funded
programs, financial issues ___________________

Working or going back to Vocational counselor:

school, getting job training
___________________

My living situation, Residential counselor:

roommates, house rules, etc.
___________________

Other:

___________________

Other:

___________________

CBT Client Manual 8-10-07 102

 Information Handout 17: Facts about Communicating with Doctors

Keeping up with your mental and physical health often involves attending appointments with
physicians, psychiatrists, and other medical professionals. Sometimes, these appointments occur
frequently (like every week), but usually they come up about once a month or so. Often, the
appointments can be very short (between 10 and 30 minutes) because most doctors take care of a
lot of patients

Because you may not know your doctor very well or may not see him/her too often, sometimes it
feels uncomfortable to meet with him/her. This is natural. However, there is usually important
information that you need to tell the doctor or that the doctor needs you to understand. So
working on how you and your doctor communicate can be very valuable.

Feeling comfortable and communicating with your doctor can be a challenge.

Working on what is getting in the way of good communication can help a great deal.

Below is a list of common difficulties that may get in the way of good communication with your
doctor. Following each difficulty are some ideas for possible solutions to that problem.

PROBLEM: Anxiety or Nervousness

It is not uncommon to feel nervous or anxious around others, especially your doctor. Anxiety
reduces your ability to communicate important information. It can also get in the way of
understanding what your doctor is trying to convey.

SOLUTIONS:

• Practice deep breathing and muscle relaxation before, and even during the
appointment. Ask a therapist or case manager for a lesson in how to do this.

• Let the doctor know that you sometimes get anxious. If the doctor knows this
ahead of time, he/she can work with you to help you relax a bit.

• Bring a list of questions with you. Then if you become anxious, you can refer to
the list to help keep you focused.

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PROBLEM: Memory Difficulties

Many times it is difficult for people to remember in the moment their questions or concerns
about their medications or other health-related issues. When this happens, the doctor’s
appointments can feel unproductive. In addition, it can be a challenge to remember what the
doctor has said after the appointment is over. This can cause problems if you end up not being
sure about how to take your medications or treat another health-related problem.

SOLUTIONS:

• Write down all questions and comments beforehand and bring this list to the
appointment.

• Take notes or ask to tape record your conversation so that you can look review it later.

• Bring your case manager, or a supportive friend or relative to your appointments

whenever possible. That way you will have an “extra set of ears” to be sure that no
important information gets missed. This also can be helpful because the person you bring
can remind you of some of your questions if you forget during the appointment.

PROBLEM: Feeling that the Appointment is too Short

Because clinics are very crowded and lots of patients need care, there often aren’t enough
doctors to go around. Unfortunately, this means that the appointment times are usually pretty
short, between 10 and 30 minutes. Here are some tips to make the best use of your time together.

SOLUTIONS:

• Come prepared with a list of questions, concerns, or things you would like to address
with the doctor. Prioritize the list so that you discuss the most important things first.

• Request a longer appointment from the receptionist. While your doctor probably won’t be
able to make every appointment longer, he or she may be willing to set up a longer
appointment from time to time.

• Discuss your concern with your doctor. He/she can often help problem-solve around how
to make the best use of your time. Also, if he/she shares this concern, he/she may agree to
a longer appointment with you in the future.

CBT Client Manual 8-10-07 104

PROBLEM: Having Trouble Understanding what the Doctor is Saying

Sometimes the doctor talks fast, uses technical language, or has an accent.

SOLUTIONS:

• Ask the doctor to repeat himself/herself again if something seems unclear. Request that
the doctor use different words to explain something if you are unsure what he/she is
saying. Sometimes, having someone describe something in a different way can make it
more understandable.

• Ask your case manager or friend or relative to attend the appointment with you.
Afterwards, you and that person can go over the information that was discussed during
the appointment in a slower way.

• Practice and use the “Listening to Others” skill (See Client Exercise “How to Improve
Communication with your Doctor”). Be sure you are listening and doing your best to
show the doctor you are paying attention. Making the best effort you can to understand
what is being said can make a big difference in how the appointment goes.

• Also practice and use the skill “What to Do When you Do Not Understand What a Person
is Saying” (See Client Exercise “How to Improve Communication with your Doctor”).

PROBLEM: Wanting a Medication Change or Having Questions but Not Knowing

How to Ask

Medical treatment often involves a lot of trial and error. Effective treatment depends on
receiving good information from the client about medication effects combined with the physician
having knowledge about medication effects. It is helpful for clients to consider themselves
partners in the treatment process and feel free to ask questions or express doubts regarding
medications.

SOLUTIONS:

• Figure out what your concerns and questions are ahead of time and practice stating them
with your case manager or a friend.

• Write down your questions and bring them to the doctor at your next appointment.

• Ask your case manager or a friend or family member to attend the appointment with you.
This person can help explain your concerns to the doctor or ask your questions.

CBT Client Manual 8-10-07 105

PROBLEM: Feeling like you and the Doctor aren’t a Good Fit

Sometimes we feel like we don’t “mesh well” with certain people. We may be soft-spoken and
they may be loud. We may like to make jokes and they may be serious most of the time. Just like
in the real world, this can happen with doctors who we see too.

SOLUTIONS:

• Figure out specifically why you feel this doctor is not a good fit for you.

• Discuss your concerns with your case manager or therapist. Sometimes they can help you
see a different way of looking at things. Or they can help you figure out what your
options are as far as switching doctors if this is a possibility.

• If it is an option at your clinic, put in a request to switch doctors. If there are other
doctors to work with, these types of requests can sometimes be honored. However, be
aware that there may be a wait list if you request a switch. Your case manager may be
able to help you through this process.

* See “How to Improve Communication with your Doctors Client Exercise” for extra practice on
talking with your doctors.

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 Exercise 17A: How to Improve Communication with your Doctors

Below you will find some communication skills that will help specifically with talking to your
doctors. Based on the particular difficulty you are experiencing (See Information Handout “Facts
about Communicating with Doctors” for help identifying specific difficulties or concerns that
you might have), choose which skill would be most helpful to try out.

Next, go through the steps of each skill, making sure you understand each. Specific examples are
also provided below. Ask your case manager, a friend, or a relative to help you practice the skill,
using the particular difficulty that you want to work on as the example. Have that person pretend
to be the doctor, while you go through the steps of the skill, pretending you are at your
appointment. This is called a “role play.”

Practice, practice, practice! The more role-plays you do, the easier it will be to use these skills
when you are meeting with your doctor.

*Note: all skills are taken from Bellack, et al (1997) Social skills training for schizophrenia: A
step-by-step guide. NY: Guilford.

Listening to Others:

Steps of the Skill:

1. Maintain eye contact.

2. Nod your head.
3. Say, “uh-huh,” or “okay” or “I see.”
4. Repeat what the other person said.

Example:
Psychiatrist: “Take this medication once a day in the morning.”
Client: “Okay, once a day.”
Psychiatrist: “Make sure you take it with food as well.”
Client: “With food, uh-huh.”

What to Do When You Do Not Understand What a Person is Saying:

Steps of the Skill:

1. Tell the person that you are confused or that you did not understand what was said.
2. Ask the person to repeat or explain what was just said.
3. Ask further questions if you still do not understand.

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Example:

Physician: “You need to get a blood draw tomorrow morning. You can only come
between 7:15 AM and 8:45 AM, and you can’t eat for 12 hours prior to the test.

Client: “I’m sorry. I didn’t catch what those hours were. Can you repeat them please?”

Physician: “No problem, between 7:15 and 8:45.”

Client: “And can you explain when my last meal needs to be?”

Physician: “Sure, have your dinner no later than 7PM, and then nothing until after the
test.”

Client: “Now I understand, thank you.”

Asking for Information:

Steps of the Skill:

1. Use a calm and clear voice.

2. Ask the person for the information you need. Be specific.
3. Listen carefully to what the person says.
4. Repeat back what he or she says.

Client: “Can you please tell me when I need to get my Lithium levels rechecked?”
Psychiatrist: “Sure. Make sure you get them checked the first week of March.”
Client: “First week of March. Got it. Thank you.”

Making Requests:

Steps of the Skill:

1. Look at the person.

2. Say exactly what you would like the person to do.
3. Tell the person exactly how it would make you feel.

In making your request, use phrases like:

“I would like you to _____.”
“I would really appreciate it if you would_____.”
“It’s very important to me that you help me ___.”
“I would feel so much more relaxed when we meet if you could help me by __.”

CBT Client Manual 8-10-07 108

Example:

Client: “I would really appreciate it if we could make our next appointment 10 minutes
longer if possible. I have several questions about these new medications and it
would make me feel more relaxed if I had a little more time to ask them.”

Physician: “I would be happy to do that. Just arrange that with the receptionist on your way
out today.”

Client: “Thank you very much.”

Asking Questions about Medications OR Health-Related Concerns:

Steps of the Skill:

1. Ask the person about your question about medication or your health. Be specific.
2. If you do not understand the person’s answer, ask more questions.
3. Thank the person for his/her help.

Example:

Client: “Dr. Jones, I would like to know what some of the most common side effects are
of this new medication you are thinking about prescribing to me.”

Psychiatrist: “It is possible that you may experience some lethargy, as well as \
occasional headaches.

Client: “Can you tell me what you mean by ‘lethargy?’

Psychiatrist: “Certainly. ‘Lethargy’ means feeling drowsy and having difficulty ‘getting
going.’ ‘Sluggish’ is another word used to describe this side effect.”

Client: “I understand now. Thanks for the information.”

CBT Client Manual 8-10-07 109

 Information Handout 18: Staying Well and Reducing Relapses

Symptoms of mental illness tend to vary in intensity over time. When the symptoms become
more severe and disabling, a person may be said to be experiencing a relapse. Researchers have
not been able to identify all the reasons that people have relapses of their symptoms. Research
has shown, however, that relapses are more likely to occur when: 1) People are under more
stress; 2) People stop taking their medications, and 3) People use alcohol or drugs.

When a person’s mental illness symptoms become more severe and disabling, he
or she may be said to be experiencing a relapse.

Is there anything I can do to prevent a relapse?

Although there is no full-proof plan that can prevent a relapse from occurring, there are a number
of steps that you can take to make it less likely that you will experience a relapse (or reduce the
severity of a relapse if one does occur). Some of these include:

1. Take your medication as prescribed. People who take their medications exactly as they
are prescribed, even when they are no longer experiencing symptoms, are much less
likely to experience relapse. Studies show that most people who stop taking their
medications will relapse within a year of stopping their medication.

2. Learn to identify early symptoms of relapse and act to deal with them: Individuals differ
in the type of symptoms they experience, but for each person, the symptoms of relapse
may be similar. One skill that you can learn is to identify early signs of relapse and take
steps to prevent them from worsening (see below for details on common early signs). It
can also be very helpful for your family to learn about your illness and symptoms so they
can help you to deal with early warning signs when they occur.

3. Participate in treatments that help you recover. Participating actively in treatment and
seeking help from your treatment team can be very helpful in preventing relapses. Make
every possible effort to attend all appointments, especially at times when you may be
feeling more symptomatic (e.g., feeling depressed, down, exhausted, anxious, or
paranoid). The sooner you get help, the more likely you will be able to prevent a relapse
from occurring.

4. Build and maintain a good social support system. Social support is crucial for dealing
with stress and reducing risk for relapse.

5. Avoid alcohol and drugs. People who use alcohol and street drugs are much more likely
to experience relapses.

CBT Client Manual 8-10-07 110

 6. Maintain a healthy lifestyle. Maintaining a healthy, balanced lifestyle involves getting
enough (but not too much) rest, eating healthful foods, exercising moderately, and
keeping a regular daily structure that includes both pleasurable and productive activities.

7. Develop a relapse-prevention plan. A relapse prevention plan can help you to respond to
early warning signs of relapse so that you can minimize the severity of the relapse or
even avoid it all together. The key components of a relapse prevention plan involve
identifying potential triggers for relapse and early warning signs and identifying an action
plan for responding to these early warning signs.

What situations can be triggers for relapse?

Some people can identify certain events or situations that appear to have led to relapses in the
past. The events or situations that seemed to contribute to relapses can be thought of as relapse
“triggers.” Not everyone experiences a relapse in the same situations, but some common
examples of situations that can trigger relapses for some people include:

• Staying up late and becoming overtired

• Stress at work or school
• Starting a new job or starting school
• Arguing with a relative or friend
• Experiencing a loss, such as the death of a family member or friend
• Using alcohol or drugs
• Having a member of the treatment team leave and needing to start with a new therapist,
doctor, or case manager.
• Experiencing any big change—positive or negative (e.g., moving to a new apartment,
starting a new romantic relationship)
• Changing of the seasons

If you can identify which situations have been triggers for relapse in the past, it is possible to
plan for handling the situation differently if it were to happen again. For example, if you have
found that going out with friends and using alcohol or drugs has triggered a relapse in the past,
you might plan some activities with friends that do not involve drinking or using drugs. If you
have found that arguing with a relative has been a trigger, you might learn some techniques for
improving your communication with that relative, or some new relaxation strategies to help you
cope when stressful situations occur.

Identifying situations that have been triggers for relapse in the past can help you
to prevent future relapses.

CBT Client Manual 8-10-07 111

What are early warning signs?

Even when a person does all they can to prevent a relapse and to avoid relapse triggers, that
person may experience times when their symptoms get worse and may even experience a
relapse. Some relapses come on quickly, over a few days with little warning. However, most
relapses come on more gradually and there may be subtle warning signs that appear weeks or
months before a relapse occurs. These warning signs can include small changes in the way you
feel or behave that may signal that your symptoms are beginning to worsen. These changes may
be so subtle that they do not seem worth noticing. However, when people look back after a
relapse, they often notice that these subtle changes were some of the earliest signs that a relapse
was occurring. Some examples of early warning signs can include:

• Sleeping more or less.

• Changes in appetite.
• Missing treatment appointments (therapy, day program, etc.).
• Skipping medication doses or stopping medication completely.
• Not feeling like being around people—withdrawing from family or friends.
• Feeling irritable or “on edge.”
• Feeling like people are watching you or want to harm you.
• Engaging in quirky behaviors or superstitions (e.g., feeling like it is important to wear a
particular color, or engage in a particular ritual).
• Suddenly become more or less religious than is usual for you.
• Feeling like people are against you.
• Hearing voices.
• Engaging in unusual activities or behaviors that were similar to those you engaged in when
had more severe symptoms in the past .

By learning to recognize and take action and respond to early warning signs, a person can reduce
the risk of having a full relapse. For example, a small change in medication or getting some help
from your support system to help deal with a stressful situation reduce early warning signs and
prevent the relapse from happening.

Will I be able to recognize and respond to early warning signs on my own?

It can often be hard to recognize early warning signs on your own. Most people find it helpful to
enlist help from their treatment team, family, and friends to monitor early warning signs. One
way to enlist the help of your support system is to develop a relapse prevention plan (see
Wellness/ Relapse Prevention Plan handout for an example).

CBT Client Manual 8-10-07 112

 Exercise 18A: Wellness/ Relapse Prevention Plan

By filling this out with the help of your treatment team, family and/or trusted friends, you can
minimize your risk for experiencing a relapse.

Some things that I can do on a daily basis to help me to stay well include:

1. ____________________________________________________

2. ____________________________________________________

3. ____________________________________________________

4. ____________________________________________________

Some events or situations that have been relapse triggers for me in the past include:

1. ____________________________________________________

2. ____________________________________________________

3. ____________________________________________________

4. ____________________________________________________

Some early warning signs of relapse that I experienced in the past include:

1. ____________________________________________________

2. ____________________________________________________

3. ____________________________________________________

4. ____________________________________________________

If I experience triggers or early warning signs, some actions that I will take include:

1. ____________________________________________________

2. ____________________________________________________

3. ____________________________________________________

4. ____________________________________________________

CBT Client Manual 8-10-07 113

Some people that can help me to recognize and respond to triggers and early warning
signs include:

Name Contact Info: What they can do to help:

CBT Client Manual 8-10-07 114

 Part III: Appendix:
Additional handouts for multiple problems and information handouts on
topics not covered in Clinician Manual

CBT Client Manual 8-10-07 115

 Appendix Fact handout 1: Facts about Anxiety

What is anxiety and how do I know if I have anxiety?

In general, anxiety is having nervous feelings, thoughts, and/or bodily sensations. Occasionally,
we all get “butterflies” in our stomach before a big event, or during an argument with a family
member who is important to us, or sometimes when we are doing something new for the first
time. However, anxiety is more serious than that because it can be frequent, overwhelming, and
cause a great deal of distress for people.

Anxiety is having nervous feeling, thoughts and bodily sensations.

It can be frequent and overwhelming for people.

Below are some common feelings, thoughts, and bodily sensations that are related to anxiety.
Place a check in the box next to the items that you have experienced:

• Anxious Feelings:

___ Nervous
___ Scared
___ Worried
___ Overwhelmed
___ Other feelings? ___________________

• Anxious Thoughts:

___ “I’m in an unsafe place”

___ “I’m not able to control things”
___ “I’m out of control”
___ “I’m going crazy”
___ “I can’t handle this situation”
___ “I can’t survive this”
___ “I’m in danger”
___ “I’m going to die”
___ Other thoughts? ____________________

• Anxious Bodily Sensations:

___ Sweating
___ Heart Racing

CBT Client Manual 8-10-07 116

 ___ Trembling or Shaking
___ Nausea
___ Tightness in Chest
___ Dizziness
___ Shortness of Breath
___ Numbness
___ Other sensations? ______________________

What happens when people have anxiety?

Because anxiety causes often causes many unpleasant reactions (like the ones listed above),
people tend to want to avoid doing the activity that brought on the anxiety symptoms in the first
place. For example, if you experience anxiety symptoms every time you went to the bank to
deposit your monthly check, you probably would want to stop going to the bank at all. This
sounds reasonable but there’s a catch. Avoiding the situations that seem to cause the anxiety can
actually make the anxiety worse. Here’s how that works:

ANXIETY SYMPTOMS AVOIDING SITUATIONS

Let’s say you decide to stop going to the bank to deposit your check because talking to the teller
makes you feel some symptoms of anxiety and so you decide to mail it in instead. That
temporarily decreases your anxiety because you can avoid the bank. But one day, the bank calls
you and says that you forgot to sign the back of your check so they need you to come in and sign
it. When you go to the bank for this task, you will probably feel even more anxious than you did
the first time you went. This is because you have avoided it for so long that you are “out of
practice” and it seems even more uncomfortable. After that awful experience, you decide that
ordering your lunch from your favorite diner is uncomfortable too, because it is a little like
talking to the bank teller. So you decide not to go to the diner anymore. Pretty soon, you are
avoiding lots of things and experiencing lots of anxiety whenever you interact with others. That’s
the trouble with anxiety. It makes you want to avoid things, but avoiding only makes the anxiety
worse.

Having anxiety symptoms makes people want to avoid the situations

that cause the anxiety
BUT
Avoiding the situations makes the anxiety worse once you stop
avoiding and can make you anxious in other situations too.

CBT Client Manual 8-10-07 117

What kinds of situations make people anxious? What kinds of situations do people with
anxiety typically avoid?

Certainly what makes someone experience anxiety ranges from person to person. And as a result,
the situations that people will avoid vary from person to person as well. However, there are some
commonly avoided situations for people who experience anxiety symptoms. These situations
include: crowded places, public transportation, elevators, doctors offices or hospitals, bridges,
social gatherings or parties, making a phone call, talking on a phone at all and going to a gym or
health club.

Below is a short list of typically avoided situations. Read through the list and place a check in the
box next to items that you tend to avoid:

___ Crowded places

___ Public transportation
___ Elevators
___ Doctors offices or hospitals
___ Bridges
___ Social gatherings or parties
___ Making a phone call
___ Talking on the phone at all
___ Going to a gym or health club

Anxiety can be related to Depression

Many people often experience symptoms of anxiety and depression at the same time, or one can
cause the other (For more information on depression, see Information Handout 9A, “Information
about Depression).

Let’s take the bank example. If you are starting to avoid places you used to go and people you
used to talk to because of anxiety, it is likely that you are limiting the amount of time that you
spend doing activities and increasing the amount of time that you are staying at home by
yourself. If your activities are decreased and you are more isolated, this can lead to having a
depressed mood, feeling worthless, and hopeless about the anxiety and your life, and feeling out
of control and helpless. The depression makes you want to go out and experience life even less
and when you do go out, you feel increased anxiety, and so on. It can be a distressful cycle.

Anxiety and Depression often occur at the same time or one might cause the
other.

This can create a vicious cycle.

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Breaking the Anxiety Cycle:

Anxiety can be really difficult to cope with, especially if you have other symptoms you are
already struggling with, like voices or unclear thinking, or feeling paranoid. It is important to talk
to your doctor or other mental health professional about what you are experiencing. It may be
possible for your psychiatrist to prescribe a medication (in addition to your other medications)
that can help you with some of the anxiety.

Cognitive Behavioral Therapy (CBT):

CBT can also be very useful to help break the cycle. Learning which patterns have kept the
anxiety going can help you to try to change those patterns. Talking with your therapist about
your symptoms and making a plan to work on these symptoms can make a big difference in your
daily life.

Specifically, CBT can help with many components of anxiety that were described above. For
example, it can help you change some of your anxious thinking, feel more in control of some of
your anxious physical sensations, and decrease your avoidance of certain anxiety-provoking
situations. Let’s use the bank example again to illustrate how CBT can be helpful.

Working on Anxious Thoughts:

CBT can help you examine the types of anxious thoughts that you have in the moment and help
you determine how accurate or helpful these thoughts are. Then, you can learn new strategies for
challenging these thoughts when you are feeling anxious.

“I am going to lose control” Î “I am able to handle this”

When you think about going to the bank, you notice yourself saying, “I am going to lose control
in there because I will be so anxious!” In examining how accurate that thought is, you remember
back to all the other times you went into the bank for the past 15 years, and how you never lost
control then. Over time, you are then able to realize, “I guess I am able to handle this.”

Working on Anxious Physical Sensations:

CBT can help you notice the types of physical sensations that you have when you are anxious.
Then you can identify them, and learn strategies to cope with them so they don’t overwhelm you
as much. For example:

Heart racing, feeling sweaty and shaky and not knowing what to do about feeling so awful
Î Learn to cope with unpleasant physical sensations
Î Become proficient in relaxation strategies
Î Educate yourself to learn that you are not going to die just because you feel unwell
physically

CBT Client Manual 8-10-07 119

When
hen you are in the bank (or even think about going to the bank), you notice these unpleasant
sensations. Over time and with practice, you will be able to cope better when they occur (and
they will probably occur less in the future).

Working on Reducing Avoidance:

CBT can help you notice which situations you tend to avoid because of anxiety. Then you will
learn strategies to gradually decrease how much you are avoiding a particular situation. This
will help your world become larger, instead of smaller.

Avoiding the bank Î first going to the bank one time

Î then going one time per month
Î then going once a week
Î then two times per week, etc., etc.

If you’ve been avoiding the bank for several months, going back will seem very difficult at first.
That is why you take it one step at a time, slowly at first, and then more and more frequently,
until it becomes less uncomfortable. The idea that “practice makes perfect” definitely applies
here!

Medications can help with symptoms of anxiety.

CBT is also very useful in helping people “break the cycle” of anxiety.

CBT Client Manual 8-10-07 120

 Appendix Exercise 1A: A-B-C-D Theory of Feeling Nervous, Worried, or Anxious

Our beliefs or attitudes about events create our emotional reactions to different situations. This
means that how we think about a certain thing that happened makes us feel a certain way. That
is why two people who experience the same event may have very different reactions to it and
feel differently about it. You can see this when you use the ABCD method.

A: “Activating Experience:” what happened

B: “Beliefs about Experience:” what thoughts you have about what happened
C: “Emotional Consequences:” how you feel based on those beliefs
D: “What you Do:” how you react based on your beliefs and related emotions

For example:
Mary and Janet both have separate doctor’s appointments that got rescheduled at the last
minute. Now the appointment is scheduled for the early morning instead of the late
afternoon. However, their emotional reactions to the change in schedule are very different:

A: Activating experience

Having Dr’s appointment

rescheduled.

Mary’s reaction Janet’s reaction

B: Beliefs about experience B: Beliefs about experience

“This may be a little “Oh no! I will never get there on
inconvenient, but I can plan time! How will I get up and get
ahead to make sure I am on ready so early? What will happen
time. Then I will have the rest if I miss the bus? This will be a
of the day to do what I want!” disaster, I can tell.”

C: emotional Consequences C: emotional Consequences

Feels flexible, glad to have the Worried, nervous, doubtful.
whole day to herself after the
appointment.

D. What you Do D. What you Do

Plans ahead with the bus schedule the Stays home all day worrying, then
night before so she is ready for her decides to cancel the appointment,
appointment in the morning. even though there are no other
openings until next month.
CBT Client Manual 8-10-07 121
 Part II: Alternative Beliefs Exercise:

As you can see by the scenario with Mary and Janet, there are a number of different ways that a
person can interpret a situation—and these different interpretations can lead to different
emotional reactions. The thoughts that lead to different emotional reactions are like fuel to the
fire of emotions. One way to change unpleasant emotional reactions and change your behavior is
to work on changing the thoughts that power the emotions.

You can reduce the amount of worry or anxiety that you experience by considering alternate
ways of thinking about situations that come up in your daily life. It’s important to understand
that simply changing the way one thinks about things is at first not so easy because you have
probably been thinking this way for a long time. Changing your thinking is a skill that you can
work on and develop. Practice this skill by coming up with alternative beliefs about a few
different regular day-to-day situations.

For example: What are 3 different ways that a person could interpret each of the following
situations?

Event: You find out that you need to go to the Social Security office for a follow-up benefits
interview.

Possible interpretation of event Likely emotional response Behavior consequence (what

you did)
“they are going to take away my Scared, nervous, worried Don’t show up for appointment
benefits”

“they probably just need me to Content, not distressed Make an appointment with the
fill out additional paperwork” benefits counselor and attend the
appointment

CBT Client Manual 8-10-07 122

Event: You are signed up for a new Wellness group at your day treatment program that starts today.

Possible interpretation of event Likely emotional response Behavior consequence (what

you did)

Event: Even though you wake up extra early, you end up missing the bus.

Possible interpretation of event Likely emotional response Behavior consequence (what

you did)

The more you practice coming up with alternative reasons why something may have
happened, the more you can feel in control of how you react to things in your life that may
bother you.

CBT Client Manual 8-10-07 123

Write in a situation that happened to you this week and the possible ways of interpreting that event:

Event:_______________________________________________________________________

Possible interpretation of event Likely emotional response Behavior consequence (what

you did)

Try some more:

Write in a situation that happened to you this week and the possible ways of interpreting that
event:

Event:_______________________________________________________________________

Possible interpretation of event Likely emotional response Behavior consequence (what

you did)

CBT Client Manual 8-10-07 124

Event:_______________________________________________________________________

Possible interpretation of event Likely emotional response Behavior consequence (what

you did)

CBT Client Manual 8-10-07 125

 Appendix Exercise 2: Making a Decision: The Pro/ Con Matrix

There are different types of decisions that we all make regularly. Some of them are minor and
some are very important and major. When making an important decision, it can be helpful to
consider the pros (advantages) and cons (disadvantages) of each course of action you are
considering to be able to make the best decision possible. For example, if you are deciding
whether or not to move to a new, more expensive apartment, it is helpful to consider the
following: 1) Pros of moving, 2) Cons of moving, 3) Pros of not moving, and 4) Cons of not
moving.

When considering the pros and cons of each option, it is important to consider whether each pro
or con is true for the short-term (next few days to weeks) or for the long-term (after a month or
so). This form can be used to help guide you. For the example of deciding whether or not to
move to a new apartment, a completed form might look like this:

Pros of: Moving to new apartment Cons of: Moving to new apartment
Short-term: Short-term:
1. will have more space 1. more expensive—will have to cut back
on money I spend eating out to afford it
2. apartment is in a nicer neighborhood
2. it will be a lot of work to pack up and
3. will live closer to my family
move all my stuff
4. won’t have to travel as far to get to my
3. it will take a while to get used to living
day program
in a new place
Long-term:
Long-term:
1. Will like living there better
1. Will have less spending money.
2. All above are long-term also.
Pros of not: Moving to new apartment Cons of not: Moving to new apartment
Short-term: Short-term:
1. less work—don’t have to pack up my 1. will have to continue living in a
stuff neighborhood that doesn’t feel safe
2. won’t have to work on finding ways to 2. won’t be living near my family
save money to afford the rent 3. will have to continue to travel 1 hour to
Long-term: get to my day program
1. won’t have to get used to a new place 4. will continue to not have enough room
for my stuff.
Long-term:
1. Above are both short- and long-term

CBT Client Manual 8-10-07 126

Once the form is completed, it often becomes easier to see what the best course of action might
be. This might help you make a decision about what to do. Here is the decision based on the
example above.

Decision: After considering the short-term and long-term pros and cons of moving to a new
apartment I have decided to move to the new apartment and ask my case manager for help with
keeping on a budget so that I can afford it.

Attached is a blank Pro/Con Matrix for you to use with any issues that come up in life that need
to be decided. It can be helpful to complete this form with a case manager or family or friend,
because sometimes others can help you come up with pros and cons that you may not have
thought about on your own.

CBT Client Manual 8-10-07 127

 Pro/ Con Decision Matrix

Pros of ___________________________ Cons of __________________________

__________________________________ __________________________________

Short-term Short-term
1. ______________________________ 1. ______________________________

2. ______________________________ 2. ______________________________

3. ______________________________ 3. ______________________________

4. ______________________________ 4. ______________________________

Long-term Long-term
1. ______________________________ 1. ______________________________

2. ______________________________ 2. ______________________________

Pros of not_________________________ Cons of not________________________

__________________________________ __________________________________

Short-term Short-term
1. ______________________________ 1. ______________________________

2. ______________________________ 2. ______________________________

3. ______________________________ 3. ______________________________

4. ______________________________ 4. ______________________________

Long-term Long-term
1. ______________________________ 1. ______________________________

2. ______________________________ 2. ______________________________

Decision:
After considering the short-term and long-term pros and cons of: ___________________
I have decided to: _________________________________________________________

CBT Client Manual 8-10-07 128

 Appendix Exercise 3: Using a Coping Card

What is a Coping Card?

A coping card is an index card with a statement written on it to remind a person of something
that they want to do or think. Typically, positive self-talk statements are written on a coping
card. For example, let's imagine how Paul, who is working on being less nervous about new
things, might create a coping card. Paul's coping card might look like this:

Being a little nervous in new situations is normal.

I can't let this stop me from trying new things.

I'll be okay after a few minutes.

When do you use a coping card?

Coping cards work best if a person decides to look at them at regularly scheduled times, rather
than only at times when they are stressed out. For example, Paul kept the coping card in his
wallet and took it out and looked at it every day after paying for his lunch for a few seconds.
Paul also took out the coping card and read it at times that he was about to confront a new
situation. By rehearsing the statements on the coping card everyday and in preparation for
things he thought would make him anxious, Paul started to become more confident about his
ability to face new situations and eventually, he became less nervous.

In the next part of this exercise, you will work on coming up with a coping card for yourself.

List 3 areas in which you are working on improving your coping responses.

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

CBT Client Manual 8-10-07 129

Think of some positive self-statements that you think might be useful to remind yourself of in
these situations. Examples of positive self-statements are: "I can do this." "I am a strong
person." "I have to push through feeling a little uncomfortable in order to accomplish this."

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Choose the statements from above that you think have the best chance of making you cope more
effectively. Write these down on the coping card below.

Find a way to make the coping card you created above portable, so that you can carry it with
you. You may choose to copy what you wrote onto an index card, or to cut out the paper above.
Rather than carrying the coping card, some people choose to post the coping card in a place
where they will see it everyday--for example, on the refrigerator of their home or taped to the
bathroom mirror.

Where are you going to keep your coping card?_______________________________

Now think about what would be a convenient time of day to look at your coping card. You
might choose to look at it first thing in the morning, before bed, while on a break at work, or
some other time.

When are you going to review your coping card?______________________________

CBT Client Manual 8-10-07 130

 Appendix Exercise 4: General Thought Record Form

This form can help you to cope with and reduce unpleasant emotions. When you notice your mood getting worse, ask
yourself, “What’s going through my mind right now?” Then fill out this form and follow the steps for coming up with a
possible alternative response. See example below:

Day/ Situation: Automatic Thought(s): Emotion(s): New Response/ Outcome:

Time 1. Event leading to 1. What thoughts did you 1. Specify sad, Behavior: 1. Re-rate belief
unpleasant emotion, or have right before you felt anxious, angry, etc. 1. Use form on back to in automatic
2. Stream of thoughts, the emotion(s). challenge the most thought(s) 0-
daydreams or recollection 2. Rate belief in automatic 2. Rate degree of upsetting automatic 100%.
leading to unpleasant thought(s) 0-100% emotion 0-100% thought.
emotion, or 3. Circle the thought that is 2. Write alternate 10 %
3. Distressing physical upsetting you most response to automatic
sensations. thought(s).
Sad ( 80%) 2. Specify and
1. She isn’t really busy. She rate
Wed just doesn’t want to go out I am a likeable person subsequent
5PM with me. (90 %) Worried (50%) whether or not she wants
emotions 0-
Called a woman from work to date me. 100%.
to ask her to go on a date 2. She doesn’t like me._(75
tonight and she said she is %) Sad (50%)
too busy. I will keep trying to meet
new people and find
3. Nobody likes me and I will someone who is a good
always be alone. (75%) Worried (20%)
match for me.

CBT Client Manual 8-10-07 131

Questions to help formulate new response/behavior:

(1) What is the evidence that the automatic thought is true? not true?

Evidence for: I asked someone on a date and she said no.

Evidence against: I have several friends who often asked me to do things with them. Just because one person said no doesn’t
necessarily mean that no-one wants to go out with me.

(2) Is there an alternative explanation?

Maybe she really was busy and would be interested in going out another time. Maybe she isn’t interested in dating right now.
Maybe she already has a boyfriend.

(3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most
realistic outcome?

The worst thing would be if she really doesn’t like me. I wouldn’t like that but I would eventually be OK with it. Just because
one person doesn’t like me doesn’t mean that no-one will like me.

(4) What’s the effect of my believing in my automatic thought? What might be the effect of changing my thinking?

This thought makes me feel like giving up and never asking someone out again. If I change my thinking, I am more likely to
keep trying. If I keep trying, I am more likely to find someone that is a good match for me.

(5) If a friend was in this situation and had this thought, what would I tell him/her?

I would tell him to keep acting friendly with her and to ask her if she would like to go out some other time. If she isn’t
interested, I would tell him, “there are other fish in the sea” and “it’s her loss if she doesn’t realize how great you are!”

CBT Client Manual 8-10-07 132

 Thought Record:

This form can help you to cope with and reduce unpleasant emotions. When you notice your mood getting worse, ask yourself, “What’s
going through my mind right now?” Then fill out this form and follow the steps for coming up with a possible alternative response.*

Date/ Situation: Automatic Thought(s): Emotion(s): New Response/ Behavior: Outcome:

Time 1. Event leading to 1. What thoughts did you have 1. Specify sad, 1. Use form on back to 1. Re-rate belief in
unpleasant emotion, or right before you felt the anxious, angry, challenge the most automatic
2. Stream of thoughts, emotion(s). etc. upsetting automatic thought(s) 0-
daydreams or 2. Rate belief in automatic thought. 100%.
recollection leading to thought(s) 0-100% 2. Rate degree of 2. Write alternate response to
unpleasant emotion, or 3. Circle the thought that is emotion 0-100% automatic thought(s). %
3. Distressing physical upsetting you most
sensations. _________________________ 2. Specify and rate
1. _______________________ subsequent
_________________________ emotions 0-
_________________________ 100%.
_________________________
________________( %) %
2. _______________________

_________________________

________________( %)

3. _______________________

_________________________

________________( %)

*This form should be photocopied double-sided so the “Questions to help formulate new response” are on the back

CBT Client Manual 8-10-07 133

Questions to help formulate new response/ behavior:

(1) What is the evidence that the automatic thought is true? not true?

(2) Is there an alternative explanation?

(3) What’s the worst that could happen? Could I live through it? What’s the best that could happen? What’s the most realistic
outcome?

(4) What’s the effect of my believing in my automatic thought? What might be the effect of changing my thinking?

(5) If a friend was in this situation and had this thought, what would I tell him/her?

CBT Client Manual 8-10-07 134

 Appendix Exercise 5: Mark’s Story about Medication and Day Treatment

I am Mark, a 41-year-old white male. My problems started in my third year of college when I started
thinking that my roommate was spying on me. I started keeping to myself, began cutting classes. Then
I started threatening voices in my head that nobody heard. I left college and went to my parents place.
At first they were upset that I left college but later they started getting worried about me and asked me
to see a doctor. I started losing trust in them and refused to see anyone. When the voices told me to kill
myself I got scared and agreed to see a psychiatrist. Fortunately for me the psychiatrist was very
pleasant and I could trust her. I started taking medication on her advice. She suggested that I go to a
day program. I did not like the idea of sitting in groups with a bunch of people talking about problems.
Also I had two years of college education and I thought that I was better off than a lot of other people.
I did not want other people to be pulling me down.

Later that year my mother was diagnosed with cancer. I started worrying that she was going to die. My
voices got stronger and so did suicidal ideas. At that time my doctor suggested that I go into the
hospital or the partial program. I chose to go to a program. Initially it was a bit stressful to be with a lot
of strangers. Also some of the people had very different problems than mine. However I found that
many people talked about the voices and thoughts similar to mine. That made me feel that I am not
strange and that many people had problems like mine. Also people talked about their experiences with
different medicines and that was very useful information. For the first time in my life, I became
comfortable taking my medication knowing that there are many people taking medicine. In the
program I met John who was friendly to me. He had been in the program for a year. He said that he
was now looking for job and was planning to come to the evening program if he got a job. I exchanged
phone numbers with John and we met outside the program and did things together like going bowling.
John was supportive and said that I could call him anytime I needed to talk.

A month later John got a job as cashier at a supermarket. I was happy for John but sad to see him leave
the program. We decided to maintain contact even when he left the program. When John left, I did not
want to go to the program but he persuaded me to stay in the program. Within a few months my mom
completed the chemotherapy and I was very relieved. I felt I did not need the program anymore. At
that time my counselor and case manager sat with me and encouraged me work on my goal of getting a
part time job. I wanted a job but was afraid that my applications would be rejected. With
encouragement from the program I started applying for jobs. I had worked summer jobs as a sales
assistant and had some experience to put on the resume. After the third interview I was offered a part
time job for 20 hours. Even though the job was exciting, I was nervous. I was not confident about
myself. At this time, the program was very helpful. My group members were very supportive and so
was my counselor. With their help I got over my nervousness and did well. Three months later my
manager made me full time. I was proud to get a full time position based on my performance. I could
no longer go to the day program and instead went to the evening program two days a week. After three
more months, I felt confident in my job and I decided to stop the program. My counselor and doctor
agreed that it was a good idea. The combination of medicine and the program helped me deal with
stress in my life, make friends at program, get a job and become independent. I am sharing my story so
that others with similar problems can learn something from my experience. Good luck to you.

CBT Client Manual 8-10-07 135

 Appendix Exercise 6: Suzanne’s Story about her Symptoms

My name is Suzanne and I have struggled with schizophrenia for about six years. Now, things
have gotten much better for me and I feel like I have more control over my symptoms. I have
learned a lot about how this illness works and the things that I can do to prevent things from
getting worse.

It wasn’t always this way. Starting five years ago, I had a lot of difficulty. I had been working for
about 7 years after high school at the same job. I worked at a rental car company at the front
desk. I answered the phone and helped people make reservations to get their rental cars. When
customers came in, I helped them fill out the paperwork and sent them on their way. It was a
pretty good job and things were ok, although I did tend to get really stressed out when we got
busy or when my boss was in a bad mood.

During that last year on the job, when I was about 25 years old, I started to feel strange. I started
thinking that my fellow employees were trying to poison me. I began hearing voices telling me
that terrible things were going to happen to me if I kept interacting with these coworkers. I got
scared and depressed. Also around this time, I found out that I was losing my apartment that I
had lived in since graduation because they were selling it. I had only two weeks to find a new
place. Things just kept getting worse and worse.

Even though at first I went to my family and my doctor to talk about what was happening to me,
I didn’t really trust them. Instead of taking their advice, I decided to go out on my own and do
my own thing. Unfortunately, I ran into a lot of trouble: I became homeless on and off for a
couple of years. I started to drink to make the voices calm down. I only sometimes took my
medication because I would forget or not have enough money. I didn’t eat right or get good rest
at all. I was malnourished, exhausted, and even more confused than I was in the beginning. I was
ashamed and terrified of what had happened to me. I didn’t want to talk to my family, or see old
friends, or even go back and see my doctor too often.

When I did finally go back to the mental health center, things started to change for the better. My
mother told me that schizophrenia runs in the family (my grandmother was diagnosed with the
illness when she was around my age and so was my aunt) and that because of that I have
increased vulnerability to have these sorts of symptoms. My therapist told me that the stress on
the job and then the bad news about having to find an apartment acted as stressors that triggered
the start of the symptoms. My case manager explained that the choices I was making: like
drinking, not taking my medication regularly, and not getting good nutrition and rest were only
making things worse. The doctor, the therapist and the case manager also said that by isolating
myself and not getting social support from my family (who really did want to help) I was
making it less likely that I could cope with what was going on.

Hearing all this information was really helpful for me. Getting an idea about what caused the
illness (genetics and biology), what made it start (stress), and what kept it going and made it
worse (alcohol, not taking meds, avoiding appointments and my family, not eating or sleeping)

CBT Client Manual 8-10-07 136

helped me realize that it wasn’t my fault. But it also helped me realize that there are certain
things about schizophrenia that I have control over. There are things that I can do to lessen my
symptoms and make me feel better.

Things aren’t perfect now, but I have worked hard with my family and the staff at the mental
health center to come up with a plan to keep me as healthy as possible. This includes taking my
medication, checking in monthly with my case manager, going to groups to prevent alcohol use,
having therapy, calling my mother daily and having weekly contact with my family. I am feeling
much better now, much more like my old self. Now I can start to work on getting a new job and
getting back to doing some of the things I enjoy. Knowing how this illness works and figuring
out what I can do to cope with stress in my life in a healthy way has made all the difference.

CBT Client Manual 8-10-07 137

 Appendix Exercise 7: Emma’s Experience with Distressing Thoughts

What we think cannot harm us, but what we do, can harm us.

I am Emma and I am 36. I am sharing my story of some disturbing thoughts I had and how they
affected my life. At the age of 32, I was under a lot of stress because I lost my job due to layoffs
and my close friend died in an accident. I kept away from my family and friends and then some
strange thoughts started. I thought I could not trust my family and I started thinking that I was on
the government’s list of terrorists. I began to believe that my dad and my brother turned me in. I
could not go out without the thought of being followed.

When I complained to the police about my family, they asked me to see a doctor. They thought
that I was nuts. My case manager asked me not to complain to the police, as they were not likely
to take my complaints seriously. That did not stop me from making multiple 911 calls to show
them how serious this issue was. This time they came to my door and I was forced to go to the
crisis unit. Even there, they did not believe my story and they put me in hospital.

First I did not want to take any medicine, but I found out that without medicine, I would not get
out of the hospital. The medicine helped me sleep better and then I noticed something. I started
questioning if my thoughts were really true. My mom and my sister brought me the things I
needed and seemed to be concerned about me. They did not seem to want to cause me any
trouble. The therapist in the hospital was very helpful. He helped me to not automatically believe
every thought in my mind. Instead I started looking to see if there was any evidence for my
thoughts, and learned to ask myself, “would the government really be bothered by someone like
me?”

The more I questioned these thoughts and the more I talked to people whom I trusted, it became
clear to me that the thoughts I had about the government and my family were not true. I was
relieved, but at the same time was ashamed about my behavior and some of the things I said
about my sister and mother. However, both of them said that it was not my fault and that it was
due to my stress and my illness. I came up with an arrangement with my sister and case manger
so that the next time I had these thoughts, I would not call the police. As long as the thoughts
were in my mind, they could just be thoughts, that I could evaluate..But, when I did things like
call the police, that was a problem, and I was put in hospital. I do not want that.

After my discharge, I went to a self-help center and there met Nadia. When we both shared our
stories, it was clear that we went through similar types of experiences. We both have agreed to
be there for each other. When Nadia is upset she calls me to run things by me before she does
anything risky. When I am upset, I do the same. Having Nadia in my life makes me feel that I am
not the only one facing this problem.

CBT Client Manual 8-10-07 138