cpt patient manual-2016 - stanford...

CPT PATIENT MANUAL-2016 For imAPP Study Participants

THE FAST LAB, NATIONAL CENTER FOR PTSD

795 Willow Road, Menlo Park, CA, 94025

For study related questions, please email Clara Johnson at [email protected], or call 650-614-9997 x 26233

mailto:[email protected]

Summary of Session 1: Overview of PTSD and CPT

1. Administer PCL-5 (weekly version) and other patient measures before the start of this

session, collect & review. Set agenda. (5 minutes)

2. Describe symptoms of PTSD and theory of why some people get stuck in recovery (10 minutes)

➢ PTSD Symptoms: Functional Model (Handout 5.1)

- If trauma is severe enough, PTSD symptoms are normal reactions, which include:

▪ Intrusive Symptoms: thoughts, dreams, flashbacks

▪ Arousal: sleep, irritability/anger, concentration, hypervigilance, startle

▪ Autobiographical memory/Thoughts and emotions about the trauma: guilt,

anger, self-blame

▪ Avoidance: thoughts, places/activities/people, alcohol, staying as busy as

possible, physical symptoms, avoiding therapy or practice assignments.

➢ Recovery or Non-recovery from Trauma – How people get stuck in recovery

- Fight/flight, freeze

- Role of Avoidance in maintaining PTSD symptoms

3. Describe cognitive theory (5 minutes)

➢ Belief structure: categories—just world, good things to good people, etc.

➢ Change memories to fit existing beliefs (assimilation)

o [do not use terms assimilation/over-accommodation with clients] ➢ Change beliefs about the world (accommodation/over-accommodation)

➢ Stuck Points - Introduce What Are Stuck Points? (Handout 5.2)

4. Discuss the role of emotions in trauma recovery (5 minutes)

➢ Two types of emotions that follow trauma: natural and manufactured

5. Briefly review the index trauma (5 minutes)

6. Describe the overall course of therapy (10 minutes)

➢ Importance of practice and not avoiding

➢ 1st half of treatment focus on trauma and what you are saying to yourself ➢ Learn skills to tell the difference between a fact and a thought and ask yourself questions

about your thoughts.

➢ Learn to use worksheets to examine thoughts

➢ Anticipate avoidance

➢ Note importance of compliance with attendance and practice assignments

➢ Refer to Stuck Points and Stuck Point log for future

➢ In the 2nd half of therapy, address themes impacted by trauma: safety, trust, power/control,

esteem and intimacy

7. Assign practice and problem solve re: completion (Handout 5.3) (5 minutes)

➢ Write Impact Statement

➢ Read over handouts on PTSD symptoms and Stuck Points (Handouts 5.1 and 5.2)

8. Check the client’s reactions to the session & practice assignment (5 minutes)

8 digit ID # (e.g., 1023-102-04): __________________________ Date (mm/dd/yyyy): _________________________

PCL-5

9-digit ID # (e.g., 1023-102-04): Date (mm/dd/yyyy): _________________________

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience.

Please read each problem carefully and then circle one of the numbers to the right to indicate how much you

have been bothered by that problem in the past week. In the past week, how much were you bothered by:

Not at all

A little bit

Moderately Quite a bit

Extremely

1. Repeated, disturbing, and unwanted memories of the

stressful experience?

0

1

2

3

4

2. Repeated, disturbing dreams of the stressful experience? 0 1 2 3 4

3. Suddenly feeling or acting as if the stressful experience were

actually happening again (as if you were actually back there

reliving it)?

0

1

2

3

4

4. Feeling very upset when something reminded you of the


0

1

2

3

4

5. Having strong physical reactions when something reminded

you of the stressful experience (for example, heart pounding,

trouble breathing, sweating)?

0

1

2

3

4

6. Avoiding memories, thoughts, or feelings related to the


0

1

2

3

4

7. Avoiding external reminders of the stressful experience (for

example, people, places, conversations, activities, objects, or situations)?

0

1

2

3

4

8. Trouble remembering important parts of the stressful

experience?

0

1

2

3

4

9. Having strong negative beliefs about yourself, other people,

or the world (for example, having thoughts such as: I am

bad, there is something seriously wrong with me, no one can

be trusted, the world is completely dangerous)?

0

1

2

3

4

10. Blaming yourself or someone else for the stressful

experience or what happened after it?

0

1

2

3

4

11. Having strong negative feelings such as fear, horror, anger,

guilt, or shame?

0

1

2

3

4

12. Loss of interest in activities that you used to enjoy? 0 1 2 3 4

13. Feeling distant or cut off from other people? 0 1 2 3 4

14. Trouble experiencing positive feelings (for example, being

unable to feel happiness or have loving feelings for people close to you)?

0

1

2

3

4

15. Irritable behavior, angry outbursts, or acting aggressively? 0 1 2 3 4

16. Taking too many risks or doing things that could cause you

harm?

0

1

2

3

4

17. Being “superalert” or watchful or on guard? 0 1 2 3 4

18. Feeling jumpy or easily startled? 0 1 2 3 4

19. Having difficulty concentrating? 0 1 2 3 4

20. Trouble falling or staying asleep? 0 1 2 3 4

PCL-5 (8/14/2013) Weathers, Litz, Keane, Palmieri, Marx, & Schnurr -- National Center for PTSD

HANDOUT 5.1

From Cognitive Processing Therapy for PTSD: A Comprehensive Manual by Patricia A. Resick, Candice M. Monson, and Kath-

leen M. Chard. Copyright © 2017 The Guilford Press. Permission to photocopy this handout is granted to purchasers of this book

for personal use or for use with individual clients (see copyright page for details).

In normal recovery, intrusions and emotions decrease over time and no longer trigger each other.

When intrusions occur, natural emotions and arousal run their course and thoughts have a

chance to be examined and corrected. It is an active “approach” process of dealing with the

event.

Avoidance of

external reminders

However, in those who don’t recover, strong negative emotions lead to escape and avoidance.

The avoidance prevents the processing of the trauma that is needed for recovery, and it works

only temporarily.

Aggression

Self-harm behaviors

Substance abuse

Bingeing

Cognitive avoidance

Behavioral avoidance

Dissociation

Emotional suppression

Social withdrawal

Behavioral inhibition

Somatic complaints

Recovery or Nonrecovery from PTSD Symptoms

Following Traumatic Events

HANDOUT 5.2




Stuck Points are:

Black-and-white

Thoughts, not

feelings

All-or-nothing

Thoughts behind

moral statements

or the Golden

Rule

“If–then”

statements

Not always “I”

statements

Concise

What Are Stuck Points?




HANDOUT 5.3

Practice Assignment after Session 1 of CPT

Date: Client:

Please write at least a one-page statement on why you think your

most distressing traumatic event occurred. You are not being asked

to write specific details about this event. Write about what you have

been thinking about the cause of this event.

Also, consider the effects this traumatic event has had on your

beliefs about yourself, others, and the world in the following areas:

safety, trust, power/control, esteem, and intimacy.

Bring this statement with you to the next session. Also, please read

over the two handouts I have given you on PTSD symptoms and

Stuck Points (Handouts 5.1 and 5.2), so that you understand the

ideas we are talking about.

9-digit ID (e.g., 1023-102-04): Date (mm/dd/yyyy):

PCL-5 Score:

Key Stuck Points Addressed:

CPT Strategies or Worksheets Used in

today’s session

ABC

Challenging Questions

Patterns of Problematic Thinking

Challenging Beliefs Worksheet

Assigned additional Impact Statement

Psychoeducation

Review of Rationale

Assigned or Re-Assigned a CPT Module

Reviewed the Stuck Point Log

Reviewed Impact Statement

Other issues addressed

Sobriety/Substance Use

Safety

Suicidal Ideation

Depression

Anxiety

Medication use

Sleep

Emergent Current Life Events

Legal issues

Treatment compliance

Severe Mental Illness symptoms

Non-Suicidal Self-Injury

Financial Issues

___I did not complete a worksheet because:

___Engaged in crisis intervention

___Session didn’t lend itself to the use of a worksheet (not a CPT protocol session)

___Did cognitive or behavioral work verbally and didn’t capture it on a worksheet

___Concerns about therapeutic alliance

___Other (please describe): __________________________________

PLEASE Check off all items that were completed in this session.

Format

CPT=CPT without the trauma account (leave “CPT+A only” items blank)

CPT+A=CPT with the trauma account

Session 1: Check all that apply to session. Provide explanation for any items necessary in space below.

Reviewed and signed treatment agreement consent form.

Therapist provided an overview of PTSD symptoms, a cognitive explanation of the development and

maintenance of PTSD, and a rationale for CPT.

Therapist presented the patient with an overview of the 12-session treatment.

Discussed patient’s readiness to engage in treatment.

Discussing and addressing patient’s questions or concerns about treatment. Patient expressed the

following concerns [include below under Additional Notes]

Therapist asked the patient to describe a brief account of their most traumatic event.

Therapist introduced the concept of stuck points and began creating a stuck point log.

Therapist asked patient to write one-page Impact Statement and create stuck point log for practice

assignment.

Additional Notes:

Did you make any of the following Adaptations to CPT in TODAY’s session?

Tailoring/tweaking/refining (e.g., changing terminology or language, modifying worksheets in minor ways)

Integrating components of the intervention into another framework (e.g., selecting elements to use but not using the whole protocol)

Integrating another treatment into the EBP (e.g., integrating other techniques into the intervention)

Removing/skipping CPT interventions, modules or components of the treatment (e.g., didn’t assign module, didn’t use a worksheet, didn’t assign homework)

Lengthening/extending session time

Lengthening/extending number of weeks

Shortening/condensing session time (e.g., ended CPT today and have completed fewer than 12 sessions)

Shortening/condensing number of weeks—(e.g., condensing so all CPT elements are delivered in less than 12 sessions)

Adjusting other order of intervention modules, topics, or segments

Adding modules or topics to the intervention

Departing from the protocol starting to use another treatment strategy

Loosening the session structure

Repeating elements or modules (e.g., repeating a concept or activity covered in a previous session that was not intended for another session)

Substituting elements or modules (e.g., substituting an ABC sheet for the challenging beliefs worksheet)

Stopped using the CPT and used another strategy for part of the session (e.g., 10 minutes or more)

Did CPT in a different setting (e.g., delivering it on an inpatient unit).

Changed the Session format: (e.g., delivering by telephone or in a group)

MOTIVATIONAL ENHANCEMENT:

(Display only: Check all that apply.)

Identified short-term goals in several areas of functioning: (optional text box)

Identified the consequences or impact of PTSD (or other symptoms): (optional text box)

Identified the benefits of reducing the severity of the PTSD: (optional text box)

Assessed attitudes and expectations for therapy: (optional text box)

Assessed any barriers to attending therapy and assisted the patient in problem-solving these

barriers. (optional text box)

Summary of Session 2: Examining the Impact of Trauma

1. Administer PCL-5 (weekly version) and other patient measures, collect & review. Set agenda.

(5 minutes)

2. Have client read Impact Statement aloud (5 minutes)

➢ If practice not written, address nonadherence to the assignment (do this for all practice

assignments in CPT). Also, have client describe meaning of event orally and reassign

impact statement.

3. Discuss meaning of Impact Statement with patient & identify Stuck Points (10 minutes)

➢ Begin to identify Stuck Points & add Stuck Points to the Stuck Point Log (Handout 6.1)

➢ Review major issues to be focused on in treatment

➢ Therapist looks for the following: (do not use these terms with client)

- Assimilation (changing memories to fit beliefs)

- Over-accommodation (going overboard on changing beliefs as a result of

memories)

- Accommodation (changing beliefs about the world and events…this is

desirable)

4. Examine connections among events, thoughts, and feelings (Handout 6.2) (10 minutes)

➢ Basic emotions: angry, disgusted, sad, scared, happy

➢ Combined: jealous = mad + scared

➢ Varying intensity: irritated/angry/enraged

➢ ‘Manufactured’ emotions (based on our thoughts): guilt, shame.

➢ Patient examples of own feelings, including physical sensations

➢ Interpretation of events/self-talk affecting feelings (snubbed on street), alternatives

➢ Go back to Impact Statement for personal application to practice labelling emotions and

noticing the connection between thoughts and feelings

5. Introduce A-B-C Worksheets and fill one out together (Handout 6.3) (5 minutes)

6. Describing Stuck Points more fully (5 minutes)

➢ Describing them in routine examples and trauma related events

➢ Introduce Stuck Point Help Sheet (Handout 6.4)

- (Utilize Therapist Stuck Point Guide as reference – Figure 6.1)

7. Assign practice (Handout 6.5) (5 minutes)

➢ Complete A-B-C Worksheets to become aware of connection among events, thoughts,

feelings, and behavior

➢ At least one A-B-C Worksheet each day (as soon after an event as possible), at least one

worksheet directly about the Index Trauma

➢ Add to Stuck Point Log

➢ If the client did not write Impact Statement, re-assign this in addition to completion of ABC

Worksheets

8. Check-in re: client’s reactions to session & practice assignment (5 minutes)

** Therapist should make a copy of the Stuck Point log to hold on to**

8 digit ID # (e.g., 1023-102-04): __________________________ Date (mm/dd/yyyy): _________________________

PCL-5



have been bothered by that problem in the past week.

In the past week, how much were you bothered by:

Not at all

A little bit

Moderately

Quite a bit

Extremely



0

1

2

3

4




reliving it)?

0

1

2

3

4



0

1

2

3

4




0

1

2

3

4



0

1

2

3

4


example, people, places, conversations, activities, objects, or

situations)?

0

1

2

3

4


experience?

0

1

2

3

4





0

1

2

3

4



0

1

2

3

4


guilt, or shame?

0

1

2

3

4




unable to feel happiness or have loving feelings for people

close to you)?

0

1

2

3

4



harm?

0

1

2

3

4









HANDOUT 6.1

Stuck Point Log

We will be using this Stuck Point Log throughout therapy, and you will always leave it in the front

of your therapy binder or workbook. You will add to this log as you recognize Stuck Points after

writing your Impact Statement. Throughout therapy, we will add to it or cross off thoughts that

you no longer believe.

Clinician ID (4-digit)

Participant ID (3-digit)

Session #

Date of Session

Check One when retaining on file:

Completed in session

Practice assignment, reviewed in session

Practice assignment, not reviewed




HANDOUT 6.2

Identifying Emotions Handout

Date: Client:

SAD

In despair

AN

GR

Y

Slig

htly

irrit

ated

Enraged

SC

AR

ED

Terrifie

d

Uneasy

Clinician ID (4-digits)

Participant ID (3-digits)

Session #

Date of Session





From Cognitive Processing Therapy for PTSD: A Comprehensive Manual by Patricia A. Resick, Candice M. Monson, and Kathleen M. Chard. Copyright © 2017 The Guilford Press. Permission to

photocopy this handout is granted to purchasers of this book for personal use or for use with individual clients (see copyright page for details).

HANDOUT 6.3

ABC Worksheet

Activating Event Belief/Stuck Point Consequence

A B C

“Something happens” “I tell myself something” “I feel something”

Are my thoughts above in column B realistic or helpful?

What can I tell myself on such occasions in the future?

HANDOUT 6.4

Stuck Point Help Sheet

Date: Client:

What is a Stuck Point?

Stuck Points are thoughts that you have that keep you stuck from recovering.

• These thoughts may not be 100% accurate.

• Stuck Points may be:

• Thoughts about your understanding of why the traumatic event happened.

• Thoughts about yourself, others, and the world that have changed dramatically as a result

of the traumatic event.

• Stuck Points are concise statements (but they must be longer than one word—for example,

“trust” is not a Stuck Point).

• Stuck Points can often be formatted in an “If–then” structure. Here is an example: “If I let oth-

ers get close, then I will get hurt.”

• Stuck Points often use extreme language, such as “never,” “always,” or “everyone.”

What is not a Stuck Point?

• Behaviors. For example, “I fight with my daughter all the time” is not a Stuck Point, because it

is describing a behavior. Instead, consider what thoughts you have when you are fighting with

your daughter.

• Feelings. For example, “I am nervous whenever I go on a date” is not a Stuck Point, because

it is describing an emotion and a fact. Instead, consider what you are telling yourself that is

making you feel nervous.

• Facts. For example, “I witnessed people die” is not a Stuck Point, because this is something

that actually happened. Instead, consider what thoughts you had as this happened and what

you think about it now.

• Questions. For example, “What will happen to me?” is not a Stuck Point, because it is a ques-

tion. Instead, consider what answer to your question is at the back of your mind, such as “I will

not have a future.”

• Moral statements. For example, “The criminal justice system should always work” is not a

Stuck Point, because it reflects an ideal standard of behavior. Instead, consider how this state-

ment pertains to you specifically, such as “The justice system failed me,” or “I can’t trust the

government.”

Examples of Stuck Points

1. If I had done my job better, then other people would have survived.

2. Because I did not tell anyone, I am to blame for the abuse.

(continued)




HANDOUT 6.4 (p. 2 of 2)

3. Because I did not fight against my attacker, the abuse is my fault.

4. I should have known he would hurt me.

5. It is my fault the accident happened.

6. If I had been paying attention, no one would have died.

7. If I hadn’t been drinking, it would not have happened.

8. I don’t deserve to live when other people lost their lives.

9. If I let other people get close to me, I’ll get hurt again.

10. Expressing any emotion means I will lose control of myself.

11. I must be on guard at all times.

12. I should be able to protect others.

13. I must control everything that happens to me.

14. Mistakes are intolerable and cause serious harm or death.

15. No civilians can understand me.

16. If I let myself think about what has happened, I will never get it out of my mind.

17. I must respond to all threats with force.

18. I can never really be a good, moral person again because of the things that I have done.

19. Other people should not be trusted.

20. Other people should not trust me.

21. If I have a happy life, I will be dishonoring my friends.

22. I have no control over my future.

23. The government cannot be trusted.

24. People in authority always abuse their power.

25. I am damaged forever because of the rape.

26. I am unlovable because of [the trauma].

27. I am worthless because I couldn’t control what happened.

28. I deserve to have bad things happen to me.

29. I am dirty.

30. I deserved to have been abused.

31. Only people who were there can understand.

HANDOUT 6.5


Please complete the ABC Worksheets (Handout 6.3) to become

aware of the connections between events, your thoughts, and your

feelings. Complete at least one worksheet each day. Remember to

fill out the worksheet as soon after an event as possible, and if you

identify any new Stuck Points, add them to the Stuck Point Log

(Handout 6.1). Complete at least one worksheet about the traumatic

event that is causing you the most PTSD symptoms. Also, please

use the Identifying Emotions Handout (Handout 6.2) to help you

determine the emotions you are feeling.




9-digit ID (e.g., 1023-102-04): Date (mm/dd/yyyy) :

PCL-5 Score:



today’s session

ABC





Psychoeducation

Review of Rationale






Safety

Suicidal Ideation

Depression

Anxiety

Medication use

Sleep


Legal issues




Financial Issues








Format




The client and therapist reviewed the Stuck Point Log.

Had client read their Impact Statement.

Discussed the meaning of the Impact Statement with the client, with a focus on identifying stuck

points.

Collected Impact Statement from client.

Introduced relationships between thoughts, feelings, and behaviors.

Assigned practice assignment to complete A-B-C worksheets and demonstrated how to complete

them in session.

Additional Notes:

Summary of Session 3:

Working with Events, Thoughts, and Feelings

1. Administer PCL-5 (weekly version) and other patient measures, collect & review. Set agenda. (5

minutes)

2. Review completion of practice assignments. (5 minutes)

➢ If impact statement was not completed for Session 2, but was for session 3, therapist should

have client read it aloud and find any new Stuck Points.

➢ If the client has not done any assignments, address nonadherence.

3. Review A-B-C Worksheets, assist in labeling thoughts and feelings in response to events

(15 minutes)

➢ If worksheets completed, praise efforts and provide any corrections in a low key manner

➢ Label thoughts vs. emotions

➢ Recognize changing thoughts can change intensity of type of feelings

- Begin challenging self-blame and guilt

➢ Point out mismatches:

- Dominant emotion(s)? - Emotions follow thoughts?

- Dominant thought(s)? - Thoughts and emotional intensity match?

➢ Look for Stuck Points, add them to the log, and use Socratic questioning to help patient

identify alternative hypotheses

4. Discuss the A-B-C Worksheet related to trauma to challenge assimilated thoughts (15 minutes)

➢ Do one together if patient did not complete

➢ Focus on identifying assimilated Stuck Points

➢ Challenge the assimilated Stuck Point (e.g., self-blame) using Socratic questioning


➢ Daily completion of A-B-C Worksheets - at least one per day on the index trauma or other

traumas

➢ Additional worksheets can be on day-to-day events






Not

at all

A little

bit

Moderately Quite

a bit

Extremely



0

1

2

3

4




reliving it)?

0

1

2

3

4



0

1

2

3

4




0

1

2

3

4



0

1

2

3

4



situations)?

0

1

2

3

4


experience?

0

1

2

3

4





0

1

2

3

4



0

1

2

3

4


guilt, or shame?

0

1

2

3

4





close to you)?

0

1

2

3

4



harm?

0

1

2

3

4







Participant ID (3-digits)

Session #

Date of Session







HANDOUT 6.3

ABC Worksheet

Activating Event Belief/Stuck Point Consequence

A B C

“Something happens” “I tell myself something” “I feel something”

Are my thoughts above in column B realistic or helpful?

What can I tell myself on such occasions in the future?

HANDOUT 6.6


Please continue to self-monitor events, thoughts, and feelings with

the ABC Worksheets (Handout 6.3) on a daily basis, to increase

your mastery of this skill. You should complete one worksheet each

day on the trauma causing you the most distress, or other traumas,

but you can do additional worksheet items on day-to-day events.

Please put any newly noticed Stuck Points on your Stuck Point Log

(Handout 6.1) as you use the ABC Worksheets.





PCL-5 Score:


CPT strategies or worksheets used in today’s

session

ABC





Psychoeducation

Review of Rationale






Safety

Suicidal Ideation

Depression

Anxiety

Medication use

Sleep


Legal issues




Financial Issues

PLEASE Check off all items that were completed in this ___I did not complete a worksheet because:







Format




Reviewed homework (A-B-C worksheets) with client, and helped further differentiate between

thoughts and feelings.

If client did not do any sheets, therapist asked client to complete some in session.

Helped client identify stuck points and add them to the Stuck point log.

Helped the client with some initial challenging of problematic thoughts using Socratic Questions.

Assigned homework:

(CPT only) Asked client to continue completing A-B-C worksheets for homework with at least one

per day on the index trauma or other traumas.

(CPT+A only) Asked client to write an account of their most traumatic event, with full details

(Handout 11.1), and continue to complete A-B-C worksheets.

Discussed avoidance and how it might manifest in the client’s current activities and behaviors

related to therapy (e.g., not doing practice assignments) and helped the client challenge inaccurate

thoughts about completing the assignment.

Additional Notes:

Summary of Session 4: Examining the Index Event

1. Administer PCL-5 (weekly version) PHQ-9, BAI and B-IPF, collect & review. Set agenda. (5 minutes)

2. Review A-B-C Worksheets, prioritizing assimilated thoughts (10 minutes)

➢ Add any new Stuck Points to the Stuck Point Log

➢ Ensure emotions are accurately labeled

3. Address client’s assimilated Stuck Points using Socratic dialogue to clarify and examine. (10

minutes)

➢ Identify context of trauma (use of clarifying questions)

e.g., What else might you have done? And what might have happened then?

➢ Discuss hindsight bias and outcome based reasoning

4. Explain difference between responsibility and blame (5 minutes)

➢ Introduce Levels of Responsibility Handout (Handout 7.1)

➢ Help client differentiate among blame/intent, responsibility, and the unforeseeable

5. Introduce Challenging Questions Worksheet (Handout 7.2) to help patient challenge Stuck

Points (10 minutes)

➢ Go through blank question worksheet

➢ Go through example worksheets (Handout 7.2A and 7.2B)

➢ Review the Guide for the Challenging Questions Worksheet (Handout 7.3)

➢ Choose a Stuck Point to begin addressing with these questions (a focus on assimilation is

helpful at this point in the therapy)


➢ Daily completion of the Challenging Questions Worksheet, using one Stuck Point a day





Not

at all

A little

bit

Moderately Quite

a bit

Extremely



0

1

2

3

4




reliving it)?

0

1

2

3

4



0

1

2

3

4




0

1

2

3

4



0

1

2

3

4



situations)?

0

1

2

3

4


experience?

0

1

2

3

4





0

1

2

3

4



0

1

2

3

4


guilt, or shame?

0

1

2

3

4





close to you)?

0

1

2

3

4



harm?

0

1

2

3

4









HANDOUT 7.1

Levels of Responsibility Handout

Date: Client:

Your role in the traumatic event: What are the facts?

Responsibility

Played a role in

the event, but

didn’t intend

outcome

Regret

Fault/

blameworthiness

Intended harm;

intended the

outcome

Guilt

The unforeseeable

No way to

predict it would

happen Grief/sadness



for personal use or for use with individual clients (see copyright page for details). .

HANDOUT 7.2

Challenging Questions Worksheet

Below is a list of questions to be used in helping you challenge your Stuck Points or problematic

beliefs. Not all questions will be appropriate for the belief you choose to challenge. Answer as

many questions as you can for the belief you have chosen to challenge below.

Belief:

1. What is the evidence for and against this Stuck Point?

For:

Against:

2. Is your Stuck Point a habit or based on facts?

3. In what ways is your Stuck Point not including all of the information?

(continued)



Session #

Date of Session






4. Does your Stuck Point include all-or-none terms?

5. Does the Stuck Point include words or phrases that are extreme or exaggerated (such as

“always,” “forever,” “never,” “need,” “should,” “must,” “can’t,” and “every time”)?

6. In what way is your Stuck Point focused on just one piece of the story?

7. Where did this Stuck Point come from? Is this a dependable source of information on this

Stuck Point?

8. How is your Stuck Point confusing something that is possible with something that is likely?

9. In what ways is your Stuck Point based on feelings rather than facts?

10. In what ways is this Stuck Point focused on unrelated parts of the story?