(Treatments That Work) Kelly J Rohan - Coping With The Seasons - A Cognitive Behavioral Approach To Seasonal Affective Disorder, Therapist Guide-Oxford University Press, USA (2008)

Coping With the Seasons
EDITOR-IN-CHIEF
David H. Barlow, PhD
SCIENTIFIC
ADVISORY BOARD
Anne Marie Albano, PhD
Gillian Butler, PhD
David M. Clark, PhD
Edna B. Foa, PhD
Paul J. Frick, PhD
Jack M. Gorman, MD
Kirk Heilbrun, PhD
Robert J. McMahon, PhD
Peter E. Nathan, PhD
Christine Maguth Nezu, PhD
Matthew K. Nock, PhD
Paul Salkovskis, PhD
Bonnie Spring, PhD
Gail Steketee, PhD
John R. Weisz, PhD
G. Terence Wilson, PhD

Coping With the
Seasons
A COGNITIVE-BEHAVIORAL APPROACH TO SEASONAL
AFFECTIVE DISORDER
Therapist Guide
Kelly J. Rohan
1
2009
1
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Library of Congress Cataloging-in-Publication Data
Rohan, Kelly J.
Coping with the seasons : a cognitive-behavioral approach to seasonal affective disorder :
therapist guide / Kelly J. Rohan.
p. ; cm. — (TreatmentsThatWork)
Includes bibliographical references.
ISBN 978-0-19-534108-9
1. Seasonal affective disorder—Treatment. 2. Cognitive therapy.
I. Title. II. Series: Treatments that work.
[DNLM: 1. Seasonal Affective Disorder—therapy. 2. Cognitive
Therapy—methods. 3. Psychotherapy, Group—methods. WM 171 R737c 2008]
RC545.R64 2008
616.85 27—dc22
2008017766
9 8 7 6 5 4 3 2 1
Printed in the United States of America

on acid-free paper
To my parents, Betty and John F. Rohan, Jr.
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About TreatmentsThatWork TM
Stunning developments in healthcare have taken place over the last

several years, but many of our widely accepted interventions and strate-
gies in mental health and behavioral medicine have been brought into
question by research evidence as not only lacking benefit, but perhaps,
inducing harm. Other strategies have been proven effective using the
best current standards of evidence, resulting in broad-based recommen-
dations to make these practices more available to the public. Several
recent developments are behind this revolution. First, we have arrived
at a much deeper understanding of pathology, both psychological and
physical, which has led to the development of new, more precisely tar-
geted interventions. Second, our research methodologies have improved
substantially, such that we have reduced threats to internal and external
validity, making the outcomes more directly applicable to clinical sit-
uations. Third, governments around the world and healthcare systems
and policymakers have decided that the quality of care should improve,
that it should be evidence based, and that it is in the public’s interest to
ensure that this happens (Barlow, 2004; Institute of Medicine, 2001).
Of course, the major stumbling block for clinicians everywhere is the

accessibility of newly developed evidence-based psychological inter-
ventions. Workshops and books can go only so far in acquainting
responsible and conscientious practitioners with the latest behavioral
healthcare practices and their applicability to individual patients. This
new series, TreatmentsThatWork TM , is devoted to communicating these
exciting new interventions to clinicians on the frontlines of practice.
The manuals and workbooks in this series contain step-by-step detailed

procedures for assessing and treating specific problems and diagnoses.
vii
But this series also goes beyond the books and manuals by provid-
ing ancillary materials that will approximate the supervisory process in
assisting practitioners in the implementation of these procedures in their
practice.
In our emerging healthcare system, the growing consensus is that

evidence-based practice offers the most responsible course of action
for the mental health professional. All behavioral healthcare clinicians
deeply desire to provide the best possible care for their patients. In this
series, our aim is to close the dissemination and information gap and
make that possible.
This therapist guide applies cognitive-behavioral therapy (CBT) for

depression to the treatment of seasonal affective disorder (SAD). The
prevalence of winter-type SAD is significant, especially at higher lati-
tudes; even more common is subsyndromal SAD (S-SAD) or milder
“winter blues.” Dr. Rohan provides a much-needed treatment for SAD
in a complete and accessible package. The therapist guide outlines a
12-session group program to be conducted over 6 weeks during the fall
or winter. It may also be used with individual clients or in conjunction
with light therapy (LT). Participants learn effective CBT techniques that
will serve them this winter and beyond. The protocol consists of psy-
choeducation, behavioral activation, cognitive restructuring, and relapse
prevention. The corresponding workbook follows the program session-
by-session and provides forms for homework. Specifically tailored for
use with the SAD population, clinicians will find this a unique and
beneficial program for their clients.
David H. Barlow, Editor-in-Chief,

TreatmentsThatWork TM
Boston, MA
References
Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59,

869–878.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system
for the 21st century. Washington, DC: National Academy Press.
viii
Acknowledgments
First, I would like to acknowledge the contribution of all of the

participants in the Seasonality Treatment Program, formerly at the Uni-
formed Services University of the Health Sciences (USUHS) and now
at the University of Vermont, who have made this work possible and
rewarding. The development of a cognitive-behavioral therapy (CBT)
treatment for seasonal affective disorder (SAD) would not have been
possible without decades of prior work by others on the cognitive theory
and therapy of depression and on the behavioral conceptualization of
depression and behavior therapy. For this, I am most grateful to Aaron
T. Beck and his colleagues, particularly Judith S. Beck, in developing
the theory and treatment principles that inspired me to modify cogni-
tive therapy for SAD and to Peter M. Lewisohn and his colleagues for
developing pleasant events scheduling as a potent behavioral treatment
strategy that has proven very useful for SAD. These treatment compo-
nents represent much of the material contained within this manual, and
their originators deserve full credit for them. I would also like to thank
Alan Peterson for sharing his ideas on basic psychoeducation regard-
ing depression symptoms and relapse prevention. I am grateful to my
colleagues, David A. F. Haaga and Teodor T. Postolache, and to my for-
mer clinical graduate students and co-therapists, most notably Kathryn
A. Roecklein, Kathryn Tierney Lindsey, and Brenda Elliot, who pro-
vided helpful feedback on the content of this program at the time it was
initially being conceptualized and tested. Thanks also to the National
Institute of Mental Health (NIMH) and to the USUHS for funding
the clinical trials that have tested this protocol to date.
ix
Contents
Chapter 1 Introductory Information for Therapists 1
Chapter 2 Group Logistics 15
Chapter 3 Session 1: Introduction to the Group 21
Chapter 4 Session 2: Symptoms, Prevalence, and Causes

of SAD 29
Chapter 5 Session 3: How Activities Relate to Mood and

Thoughts 39
Chapter 6 Session 4: Doing More to Feel Better 47
Chapter 7 Session 5: What You Think Influences How

You Feel 57
Chapter 8 Session 6: Cognitive Distortions 67
Chapter 9 Session 7: Evaluating Your Automatic Thoughts 77
Chapter 10 Session 8: Rational Responses 83
Chapter 11 Session 9: Core Beliefs 91
Chapter 12 Session 10: Evaluating Your Core Beliefs 99
Chapter 13 Session 11: Maintaining Your Gains and Relapse

Prevention 107
Chapter 14 Session 12: Review and Farewell 115
Fidelity Checklists 121
References 135
About the Author 139
xi
Chapter 1 Introductory Information for Therapists
Background Information and Purpose of This Program
This guide presents a cognitive-behavioral group treatment for seasonal

affective disorder (SAD). The treatment is based on an integrative
cognitive-behavioral model and represents a tailoring of traditional
cognitive-behavioral therapy (CBT) for depression to the special needs
of the SAD population. CBT is placed in a seasonality framework, rec-
ognizing the role of environmental changes as well as cognitions and
behaviors.
The session-by-session protocol for conducting 1.5-hr CBT sessions

twice a week over 6 weeks (total of 12 sessions) is described in this
guide. To be implemented effectively, this program is recommended
for educated mental health professionals (e.g., psychologists, psychia-
trists, and social workers). Some prior training in cognitive-behavioral
approaches is also recommended because this manual, in itself, does
not teach providers how to do CBT and assumes a basic proficiency in
conducting cognitive therapy.
This treatment was designed as a group program, and this guide is

addressed to the group leader(s). See Chapter 2 for more information
on group logistics. Although we have not tested our treatment using an
individual therapy format, we believe that the content of this manual
could be easily adapted for use in individual therapy.
Seasonal Affective Disorder
SAD is a subtype of recurrent depression that involves a regular tem-

poral pattern in the onset and remission of major depressive episodes
1
(MDEs) at characteristic times of year (Rosenthal et al., 1984). The
substantial majority of cases are winter-type SAD, defined as recurrent
MDEs with a regular pattern of onset in the fall or winter months and
remission in the spring. A small minority of cases are summer-type SAD,
with regular MDE recurrence in the summer. Winter-type SAD is the
focus of this guide, and the term SAD will be used to refer to winter-type
SAD hereafter. In the Diagnostic and Statistical Manual of Mental Dis-
orders, Fourth Edition, Text Revision (DSM-IV-TR), SAD is diagnosed
as major depression, recurrent, with seasonal pattern (American Psy-
chiatric Association, 2000; see Table 1.1 for seasonal pattern specifier
diagnostic criteria). The DSM-IV-TR also includes a diagnosis of bipo-
lar I or II disorder with seasonal pattern (i.e., bipolar-type SAD), which
is not the focus of this guide.
DSM-IV-TR MDE criteria represent the spectrum of SAD symp-

toms. The majority of SAD patients endorse depressed mood, loss of
interest or pleasure in activities, and persistent fatigue (Magnusson &
Partonen, 2005). In contrast to nonseasonal major depression, SAD
patients more frequently endorse (a) hypersomnia than insomnia and
(b) increased appetite, excessive carbohydrate craving, or weight gain
than decreased appetite or weight loss (Magnusson & Partonen). Other
atypical depressive symptoms, not contained within the DSM-IV-
TR criteria but common in SAD, include an afternoon or evening
slump in mood or energy and reverse diurnal variation (Lam, Tam,
Yatham, Shiah, & Zis, 2001; Rosenthal et al., 1984). Seasonality, the
tendency to vary across the seasons in mood and behavior, differs
in degree across individuals, and full-blown clinical SAD symptoms
appear to represent an extreme along a continuum of human season-
ality (Kasper, Wehr, Bartko, Gaist, & Rosenthal, 1989; Rosen et al.,
1990).
SAD characterizes 10–20% of recurrent depression cases (Blazer et al.,

1998; Magnusson, 2000). In population surveys of U.S. adults, SAD
prevalence generally increases with latitude and ranges from 1.4% in
Florida to 9.9% in Alaska (Booker & Hellekson, 1992; Rosen et al.,
1990). Subsyndromal SAD (S-SAD)—defined by moderate changes
with the seasons and commonly referred to as the “winter blues”—is
even more common than SAD and ranges in prevalence from 2.6% in
Florida to 19% in Alaska.
2
Table 1.1 Seasonal Pattern Specifier Diagnostic Criteria
■ There is a regular temporal relationship between the onset of MDEs and a characteristic
time of year.
■ Full remissions (or change to mania or hypomania in the case of bipolar-type SAD)
occur at a particular time of year.
■ In the last 2 years, major depressive episodes that demonstrate these temporal seasonal
relationships have occurred.
■ Seasonal MDEs substantially outnumber nonseasonal MDEs over the lifetime.
■ There is no obvious seasonally linked psychosocial stressor responsible for the seasonal
pattern.
Available data suggest that the long-term course of SAD is variable. In a

review of four longitudinal follow-up studies of SAD patients; Lam et al.
(2001) concluded that 28–44% of these SAD patients later developed
a nonseasonal pattern of depression recurrence or incomplete summer
remission, 14–38% went from having SAD to S-SAD or into remis-
sion, and 22–42% continued to have “pure” SAD (i.e., winter depressive
episodes and complete summer remission).
The cause of SAD is yet to be established, but several hypotheses

have been proposed: phase-shift, photoperiodism, photon-count, and
serotonin. See Session 2 for summaries of each of these hypotheses.
Development of This Treatment Program
The central public health challenge in the overall management of SAD

is prevention of depressive episode recurrence over subsequent fall or
winter seasons. Therefore, the major impetus for developing this par-
ticular treatment program was the identified need for a SAD treatment
with the following qualities:
1. a time-limited treatment (i.e., acute treatment completed in a

discrete period versus daily treatment every fall or winter
indefinitely),
3
2. a treatment that effectively treats acute SAD symptoms in the
initial winter, and
3. a treatment that shows effects that endure beyond the cessation of

treatment to prevent the annual recurrence of winter depression.
Although light therapy (LT), the established and best available treat-
ment for acute SAD, clearly fulfills criterion 2 for acute efficacy (Golden
et al., 2005; Terman et al., 1989), it does not fulfill criterion 1 or 3.
For acute and long-term SAD management, available clinical practice
guidelines recommend daily use of LT, from onset of first symptom
through spontaneous springtime remission, during every fall or win-
ter season, generally spanning 3–6 months of the year (Lam & Levitt,
1999). Therefore, LT, by definition, is not a time-limited treatment (does
not meet criterion 1) but instead is a palliative treatment that presum-
ably works by suppressing symptoms so long as treatment is ongoing
and must be continued with regularity over each fall or winter season
to have continued efficacy (does not meet criterion 3). Currently avail-
able alternative treatments to LT have the same problems (see section
“Alternative Treatments”).
There would be no need to develop a treatment with these three qual-

ities if SAD patients continued using palliative treatments such as LT
with good compliance over subsequent winter seasons. However, that
does not appear to be the case. A retrospective follow-up survey of SAD
patients treated at the National Institute of Mental Health between
1981 and 1985 revealed that only 41% of patients continued regular use
of LT (Schwartz, Brown, Wehr, & Rosenthal, 1996). When queried
as to why they discontinued using LT, perceived “ineffectiveness” and
“inconvenience” were the two most commonly cited reasons.
We believe that a CBT1 tailored to SAD has potential to fulfill all the
three criteria described earlier. Cognitive therapy (A. T. Beck, Rush,
1 Our decision to call the treatment cognitive-behavioral therapy rather than cognitive therapy
reflects our theoretical stance that the behavioral treatment components such as pleasant activ-
ity scheduling directly target overt depressive behavior, in its own right, as a primary mover
to effect change in depression and that the cognitive treatment components such as cognitive
restructuring directly target negative cognitions, in their own right, as a primary mover to
effect change in depression. However, our treatment protocol is a revision of A. T. Beck et al.
(1979) cognitive therapy for depression, tailored to SAD.
4
Shaw, & Emery, 1979) is a time-limited treatment that is acutely effi-
cacious for nonseasonal depression and appears to confer benefits that
extend beyond the point of treatment termination (Gloaguen, Cottraux,
Cucherat, & Blackburn, 1998; Hollon, Stewart, & Strunk, 2006). Sev-
eral studies have found that depressed patients who demonstrated a
clinical response to cognitive therapy had a reduced risk of depression
relapse as compared to patients who initially responded to antidepres-
sant medications (Blackburn, Eunson, & Bishop, 1986; Evans et al.,
1992; Hollon et al., 2005; Simons, Murphy, Levine, & Wetzel, 1986).
In addition to reducing the more proximal risk of relapse, a recent
trial found that patients who had fully recovered from the episode
treated with cognitive therapy demonstrated a reduced risk for a wholly
new depressive episode onset (i.e., recurrence) relative to patients who
had fully recovered from the initial episode with pharmacotherapy
(Hollon et al., 2005).
Cognitive-Behavioral Model of SAD
Our conceptual model, referred to as the integrative, cognitive-

behavioral model, provides a theoretical rationale for this treatment. In
an expansion of M. A. Young’s (1999) dual-vulnerability model, our pro-
posed model maintains an emphasis on a dual (i.e., physiological and
psychological) vulnerability to SAD, but adds depth and breadth by
specifying a role for cognitive and behavioral factors in contributing to
the psychological vulnerability. According to our model, SAD episode
onset occurs when environmental changes activate a reverberating cycle
between the psychological and physiological vulnerabilities or when
anticipation of winter activates the psychological vulnerability, which,
in turn, activates the physiological vulnerability. Thus, the psychologi-
cal vulnerability factor has maintenance, and possibly onset, etiological
significance.
The cognitive component of the psychological vulnerability factor

(A. T. Beck, 1967, 1976) includes maladaptive schemas, attitudes,
and automatic thoughts typical of nonseasonal depression, but adds
environment-specific thoughts related to the winter season, light avail-
ability, cues that the seasons are changing, and weather. Our model
5
further incorporates another cognitive component, ruminative coping
(Nolen-Hoeksema, 1987), as well as behavioral factors such as a low rate
of response-contingent positive reinforcement (Lewinsohn, 1974) and
learned emotional and psychophysiological reactivity to low light- and
winter-relevant stimuli in the environment. Preliminary studies have
associated automatic negative thoughts (Hodges & Marks, 1998; Rohan,
Sigmon, & Dorhofer, 2003), dysfunctional attitudes (Hodges & Marks),
rumination (Rohan et al., 2003; M. A. Young & Azam, 2003), a nega-
tive attributional style (Levitan, Rector, & Bagby, 1998), and reduced
pleasant event frequency and enjoyment (Rohan et al.) with SAD. Our
CBT protocol targets these cognitions and behaviors to improve acute
SAD symptoms and to prevent episode recurrence.
As our model illustrates, perhaps LT is an insufficient treatment for

some individuals with SAD because a purely biological explanation
is incomplete. LT targets the physiological vulnerability factor, but
does not directly address the psychological vulnerability. CBT, however,
directly targets the hypothesized components of psychological vulner-
ability. In addition, the combination of cognitive-behavioral therapy
and light therapy (CBT + LT) would intervene at the level of both
vulnerabilities.
Psychological Environmental cues

appraisal/expectations (light, seasonal, weather)
(anticipation of winter)
Physiological vulnerability
Psychological vulnerability (e.g., circadian rhythms, photons)
• Cognitive (e.g., rumination, core beliefs)
• Behavioral (e.g., behavioral disengagement,
psychophysiological reactivity)
SAD episode
CBT CBT + LT LT
Interventions
Figure 1.1
Integrative Cognitive-Behavioral Model
6
Outline of the CBT for SAD Treatment Program
Our protocol uses traditional elements of CBT such as behavioral

activation and cognitive restructuring to promote improved coping
with the winter season. Some cognitive restructuring exercises focus
on challenging negative thoughts related to the winter season in gen-
eral, low light availability, seasonal cues in the environment, and
weather. Owing to the predictable nature of SAD recurrence, relapse
prevention can be more specifically targeted in SAD than is possible
in nonseasonal depression. Our relapse-prevention treatment compo-
nent emphasizes early identification of negative anticipatory thoughts
about winter and SAD-related behavior changes, using the skills
learned in CBT to cope with subsequent winter seasons, and develop-
ment of a personalized relapse-prevention plan to enhance treatment
durability.
As mentioned earlier, this program consists of 1.5-hr group CBT sessions

twice a week over 6 weeks (total of 12 sessions). Although CBT for
depression is typically administered for 12–20 weekly sessions, SAD
necessitates an intensified version. With winter lasting just 3 months,
SAD patients would spontaneously remit with the arrival of spring if
CBT were to be conducted weekly over 20 weeks. Each session typi-
cally begins with a review of the previous session and the “homework”
assignment and concludes with a preview of the next session. There
is a great deal of summarizing to reinforce learning, and we recom-
mend that the reviews be done in question-and-answer format to be
interactive.
The protocol (see Table 1.2) starts out in Week 1 (Sessions 1 and 2)
with some basic psychoeducation about SAD and depression, includ-
ing a rationale for using CBT for SAD. Week 2 (Sessions 3 and 4)
focuses on behavioral activation using pleasant activity scheduling.
This is presented as a means to get out of “hibernation mode”
and a way to develop wintertime interests. Weeks 3–5 (Sessions 5
through 10) focus on cognitive therapy. This work involves education
about the cognitive model, using thought diaries to record automatic
negative thoughts, Socratic questioning to evaluate negative thoughts,
7
Table 1.2 Summary of Sessions
Week Sessions Component
1 1 and 2 Psychoeducation
2 3 and 4 Behavioral activation
3 5 and 6 Cognitive therapy
4 7 and 8
5 9 and 10
6 11 and 12 Relapse prevention
generation of rational responses, and an exploration of core beliefs.

Week 6 (Sessions 11 and 12) focuses on maintaining gains and relapse
prevention.
Evidence Base
Preliminary data from two randomized clinical trials in our laboratory

suggest that our CBT may be an effective treatment for acute SAD
and that initial treatment with CBT may have superior outcomes when
compared to initial treatment with LT the next winter season. In our
feasibility randomized trial of 23 community adults who completed 6
weeks of study treatment, CBT alone, LT alone, and the combination
of CBT and LT all significantly improved symptoms across the 6-week
trial on two different measures of depressive symptoms (Rohan, Tierney
Lindsey, Roecklein, & Lacy, 2004).
Based on the feasibility study, we could not rule out the possibility that
apparent treatment effects were due to the passage of time or regression
to the mean. Because a larger sample size and true control group were
needed to replicate the preliminary findings regarding CBT for SAD, we
initiated a controlled, randomized clinical trial. The study randomized
61 community adults with SAD to CBT, LT, combination treatment, or
a concurrent wait-list control (i.e., a minimal contact/delayed LT con-
trol; Rohan et al., 2007). Those who received CBT, LT, and combined
treatment experienced significant and comparably improved depression
8
severity relative to the wait-list control in intent-to-treat and com-
pleter samples. CBT combined with LT (73–79%) had a significantly
higher remission rate at the end of treatment than the wait-list con-
trol (20–23%). These findings suggest that CBT, alone or combined
with LT, holds promise as an efficacious SAD treatment and warrants
further study.
Because we believe that preventing SAD episode recurrence over future

winters is a more important outcome than acute treatment efficacy in
the initial winter of study, we used our pilot data to examine longer-term
outcomes. We conducted an intent-to-treat analysis of outcomes dur-
ing the subsequent winter season (i.e., January or February of the next
new winter season; approximately 1 year after acute treatment) using
all 72 participants randomized to CBT, LT, and combination treatment
(24 CBT, 25 LT, 23 CBT + LT) across our two pilot studies (Rohan,
Roecklein, Lacy, & Vacek, submitted). We used multiple imputation
to estimate next-winter outcomes for the 17 individuals who dropped
out during treatment, were withdrawn from protocol, or were lost to
follow-up. The CBT (5.8%) and combination treatment (5.2%) groups
had significantly smaller proportions of winter depression recurrences
than the LT group (39.2%). CBT, alone or combined with LT, was
also associated with significantly lower interviewer- and patient-rated
depression severity at 1 year as compared to LT alone. Among com-
pleters who provided 1-year data, all statistically significant treatment
group differences persisted after adjustment for ongoing treatment with
LT, antidepressants, and psychotherapy.
There are several aspects of these studies that differ from clinical
practice. In both of these randomized trials, inclusion criteria for par-
ticipants were (a) aged 18 or older, (b) DSM-IV criteria for Major
Depression, Recurrent, with Seasonal Pattern, and (c) a current SAD
episode. Exclusion criteria were (a) current psychiatric treatment (i.e.,
psychotropic medications, LT, or psychotherapy), (b) another current
Axis I disorder, and (c) bipolar-type SAD. In both studies, the prin-
cipal investigator (PI), a licensed psychologist with expertise in SAD
and experience in CBT, provided the study treatment alongside a clin-
ical graduate student cotherapist. These studies were conducted in
the Washington, DC, metropolitan area, with sample demographics as
9
follows: 93% women, mean age = 47 years (SD = 12.6), 81% Caucasian,
75% college educated, 79% currently employed, and 49% currently
married. Therefore, it is not known whether these findings generalize
to SAD patients with comorbid diagnoses or bipolar-type SAD or to
SAD patients who are also concurrently involved in other treatments,
to professional interventionists other than the PI, and to samples with
different demographic characteristics.
Risks and Benefits of This Treatment Program
The benefits of this treatment program to participants include the

possibility of improving across the course of acute treatment and the
possibility of continued benefits from treatment over the next winter
season and possibly beyond. We believe that the risks to participants
associated with this treatment program are minor. There are no known
negative side effects to CBT. However, it is possible that some individ-
uals may not feel comfortable discussing or thinking about personally
sensitive information or events during the group CBT sessions. Some
individuals prefer individual to group therapy. Some individuals may
find it inconvenient to attend the twice-weekly therapy sessions over
the 6-week course of this program and/or to complete the “homework”
(i.e., self-help) assignments between meetings. Participants who can-
not fairly consider any possible role for nonbiological factors in SAD
and/or any nonbiological treatment option may not be appropriate for
this program.
Alternative Treatments
LT, a minimum of 30 min of daily scheduled exposure to 10,000 lux of

cool-white or full-spectrum fluorescent light with ultraviolet rays filtered
out, is recommended as the first-line treatment for SAD (Lam & Levitt,
1999). Available treatment options for SAD include LT and antidepres-
sant medications, both of which are supported by evidence from several
studies, and newer treatments that show promise, such as dawn simula-
tion and negative ions (Westrin & Lam, 2007). Aerobic exercise has also
shown promise as an acute SAD treatment in a preliminary investigation
10
(Pinchasov, Shurgaja, Grischin, & Putilov, 2000). These treatments are
palliative treatments that presumably work by suppressing symptoms
so long as treatment is ongoing. Therefore, patient preferences and the
likelihood of adhering to a daily treatment regimen during the symp-
tomatic months each year warrant careful consideration in selecting a
treatment plan.
The Role of Light Therapy and Medications
For clinical use, we believe that this CBT program can be combined
with LT in a synergistic effect to maximize acute treatment efficacy. This
is based on our data that CBT combined with LT had the highest post-
treatment remission rate in our randomized clinical trial (Rohan et al.,
2007). Our model conceptualizes SAD as a multifaceted disorder with
both physiological and cognitive-behavioral factors involved in the onset
and maintenance of symptoms. This protocol was designed to present
a rationale for CBT that compliments, and does not compete with, the
rationale for LT. However, in our pilot studies, only four participants
(two treated with solo LT and two treated with CBT + LT) reported
any ongoing use of LT at follow-up the next winter. If this finding gen-
eralizes to clinical practice, the majority of patients who are treated with
combination treatment may not persist with continued LT on their
own past the first winter and, therefore, may require explicit instruc-
tions to rely on proactive use of their CBT skills to cope with future
winters and/or additional treatment to address long-term compliance
with LT.
Because internal validity was of primary importance in testing our

new CBT for SAD treatment, our preliminary clinical trials excluded
individuals who were currently taking antidepressant medications. To
increase sample size, we ended up allowing three participants on stable
doses of antidepressants into the feasibility study (one randomized to
each of the three treatment conditions). Conclusions cannot be reached
on the basis of such small numbers, and more data are needed to
determine whether the preliminary outcomes for CBT for SAD gen-
eralize to individuals taking stable doses of medications. CBT for SAD
11
has not been tested against medications in a head-to-head comparison
to date.
Assessment
Before enrolling a participant in this program, we recommend a thor-

ough evaluation to ensure that the individual has SAD. Consistent
with the principles of CBT, we recommend administering an objec-
tive outcome measure on a weekly or session-by-session basis during
the treatment program. We recommend using the Structured Interview
Guide for the Hamilton Rating Scale for Depression—Seasonal Affec-
tive Disorder Version (SIGH-SAD) (Williams, Link, Rosenthal, Amira,
& Terman, 1992) and/or the Beck Depression Inventory—Second Edi-
tion (BDI-II) (A. T. Beck, Steer, & Brown, 1996) to measure depressive
symptom severity. The BDI-II is a 21-item measure of depressive symp-
tom severity that captures many of the atypical depressive symptoms
common in SAD and can be quickly and easily administered before
sessions. The SIGH-SAD is a semi-structured interview that includes
the 21-item Structured Interview Guide for the Hamilton Rating Scale
for Depression (HAM-D) and a supplementary eight-item subscale to
assess atypical depressive symptoms associated with SAD. The follow-
ing criteria define SAD episode onset or recurrence (Terman, Terman,
& Rafferty, 1990): total SIGH-SAD score ≥ 20 + HAM-D score ≥
10 + atypical score ≥ 5. Remission at treatment endpoint can be clas-
sified by satisfying one or both of the following SIGH-SAD criteria
(Terman et al.): (1) pre- to post-treatment reduction in total SIGH-
SAD score ≥ 50% + HAM-D score ≤ 7 + atypical score ≤ 7 and (2)
HAM-D score ≤ 2 + atypicalscore ≤ 10.
Use of the Client Workbook
The workbook for participants follows the treatment program, with

each chapter corresponding to a session. The beginning of each chapter
lists goals and gives an overview of what participants can expect to
learn in group. Session elements are then summarized; participants are
encouraged to review the corresponding workbook chapter after each
12
group meeting. Each session chapter ends with a list of homework
assignments. Forms are included in the workbook to help participants
apply new skills, such as weekly plans for pleasant activity schedul-
ing and thought diaries for cognitive restructuring. Participants should
bring workbooks to every session to facilitate homework review and
group discussion.
13
Chapter 2 Group Logistics
Forming a Group
Adult participants should be recruited for this group program on the

basis of having seasonal affective disorder (SAD), their willingness to
participate in this treatment program, and their availability to attend
the majority of sessions. We have successfully conducted cognitive-
behavioral therapy (CBT) for SAD with groups of participants who vary
widely in age. Although it may be desirable from a group cohesion per-
spective to have same-sex group members, this will not likely be feasible
as the majority of our participants (90%) have been females. We have
successfully conducted CBT for SAD groups with no or only one male
in the group. We have observed that regardless of age or gender, partici-
pants generally form a cohesive group around their common experience
with SAD.
Group Size
Based on our experience conducting these groups, the ideal group size
is four to six group members, with no more than eight per group. This
number ensures an adequate balance between the group leaders present-
ing new didactic material and group discussion or homework review.
Groups of four allow for more individual attention and more thorough
processing of each member’s homework. With a group size of eight,
group leaders will not be able to thoroughly review homework from
every member at each session and will need to ensure equal time to each
member across the course of the program.
15
Each of our past groups had the same two group leaders throughout the
program. We recommend two group leaders, if possible, to help change
the focus of attention frequently within each session and to keep discus-
sions going. However, we believe that the program can be successfully
conducted by one group leader.
Group Meetings and Program Duration
This CBT for SAD program consists of twelve 1.5-hr sessions, deliv-
ered twice per week over a 6-week period in the fall and/or winter.
The full 12-session program should be started by early February and
completed by early March at the latest to avoid running into sponta-
neous springtime remission. At Southern locations, it may be necessary
to start and end even earlier, depending on when spring arrives. The
scheduled meeting time and days for the group should be consistent for
the duration of the program. There should be at least 1 day in between
the twice-weekly sessions. For example, we typically ran a group on a
Monday/Wednesday schedule or on a Tuesday/Thursday schedule. It is
important to agree on optimal meeting days and a meeting time slot
that works for everyone.
The 6-week period should generally be continuous; however, given the

large number of federal and religious holidays in the wintertime, groups
may wish to break at one or more mutually agreed-upon times and then
resume after the break. For example, we made it a policy not to hold
any group sessions between Christmas Eve and New Year’s Day because
we found that the vast majority of participants were not able or willing
to come in during that time. In the event of a scheduled break, it will be
important to prepare participants to plan to keep using the skills learned
to date over the break rather than taking a complete “vacation” from
treatment. This is especially important for SAD because unstructured
time can perpetuate winter depression through low activity level and
rumination. Group leaders should also have a plan in place for how
they will handle any snow days and should make participants aware of
that plan. For example, we made it a policy to decide about canceling
a scheduled session because of inclement weather as early in the day as
16
possible and for the group leaders to call all participants in the event of
a cancellation.
Because the 12 sessions progressively build on one another, it is essential

that participants progress through the program in sequence. Therefore,
this program is delivered in a closed-group format. In some cases, it is
permissible for a participant to join a group in progress in the second
or third session if one of the group leaders reviews the missed session(s)
with the participant in detail ahead of time, especially group format,
rules, and confidentiality from Session 1. Similarly, if a participant must
miss one or more scheduled sessions, it is essential that one of the group
leaders meet with the participant to review the missed material and
ensure that the participant has a clear understanding. If the absence is
anticipated, it is ideal to conduct the review ahead of time, although it
can be done after the participant returns.
SAD patients frequently elect to travel South in the winter. These trips
can be disruptive to the group in several ways. Other group mem-
bers who are aware of the trip may think that they are missing out
on a vacation South and feel disappointed. For the individual partici-
pant who travels South, there is a disruption in group attendance that
interferes with learning the material in sequence. In addition, assuming
the trip is far enough South, patients generally experience a temporary
remission of SAD symptoms while away, followed by a return of symp-
toms within a few days of return from the South. This contrast can
be difficult for some people. If the group leaders are aware that a par-
ticipant is contemplating a trip, we encourage a discussion with him
or her outside of the group around the costs and benefits of traveling
versus not traveling. We do not advocate that SAD patients set aside
money to use for spontaneous trips South when they deem a trip is
needed because doing so positively reinforces the depression and nega-
tively reinforces taking trips South in the winter (e.g., the contingency,
“If I feel bad enough, I get to go to Florida for a week,” increases the
chances that one will become more severely depressed and increases
the probability of future trips to escape winter). If winter trips South
must be taken, they should ideally be scheduled in advance and before
symptomatic [e.g., putting the contingency for a trip on an external
stimulus (i.e., a date) rather than an internal stimulus (i.e., how badly
one feels)].
17
Maintenance or Follow-Up Sessions
This program, as designed, does not include maintenance or follow-up

sessions because it operates on the assumption that once participants
complete the program, they keep using the skills on their own to cope
with future fall or winter seasons. We have not tested whether follow-
up sessions add any benefit above-and-beyond the 12-session format.
However, we can see the possible clinical utility of one or two follow-up
sessions with participants just before the next wholly new fall or winter
season begins to reinforce the skills learned and prepare for relapse pre-
vention. The content of Sessions 11 and 12 would be particularly relevant
for follow-up.
Group Rules
The basic rules that group members are expected to follow include
confidentiality (e.g., using first names only, not discussing personal
information disclosed by other group members outside of the group),
mutual respect (e.g., providing equal time in discussions and not inter-
rupting when another member is speaking), arriving on time and staying
until the session ends, and calling a group leader ahead if unable to
attend a meeting.
Role of Group Leaders
Mental health professionals (e.g., psychologists, psychiatrists, and social

workers) with some prior training in cognitive-behavioral approaches
are appropriate group leaders. The role of the group leaders is to
provide the didactic information outlined in this manual, structure
the sessions, offer observations where appropriate, promote interac-
tion among group members, and provide social support. The two
group leaders work in a collaborative relationship with each other
toward accomplishing these tasks. In advance of every session, it is
18
recommended that the group leaders meet briefly to review the ses-
sion content and to divide up the didactic material in a way that
will frequently change the focus of attention from one to the other.
After each session, it is recommended that the group leaders meet
to discuss their impressions of how the session went and to prob-
lem solve any difficulties specific to the group. The fidelity checklists
included in an appendix may be used as part of a supervision pro-
cess or to rate self-adherence. You may photocopy checklists from the
book.
All forms are provided in the workbook and participants should bring
their workbooks to every session. For forms that are used more than
once (e.g., Thought Diaries), group leaders may want to provide addi-
tional copies to participants. You may photocopy these forms from the
workbook.
19
Chapter 3 Session 1: Introduction to the Group
(Corresponds to session 1 of the workbook)
Materials Needed
■ Nametags
■ Flip chart or writing board
■ Copy of client workbook
Outline
■ Set agenda (5 min)
■ Introduce group leaders and members (15 min)
■ Review the goals of this group (15 min)
■ Explain the purpose of this group (5 min)
■ Discuss the issue of confidentiality (5 min)
■ Introduce cognitive-behavioral therapy (CBT) (15 min)
■ Discuss changes that the group members can expect to make

(15 min)
■ Present the rationale for homework (10 min)
■ Assign homework (5 min)
Setting the Agenda (5 min)
Begin the session by setting the agenda and writing it on the flip chart.
Tell group members that today you will provide them with an overview
21
of the group, its goals, and what they will be working on over the next
12 sessions. You will also describe the kind of treatment this group will
be using—CBT. Tell the group that first, however, you would like to do
some introductions.
Introductions (15 min)
Introduce yourself as the group leader. You may want to mention

your background and experience. Next, have group members intro-
duce themselves (first names only). It is helpful for members to wear
nametags. Have members include in their introductions something
about themselves; for example, where they are from, what they do, or
what their interests are.
Goals of This Group (15 min)
Present the following goals of this group using the dialogues in italics.
1. Increase knowledge and understanding of seasonal affective

disorder (SAD). Understand common signs and symptoms and
what may cause SAD.
Having seasonal affective disorder (SAD) means regularly

experiencing symptoms of depression each fall and/or winter
season that improve with the arrival of spring. It’s important that
you understand what the symptoms of SAD are so you can
recognize them when they occur. This helps you to realize when
you are getting better and when you are getting worse. This also
allows you to notice when your symptoms are starting before they
get really bad. Recognizing symptoms early on means you can do
something to interrupt them and prevent them from getting a lot
worse.
2. Learn how common SAD symptoms are.
We’ll review the prevalence of SAD and SAD-like symptoms at

different latitudes. We’ll emphasize that SAD symptoms happen
22
on a continuum, where most people experience them to a certain
extent. In other words, most people experience some changes in
their mood or behavior with the changing seasons, although the
severity of these symptoms differs from person to person.
3. Learn skills to help you cope better with seasonal changes.
We would like for you to think of the arrival of the fall/winter

season as a life circumstance or event that precedes (or comes
before) your depressive symptoms. We will be focusing on the way
you typically cope with winter and teaching you new ways to cope
with the arrival of fall or winter that will be more helpful. We
can’t change the fact that winter will arrive every year, but we
can work to change the way you cope with it. You will learn and
practice skills to help you manage, reduce, or eliminate seasonal
symptoms.
4. Learn skills to help you prepare for SAD symptoms before they
start so you may be able to lessen their impact or even prevent
them over future winter seasons.
You will develop a long-term plan to cope with SAD so you’ll be

ready for it next year and every year after that. As we’ve
mentioned, recognizing your SAD symptoms early on is part of
this plan. It’s also important to do something about those
symptoms early on before they get worse. It is even better to try
and prevent these symptoms before they start; this is called “relapse
prevention.”
Purpose of the Group (5 min)
You can use the metaphor of a “driving instructor” to explain how this
group works:
When you are learning how to drive a car for the first time, you
usually have a driving instructor sitting next to you, telling you what
to do, and even hitting the brakes if needed. Eventually, you develop
your own driving knowledge and rely less and less on the instructor
23
until you finally become an independent licensed driver. You can think
of this group as your driving instructor. We will teach you skills that
you can use to manage your SAD symptoms. We will give you a lot of
guidance at first. After the group, you will be your own therapist. You
will know how to recognize your SAD symptoms and have a plan in
place to deal with them.
Explain that this is a skill-based treatment group—not a process,

encounter, or support group. Tell group members that rather than just
talking about their problems, they will learn skills to deal with them.
This may be different from other groups they have been in. Emphasize
that the group will be interactive. In every meeting, you will ask them
questions about their experience with SAD related to the skill they will
be learning that day. The group will also talk about how to apply the
skills to members’ everyday lives.
Ask group members to be courteous to the other group members. You

will try to provide participants with equal time to share ideas, ask
questions, and discuss any difficulties in using the various skills.
Confidentiality (5 min)
Explain that this group will be more beneficial if everyone can feel com-
fortable discussing things without worrying that others will find out.
To help with this, ask that everyone keep the information discussed in
group confidential. In other words, they should not discuss anything
about other group members outside of the meeting. You may want to
use the following dialogue:
It might be tempting to discuss the group with your family and friends.
That’s okay as long as you don’t talk about other group members or
personal things said by other group members. Is this acceptable to
everyone?
Obtain group consensus for confidentiality of all personal infor-

mation revealed by group members before moving on to the next
section.
24
Cognitive-Behavioral Therapy (15 min)
Tell the group that research has identified some of the most effec-
tive nondrug treatments for depression, including the types of skills
that are part of this program. Explain that this group will use a CBT
approach:
“Cognitive” refers to thinking and “behavioral” refers to behavior or

things you do. It makes sense then that cognitive-behavioral therapy
focuses on changing your thinking and your behavior to help you feel
better emotionally.
Inform the group that this program is based on research that has shown
that people with SAD participating in a CBT group improved as much
as those who used light therapy (LT) over the winter. Furthermore, there
is evidence that people with SAD who participated in CBT were less
likely to have their SAD return and experienced less severe symptoms
in the next winter season compared with people with SAD who used
LT in the winter before. In other words, prior exposure to CBT may
have some long-lasting benefits for SAD compared to prior exposure
to LT.
Based on three decades of research, all of the following statements are

true of CBT:
1. CBT is effective in treating both mild and more severe

depression.
2. Most comparisons have shown CBT to be as effective as

medications in treating depression.
3. CBT has no known adverse physical side effects.
4. CBT may prevent or help delay relapse (or return) of depressive

symptoms in the future better than other forms of treatment for
depression.
5. Preliminary studies suggest that CBT may be as effective as LT in

treating SAD and that prior treatment with CBT may prevent the
return of SAD in the next winter season better than prior
treatment with LT.
25
WhattoExpect(15min)
Tell group members that the benefits they will receive from this program
depend on their willingness to keep an open mind and try new things.
Some changes they may make through this group include becoming
more active and thinking more positively (see sample dialogues).
1. Becoming more active.
Individuals with SAD tend to withdraw or “hibernate” during

the fall and winter months. Therefore, they don’t do things they
would normally enjoy doing—things that are fun. This tends to
make SAD even worse. Not only are you suffering from your SAD
symptoms, but also you are cutting yourself off from enjoyable
activities that may boost your mood a bit. In this group, you will
learn how to increase your frequency of pleasurable activities in
the winter to improve your mood. When you feel a little bit
better, you should have even more energy to do fun things.
2. Thinking more positively.
Just like those with nonseasonal depression, people with SAD tend
to think very negatively. During the fall or winter, it is like they
are seeing the world through dark glasses which make everything
seem pretty bad. People with SAD also tend to spend a lot of time
thinking about how badly they feel and often anticipate their
symptoms before they even start. Most of you are probably
familiar with that sense of dread or foreboding you get about the
winter season before it even gets here. Sometimes the end of
summer or seeing things like leaves changing color or days getting
shorter can set this off. Again, this way of thinking tends to make
SAD symptoms even worse. In addition to thinking negatively
about the winter and the weather, SAD is also associated with
thinking negatively about yourself, daily situations, other
people, and the future. This way of thinking helps keep you
down.
Explain that this group will help members understand how the way they
think relates to how they feel. They will learn to identify and challenge
26
negative thinking in order to improve their mood. They will also learn
to think more positively (or at least less negatively) about the winter
season.
Rationale for Homework Assignments (10 min)
You may want to present the rationale for homework assignments using
the analogy of learning to play a new sport. Ask the group what are the
things they might do if they wanted to learn something new, like how
to play golf or tennis. If not mentioned by the group, list these:
■ Try it on your own
■ Buy a book
■ Get a video
■ Take lessons
■ Practice
Emphasize that practice is necessary to learning something new, whether

it be a sport or the kind of skills taught in this program. This program
will include “homework” to practice the skills reviewed in group. This
homework is practical and meant to help them feel better.
Inform group members that they will not be graded or evaluated on this
homework; you just ask that they try their best. In general, the more
effort they put into homework assignments, the better they will feel.
People who do not do the homework will probably not benefit much
from this group. Research actually shows that people who do the most
homework in CBT for depression improve the most, regardless of how
depressed they were at the start of treatment. You may want to sum up
with the following dialogue:
It does not matter if we are the best therapists in the world or if the
information presented in this group is excellent if you don’t practice
what you learn here outside of the meetings. Remember our driver
instructor/student driver analogy? These homework assignments will
allow you to practice your skills between sessions. We and the other
27
group members can give you suggestions about how to make the most
out of your homework assignments.
Homework (5 min)
✎ Have group members complete the Identifying SAD Symptoms form.
✎ Have group members review Session 1 of the workbook.
✎ Have group members read the overview of Session 2.
28
Chapter 4 Session 2: Symptoms, Prevalence, and Causes
of SAD
Materials Needed
■ Group members’ completed Identifying SAD Symptoms

forms
■ Nametags
Outline
■ Review content of Session 1 (5 min)
■ Discuss SAD and its symptoms (40 min)
■ Introduce the vicious cycle of SAD symptoms

(10 min)
■ Explain the prevalence of SAD (5 min)
■ Present possible causes of SAD (15 min)
■ Discuss the importance of psychological factors in maintaining

SAD (10 min)
29
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
Review of Session 1 (5 min)
Remind group members that in the last session you gave an overview
of what this group will be like. Discuss any questions they may have.
Review the following points:
1. Group members will be learning skills to help them cope better

with the fall or winter season. We cannot change the fact that
winter rolls around every year without exception, but we can
change the way we cope with its arrival.
2. The kind of therapy we are doing is called cognitive-behavioral

therapy (CBT). It is a tried-and-true treatment for depression,
with three decades of research to back it up. Evidence over the last
several years suggests that CBT may also be helpful in treating
SAD and may have benefits that extend into the next winter
season.
3. Some of the changes that participants can expect from this group
include:
a. Becoming more active. Group members will learn to fight their

tendency to hibernate and will begin to engage in activities
that they enjoy in order to feel better and have more energy.
b. Thinking more positively. Group members will learn ways to
view things in their lives and the winter season less negatively
and more positively.
SAD and Its Symptoms (40 min)
Discuss with the group why it is important to start out by talking about
common signs and symptoms of SAD:
30
■ To become aware of and understand the different types of
symptoms
■ To understand how to know when SAD is getting better or worse

(symptoms increase or decrease)
■ To be able to recognize symptoms early on when they are just

starting
Group members may not be aware of all the symptoms of SAD. By rec-
ognizing the different types of symptoms, they may better understand
the way SAD affects them. Paying attention to when symptoms increase
and decrease can help members track their progress. Early intervention
in symptoms can prevent SAD from becoming full-blown.
What Is SAD?
Explain that SAD is a form of clinical depression. Clinical depres-

sion involves experiencing at least five significant changes in mood
and behavior that last most of the day, nearly everyday for 2 weeks or
longer and cause distress and impairment in day-to-day life. The possi-
ble symptoms that can be present in SAD and in nonseasonal depression
are the same. However, SAD is different from nonseasonal depression in
that it tends to recur every year and follows a seasonal pattern of onset
in the fall or winter and remission in the spring or summer. In con-
trast, nonseasonal depression can occur at any time, often in response
to stressful life events.
Symptoms of SAD
Ask group members to look at their Identifying SAD Symptoms forms

that they completed for homework. Tell them that you are going to
talk about some of the symptoms of SAD and would like their input
based on their own experiences. Use the following questions in your
discussion:
■ How do you know when you or someone else is experiencing SAD?

■ What are the things you notice or the signs/symptoms?
31
List responses in four columns across the board without telling the group
what the column headings are or what they mean. Separate responses
into the following categories:
Physical: low energy, appetite changes (craving starches or sugars),

increase in appetite, loss of appetite, weight gain or loss, muscle
tension, pain, stomachache, headache, sensations of being weighted
down or walking through water.
Emotional: depressed or anxious mood, sadness, feeling blue,

decreased enjoyment or interest in things previously liked, irritable
mood.
Cognitive: trouble concentrating, forgetfulness, thoughts about being

worthless or a failure, negative thoughts about winter (e.g., “I can’t
cope with this,” “I hate winter,” and “Winter is never going to end”),
thoughts about death or suicide.
Behavioral: less active, withdrawing from others, crying, sleep

problems (oversleeping, napping, insomnia, or restless sleep), changes
in eating (overeating, excessive carbohydrate consumption, or eating
less).
Point out the diversity of symptoms and the polar opposites (e.g.,
increase in and loss of appetite). Explain that any two people with SAD
can have very different symptoms. Now ask participants what each of
the things listed in each unnamed category have in common. Have the
group to try to name the titles of the columns and then add them to the
board (“Physical,” “Emotional,” “Cognitive,” and “Behavioral”).
Degree of Emotional Symptoms
This section discusses the varying degree of symptoms, in particular,

emotional symptoms. First, ask the group how they define emotions.
Ask participants for examples of words that we use to describe to our-
selves or to others how we are feeling. Put “I feel ” on the
board and have participants fill in the blank.
Discuss the concept of emotional continuity. Ask members whether our

emotions are like an on–off light switch or more like a dimmer switch.
32
Explain that emotions are not all or nothing—they have various degrees.
Choose one emotion from the list generated by the group and discuss
how to use a 0–10 scale to describe its degree.
Next, explain the difference between sadness and depressed mood. It is

normal for people to feel sad at times, especially in the face of loss or
disappointment. The depressed mood associated with clinical depres-
sion is more intense (like the 7–10 level of sadness). In depression, the
sad feelings are present most of the day, nearly every day for 2 weeks or
longer, and can lessen self-esteem.
Tell the group that any one of the symptoms on our list from any col-
umn can be thought of on a continuum like this. We all have trouble
sleeping or have low energy at times, but when these symptoms occur
to a greater degree and last for 2 weeks or longer, they may be a sign
of SAD.
The Vicious SAD Cycle (10 min)
Discuss how all the different types of SAD symptoms can interact or
influence each other. The SAD cycle could start with any one of these
symptoms. Use the following dialogue to illustrate this cycle:
For example, if you are feeling especially fatigued, you could end up
sleeping too much. Your tiredness and oversleeping might make you
feel less like doing things that you would normally enjoy or being
around other people. This could then make you feel sad, which may
actually make you have even less energy and want to sleep even
more, etc.
Give other examples of the SAD cycle. Explain that the cycle is like
a snowball effect in which SAD symptoms gradually increase. Inform
the group that there is some research to suggest that SAD usually starts
with one or two symptoms in the early fall and then gradually the other
symptoms build on top of those. For many—but certainly not all—
people with SAD, fatigue, oversleeping, and increased appetite come
first. Ask group members these questions to help them think about their
individual SAD cycles:
33
■ Have you ever noticed which SAD symptom starts your cycle?
■ What symptoms follow along behind?
■ What is your pattern of symptoms?
Tell the group that the good news is that they can intervene on any one
component to reverse the cycle. In this group, they will learn how to
intervene at the cognitive and behavioral levels.
■ Cognitive intervention—learn to view things in a less negative

light
■ Behavioral intervention—increase the number of pleasant

activities
Prevalence of SAD (5 min)
Explain that, in general, SAD prevalence increases with latitude in the

United States. We can think of SAD symptoms on a continuum in the
general population. At Northern latitudes, the majority of people expe-
rience SAD symptoms to a certain extent and very few people do not
experience any changes in their behavior during fall and winter. Peo-
ple who experience moderate changes with the seasons are said to have
subsyndromal SAD or (S-SAD), also known as the winter blues. Popula-
tion studies have found that the prevalence of SAD in U.S. adults ranges
from 1.4% in Florida to over 9% in New Hampshire and Alaska (Booker
& Hellekson, 1992; Rosen et al., 1990). S-SAD is even more common
than SAD and ranges in prevalence from 2.6% in Florida to 19% in
Alaska. The bottom line is that SAD symptoms are very common and
get more common as distance from the equator increases.
Causes of SAD (15 min)
After more than two decades of research, we still do not know why
people experience SAD. It is clear that winter or something about it is
somehow related to SAD onset, but the specific mechanism is still not
34
known for sure. Explain to the group that there are some hypotheses (or
educated guesses), but none of these has been definitively proven.
Phase-Shift Hypothesis
Biological (circadian) rhythms of individuals experiencing SAD may be

abnormally phase delayed (i.e., shifted later than normal) in response to
shortened day length during the winter. These body rhythms are linked
to the day–night cycle and operate on roughly a 24-hr clock. The body’s
biological clock (a tangle of neurons in the part of the brain called the
hypothalamus) takes cues from light that enters the eyes and controls
the release of hormones that influence alertness, hunger, and sleepiness.
The level of one of these hormones, melatonin, rises in the evening
to make us feel sleepy and then falls before dawn to help us wake up.
The phase-shift hypothesis proposes that later dawns in the winter make
the biological clocks of people with SAD run slow, meaning that their
melatonin levels have not had enough time to fall by morning, and it is
difficult to wake up because their biological clocks are still telling their
bodies that it is night. These delays in body rhythms lead to feeling out-
of-sync with the natural day–night cycle. This hypothesis likens SAD to
jet lag that lasts for months.
Photoperiodic Hypothesis
According to this model, people with SAD may have retained a prim-
itive biological mechanism for tracking changes in day length (and,
therefore, changes in the seasons). This hypothesis likens people with
SAD to photoperiodic mammals or mammals that are highly influenced
by seasonal changes in the day–night cycle, such as sheep, cattle, and
rodents. These animals’ bodies use day length to determine what season
it is, and in turn, determine the appropriate times to breed, hibernate,
and forage for food. This hypothesis relates to the hormone melatonin
mentioned previously, but is more focused on the overall length of
the period of melatonin release than on how the circadian rhythm is
affected based on the ebb and flow of melatonin. In humans, the pineal
gland releases the hormone melatonin from dusk to dawn. Melatonin
35
is commonly referred to as “the hormone of darkness” because the bio-
logical clock begins to signal its release in the late evening and its offset
in the morning. In people with SAD, the photoperiodic hypothesis pro-
poses that the period of melatonin release at night is longer in the winter
than it is in the summer, whereas in people without SAD, how long the
body is releasing melatonin each night does not differ across the sea-
sons. A research study conducted by Thomas Wehr and colleagues at
the National Institute of Mental Health found that SAD patients had
a difference in the nighttime length of melatonin release in the winter
versus summer of about 38 min, whereas there was no such difference in
controls without SAD (Wehr et al., 2001). The summer–winter differ-
ence in nighttime melatonin release observed in SAD individuals may
indicate that their bodies use day length to track the changing seasons
and use this information to lengthen melatonin release in winter and
shorten it in summer. Given that only people with SAD showed this
seasonal change in nighttime melatonin release, it is possible that only
people with SAD track the changing seasons biologically. This might be
part of the reason why people with SAD feel and behave differently in
the summer than they do in the winter. This hypothesis has not been
tested again in another study so the jury is still out on whether or not
lengthened melatonin release in winter is a cause of SAD or is rather
just a consequence of having SAD.
Photon-Count Hypothesis
SAD may result when a dose of light (total number of photons received
by the retina) falls below a critical threshold that is needed to main-
tain well-being. According to this model, any decrease in environmental
lighting (e.g., cloudy weather) regardless of season should produce SAD
symptoms.
Serotonin Hypothesis
Serotonin is a neurotransmitter (chemical messenger between neurons

in the brain) that is involved in regulating sleep, appetite, and biolog-
ical rhythms. In humans, levels of serotonin in the brain are lowest in
36
the winter and highest in the summer. Scientists have shown this by
examining the brains of people who died in different seasons (Carls-
son, Svennerholm, & Winblad, 1980) and by examining blood samples
drawn in different seasons from living people through a catheter in the
internal jugular vein in the neck, which collects blood coming from
the brain (Lambert, Reid, Kaye, Jennings, & Esler, 2002). Given that
serotonin varies with the seasons and that SAD tends to be related to
significant seasonal changes in sleep and appetite, there may be a role
for serotonin in SAD symptom onset in the winter. However, it is not
known exactly how low serotonin levels could lead to the symptoms of
depression. It is possible that SAD-prone individuals may be especially
sensitive to these seasonal changes in serotonin levels or may show an
even larger wintertime decrease in serotonin than people without SAD.
At the time of writing, there is no available test to measure brain sero-
tonin levels in a living person. Because serotonin levels in the brains
of people with SAD cannot be measured directly, this theory remains a
hypothetical explanation for SAD.
Remind the group that all of these are just educated guesses; none of
these hypotheses has been proven.
Psychological Factors in SAD (10 min)
Next, explain that even if biological factors are involved in SAD onset,
psychological factors may be involved in maintaining SAD symptoms.
We do not believe that SAD is a purely biological process or that peo-
ple with SAD have to passively surrender to their biology and suffer
from SAD symptoms every year. Instead, we believe that thoughts and
behaviors also play a role in SAD and that these thoughts and behaviors
are within a person’s control and can be changed to reduce or eliminate
SAD symptoms. Use the following example to illustrate:
For example, as the days get shorter, you may have certain expectations
for what’s ahead. You may think, “Oh no, it won’t be long now. Here
comes winter again. In no time, I’ll be suffering from SAD.” These
thoughts may lead you to change your behavior by withdrawing from
other people, spending more time on the couch or in bed, and doing
less of the things you enjoy.
37
Ask group members what they think about or say to themselves when
they notice the leaves changing or when they are watching the weather
report and see the minutes of sunshine decreasing every day. Ask group
members how these thoughts influence the everyday things they do.
Explain that negative expectations and becoming less active or engaged
may actually influence SAD symptoms—make them start earlier, last
longer, or be more intense.
Emphasize that group members can do something about the negative

thinking style and reduced activity level that can make SAD worse:
Just because you are biologically prone to experience SAD does not
mean that there isn’t anything you can do about it. If you were
biologically prone to heart disease, what steps would you take to try to
prevent getting it? (Exercise, low-fat diet, reduce stress, quit smoking,
etc.) Through CBT, you can change your thoughts and your behavior
to begin to feel better. So, in other words, you don’t have to be a victim
of your body, which is telling you to retreat and hibernate the winter
away!
Tell the group that people with a more biological nonseasonal

depression—depression that occurs out-of-the-blue, without any appar-
ent life event triggering it—also tend to get better with CBT just like
those who get depressed in reaction to life circumstances. CBT has
shown to work just as well as medications for this biologically caused
depression (which presumably results from a neurotransmitter imbal-
ance and/or genetic factors). Regardless of the cause of depression, CBT
treatment can help improve the depressive symptoms. It is good news
that the treatment does not have to match the initial cause of the
depression because that means there are several ways to intervene.
Homework (3 min)
✎ Have group members complete the Pleasant Activities Rating Scale.
38
Chapter 5 Session 3: How Activities Relate to Mood
and Thoughts
Materials Needed
■ Group members’ completed Pleasant Activities Rating Scales
■ 3 × 5 cards for positive self-statements
■ Nametags
Outline
■ Review Pleasant Activities Rating Scale homework (20 min)
■ Discuss pleasant activities and how they relate to mood and

thoughts (25 min)
■ Teach the group how to reverse the depressed mood–activity level

cycle (5 min)
■ Teach the group how to change thoughts in order to increase

activity level (10 min)
■ Help group members choose positive self-statements and plan a

pleasant activity (20 min)
39
Briefly review the following points from Session 2:
1. Common signs and symptoms of SAD (Ask the group whether

anyone can name the main categories symptoms fall
into—physical, emotional, cognitive, and behavioral. Ask the
group to give a few examples of symptoms from each category.)
2. Interaction of SAD symptoms in a vicious cycle that may start

with any one symptom
3. Prevalence of SAD
4. Possible causes of SAD: phase-shift, photoperiodism,

photon-count, and serotonin hypotheses
5. Psychological factors that may be involved in onset and

maintenance of SAD
6. Effectiveness of CBT
Homework Review: Pleasant Activities Rating Scale (20 min)
Examine group members’ Pleasant Activities Rating Scales. Everyone in

the group should have been able to identify some activities they like
doing. If not, tell participants that if they do not like to do anything
currently, to think about things they typically enjoy doing during spring
and summer. Get some examples from the group.
Discuss group members’ reactions to completing the scale. Ask whether

the group members learned anything about themselves by thinking
about activities that they enjoyed. Maybe they realized how inactive
40
they have become. Perhaps they forgot about some things they used
to really enjoy, including some that can be done in the winter. Per-
haps they realized that many of the activities they enjoy are summer
specific.
Pleasant Activities (25 min)
Discuss what constitutes a pleasant activity. Basically, it is something a

person enjoys doing for fun. Thus, every person has different pleasant
activities because of different interests. Use examples from the group to
illustrate the personal nature of pleasant activities.
Ask group members how they typically feel during and after doing one
of their pleasant activities. Explain that the frequency with which a
person engages in pleasant activities impacts mood:
■ A high frequency of pleasant activities is associated with

satisfaction and happiness
■ A low frequency of pleasant activities is associated with depressed

mood
Emphasize that people feel good when they do a lot of things they enjoy.
Ask participants what they have noticed about their activity levels across
different seasons (“Does it change at all, say from summer to fall to
winter to spring?”). During winter, people with SAD commonly do not
engage in many pleasant activities. However, during spring and summer,
they frequently engage in pleasant activities. You may want to use the
following dialogue in your discussion.
Your lack of activity in the winter is like cabin fever. This actually
happens to a lot of people during winter, not just those with SAD. The
winter season can make it difficult to be active in general. With SAD
it’s more extreme than that. People with SAD typically have little
energy and their bodies seem to be telling them to sleep, sleep, sleep.
This is like going into hibernation mode and leads to a lot of sleeping
and sitting around versus doing a pleasant activity. In spring and
summer, though, people with SAD become more active again.
41
How Activities Relate to Mood
We do not think that the seasonal pattern in pleasant activities associ-

ated with SAD is just a coincidence. Instead, we think that the decrease
in activity in the fall and winter is actually an important part of the prob-
lem in SAD and helps to maintain SAD symptoms. When a person is
experiencing depressed mood with a SAD episode, she is less motivated
to do things. This results in a decrease in pleasant activities. Use the
following dialogue and show Figure 5.1 to illustrate this relationship.
When you feel depressed, you engage in fewer activities, which makes
you feel even more depressed. More depressed, you then do even less,
which intensifies your depression and so on the cycle goes.
Explain that decreased activity may be a cause or a consequence of

depressed mood (Use the metaphor of what comes first—the chicken
Depressed Mood Do Less Activities
Depressed Mood
Do Even Less Intensifies
Things You Enjoy
Figure 5.1
The Negative Mood–Activity Level Cycle
42
or the egg). When a person’s rate of pleasant activities is low, she is
likely to experience depressed mood. Refer again to Figure 5.1 and use
the following dialogue:
If for some reason or another, you are not able to be as active as usual,
you may begin to feel depressed. Then feeling depressed, you may
engage in even fewer activities. As you become less active, you feel even
more depressed and so on the cycle goes.
How Activities Relate to Thoughts
Lack of activity not only affects mood, but also tends to result in pes-
simistic thinking, which can bring mood down even more. Use the
following dialogue to stimulate a group discussion:
When you are experiencing a lot of SAD symptoms and sitting around
thinking about how bad and tired you feel (instead of doing a pleasant
activity), how do you feel about yourself? What is your self-esteem like
at these times? Do you feel worthless? Are you optimistic or pessimistic
as you think about your life, your work, and future? Are you cursing
the winter weather?
Explain to the group that thoughts of worthlessness, pessimism, and

blaming yourself for your own inactivity and fatigue are common
among people experiencing SAD and are part of the negative mood–
activity level cycle. Give examples (“I’m so useless I can’t even get off the
couch and do something.”) and ask the group whether these kinds of
thoughts are familiar.
Reversing the Depressed Mood–Activity Level Cycle (5 min)
A positive spiral of mood and activity is also possible. Show Figure 5.2
to illustrate the positive mood–activity level cycle.
Explain that people try to intervene on the emotional component first,

but that is the hardest to change. It is not easy to just feel better, snap out
of a sad mood, etc. It is less difficult to intervene at the behavioral level.
Changes in behavior can lead to changes in emotions. Increasing the
43
Do More Activities
Depressed Mood
Do Even More
Things You Enjoy
Depressed Mood
Lessens
And so on. . .
Feel Even Better To even better activity level
and better mood!
Figure 5.2
The Positive Mood–Activity Level Cycle
number of pleasant activities is one way to intervene. Use the following

dialogue to encourage participants to become more active:
To start a positive cycle, you have to get back in touch with your
pleasant activities even though you may not feel like it. This is going to
be really hard when you are experiencing SAD. You need to fight your
cabin fever and low energy level to do something active. This is your
chance to try to reverse the vicious SAD cycle so you have to commit to
the challenge. You may need to really push yourself to engage in
pleasant activities. You may not feel like doing anything at first. If you
push yourself and do something active, I think you’ll find you feel a
little bit better though and have a little bit more energy. This will, in
44
turn, make you feel like you can do a little more, which will make you
feel a little better and so on.
Changing Thoughts to Increase Activity Level (10 min)
People with SAD often have negative thoughts that make them feel
worse. These kinds of thoughts may keep them from trying the activities
that just might make them feel better. Ask participants:
■ What are some unhelpful thoughts that get in the way of doing
pleasant activities?
■ What goes through your mind when you are contemplating doing
something active?
Elicit examples: “I can’t do anything.” “I’m so tired.” “I just want to

sleep.” “I don’t feel like it.” “Things are too difficult.” “I won’t enjoy it
anyway.” “What’s the point?”
Discuss how these thoughts impact the decision about whether to do

a pleasant activity or whether to remain inactive. Emphasize the short-
and long-term consequences of doing versus not doing a pleasant activ-
ity. In the short term, it may be easier not to do it, but in the long term
being inactive helps to maintain the vicious SAD cycle of symptoms. In
the short term it may take some effort to do it, but one may actually feel
better during and immediately after doing the activity, and, in the long
term, one will feel the benefits of the positive mood–activity level cycle
if one regularly engages in pleasant activities. To increase the likelihood
of doing pleasant activities, a person needs to replace negative thoughts
with more positive ones. Ask participants:
■ When you catch yourself having these unhelpful thoughts, what

else could you say to yourself to increase the chances of your doing
a pleasant activity after all?
Elicit examples: “I can do it.” “I’ll feel better if I do it.” “Even if I’m
not overjoyed by it, it beats sitting on the couch.” “I know that, over
time, the more pleasant activities I do, the better I will feel.” “I do feel
bad right now, but I have the power to change that somewhat by being
active.”
45
Choosing Positive Self-Statements and Planning Pleasant Activities (20 min)
Have group members turn to the Positive Self-Statement Cards sheet

in the workbook. Distribute 3 × 5 cards. On their cards have them
write down statements that seem helpful to them and that they believe.
They should keep these cards somewhere easily accessible (e.g., on the
bathroom mirror or on the refrigerator).
They will be using these cards to help motivate themselves to do a pleas-

ant activity of their choice in the coming week. Help participants select
and plan a pleasant activity that is feasible to do, problem solve around
any obstacles in doing the activity, and consider selecting a backup activ-
ity in the event that the first choice falls through. Keep it simple for now,
choosing something that represents a modest increase in activity level
with a minimum duration of 10 min. Have each member make a verbal
commitment to the group to do a specific pleasant activity between now
and next session. Ask each member:
■ What have you decided on?

■ How will you make sure you get to do the activity?
Tell participants that they should be prepared to tell the group about
how their pleasant activity went and how they felt afterward. If they
want, they may choose to involve a friend, family member, or significant
other in the activity to help them get started this first time.
Homework (3 min)
✎ Have group members choose and complete a pleasant activity from the
Pleasant Activities Rating Scale before next session.
✎ Have group members use the Positive Self-Statement Cards for

motivation to complete activities.
46
Chapter 6 Session 4: Doing More to Feel Better
Materials Needed
■ Menu of Pleasant Activities
■ Weekly Pleasant Activities Plan (additional copies of form

optional)
■ Nametags
Outline
■ Review pleasant activities completed for homework (20 min)
■ Discuss important mood-related activities (5 min)
■ Review possible problems in doing pleasant activities (10 min)
■ Discuss how to get started on a balanced activity plan (8 min)
■ Review strategies for creating balance (10 min)
■ Introduce steps to activity scheduling (10 min)
■ Have group members create an activity plan (20 min)
47
Briefly review the following points from Session 3:
1. A high frequency of pleasant activities is associated with

satisfaction and happiness; a low frequency of pleasant activities is
associated with depressed mood.
2. During fall and winter, people with SAD tend to experience

fatigue and lack of energy, like extreme “cabin fever,” when they
do not feel like doing anything.
3. Decreased activity may be a cause or a consequence of depressed

mood (the chicken or the egg). There is a vicious cycle between
decreased activity and depressed mood in which a person becomes
increasingly depressed and less and less active over time.
4. By gradually increasing the number of pleasant activities, one can

reverse this cycle to feel increasingly better over time.
5. People with SAD often have negative thoughts which make them
feel worse and even less likely to engage in activities.
6. Positive self-statements can be used for motivation to follow

through on activities.
Homework Review (20 min)
In the last session, you asked group members to select and complete a
pleasant activity. Review what activities group members did. Discuss the
emotional, cognitive, and physical impact of the activity for each group
member:
48
■ How did you feel during the activity?
■ How did you feel after the activity? How long did these feelings
last?
■ What did you think during the activity?
■ What did you think after the activity?
■ Did you notice any changes in your body or in your energy level?
Ask whether group members used the Positive Self-Statement Cards

to help motivate them to do the activity. Discuss whether these
were helpful or whether they found other useful ways to motivate
themselves.
Mood-Related Activities (5 min)
There is a subset of pleasant activities that is especially important in

keeping mood positive. Elicit examples for each category from the group
and discuss their impact on mood.
Positive social interactions—pleasurable interactions with other people

(e.g., conversations or activities with friends or family).
Competency experiences—doing things that make you feel skilled and

competent (e.g., performing a task well or learning to do something
new).
Incompatible responses—doing things that are not compatible with

feeling depressed (e.g., enjoying the company of a good friend,
laughing or smiling, feeling truly relaxed, getting a good night’s sleep).
Physical activities and exercise—doing as little as 10 min of continuous

physical activity can improve mood. Engaging in regular, consistent
aerobic exercise is even better (e.g., walking, swimming, biking, snow
shoeing, or cross-country skiing). Current health guidelines
recommend accumulating at least 30 min of physical activity (in
10 min bouts or more) over the course of most (at least 5) days a week
(Pate et al., 1995).
49
Problems in Doing Pleasant Activities (10 min)
People with SAD may come across obstacles to doing pleasant activi-
ties. It is best to address these ahead of time so participants will know
how to react to them when they occur. Go over the following common
problems and discuss solutions.
Fatigue
Problem: People with SAD frequently find it difficult to engage in

pleasant activities because they feel so tired. It is hard to motivate and
get off the couch or out of bed to do something active.
Solution: Push yourself to do it anyway and watch how the activity

affects your mood. If it helps, you can remind yourself that activities make
you feel a bit better, making yourself more likely to do activities in the
future even if you are tired. Use positive self-statements to help with your
motivation. Consider that if you do not do the pleasant activity, you will
just stay stuck in the negative mood–activity level cycle and continue to
feel tired.
Problem: Sometimes people with SAD feel tired after doing a pleasant
activity.
Solution: Start with a small activity and gradually build up to bigger,

longer ones so as not to tire yourself too much. Again, if you see over time
that activities help your mood, you should look forward to doing them as a
means to feel better. Your fatigue should even reduce over time as activities
gradually improve your mood.
Loss of Enjoyment or Pleasure in Activities
Problem: With SAD, like with depression, there is often a lack of plea-
sure in activities that are normally enjoyed. Recall that this is actually an
emotional symptom and can increase or decrease in severity over time.
Solution: Fake it until you make it. Studies show that the sense of
enjoyment/pleasure comes back gradually with repetition of pleasant
activities over time.
50
Pressure From Necessary Activities That are Neutral or Unpleasant
Problem: Responsibilities such as work and household duties can often

get in the way of doing fun things.
Solution: Use time management to complete your responsibilities, but also

schedule time for pleasant activities. Pleasant activities should not be the
first thing to go when your schedule is tight, but instead should be a
priority, especially now when you are actively working on ways to feel
better. Also, you will be more likely to perform your responsibilities well if
your mood has been boosted with pleasant activities.
Lack of Care in Selecting Activities
Problem: Not selecting activities carefully can result in a mismatch

between what one is actually doing and what one likes to do (e.g., spend-
ing the weekend working around the house instead of going shopping
or to a movie).
Solution: Think about the things you like to do and make time for them.
Avoid scheduling “pleasant activities” that are really not at all pleasant for
you.
Change in the Availability of a Pleasant Activity
Problem: Sometimes something happens that removes the possibility

of doing something one enjoys (e.g., death of a loved one, moving, end
of a relationship, or getting a divorce). With SAD, sometimes activities
that one likes doing in the spring or summer are less available or not
at all available during winter (e.g., spending time outside, going to the
beach, or gardening outdoors).
Solution: Work on finding substitute pleasant activities or activity

partners. You may be able to modify a summer-specific activity so it can be
done in the winter (e.g., grow a window herb garden or dress warmly and
continue to go for walks outside). Develop a new “wintertime interest” that
51
you can look forward to this time of year (e.g., interest yourself in winter
sports such as skiing, snow shoeing, or ice skating or in an indoor hobby
that you would not ordinarily do in the spring or summer, such as artwork,
home decorating, or crafting).
Emotional Interference
Problem: Emotions such as anxiety, irritability, and discomfort can

interfere with one’s enjoyment of otherwise pleasant activities (e.g.,
being nervous or irritable in social situations makes it difficult to enjoy
them).
Solution: Identify the source of the emotional discomfort and work on

removing it. If you feel irritable or anxious, find effective ways to relax
before doing a pleasant activity. If certain pleasant activities make you feel
anxious, regularly practice doing those activities; do not let yourself back
out or make excuses, and you should become more and more comfortable
doing them over time.
Getting Started on a Balanced Activity Plan (8 min)
Tell group members what is required of them to increase their frequency

of pleasant activities in order to improve their mood. Stress that they
must commit themselves to putting the plan into effect. They must be
willing to make choices, establish priorities, and rearrange their lives
a bit.
Explain that the goal is to achieve a balance between the things they
have to do and the things they want to do. It will involve planning, and
they should try to anticipate any problems that might interfere with
carrying out their plans. Emphasize that they will achieve a sense of
self-control to the extent that they stick to their plans. By controlling
their time, they are taking a step toward controlling their lives and their
moods.
52
Creating a Balanced Activity Level
Tell the group that in making a plan, it is important to create a balance

between:
(1) Neutral or unpleasant activities—things you have to do (e.g.,

housework, work, or errands)
(2) Pleasant activities—things you enjoy doing
Use the following dialogue for further explanation:
Balance between these kinds of activities allows you to accomplish the

neutral and unpleasant things you have to do, while ensuring that you
set aside time to also do the things you enjoy. It also ensures that you
have some energy left over to do pleasant activities.
Also explain that the difference between these activities is very indi-
vidual. What someone considers a chore, someone else may consider a
pleasant activity (e.g., cooking or shopping).
Strategies for Balance (10 min)
Review the following strategies for creating balance. Prompt for exam-
ples and elicit additional strategies from the group.
Use Your Time Efficiently
1. Set aside blocks of time for neutral or unpleasant activities.
2. Create a “to do” list.
3. Consider whether those things really need to get done today.
4. Ask other people to help in getting necessary activities done.
5. Use a timer to stick to the amount of time designated for a neutral

or unpleasant activity or for a pleasant activity.
53
Plan Ahead
1. Schedule each pleasant activity at least 1 day in advance.
2. Designate a time and place for each pleasant activity.
3. Do not allow yourself to make excuses or back out.
Anticipate and Prevent Problems
1. Avoid distractions and focus only on the pleasant activity at hand

(e.g., unplug the phone).
2. Make the necessary arrangements ahead of time (e.g., make

reservations, buy tickets, get supplies, or arrange for a babysitter).
3. Be prepared to substitute activities when unexpected problems

arise. Have a backup plan if your planned activity involves another
person who cancels or is dependent on getting outside and the
weather suddenly becomes inclement. Otherwise, you will be at
risk of not doing something pleasant and backsliding.
Steps to Activity Scheduling (10 min)
Next, teach the group the steps to activity scheduling: (1) set a specific
goal; (2) plan, schedule, and record; and (3) reward yourself.
Step 1: Set a Specific Goal
Tell group members to consider what they are doing currently and
decide what would be a modest increase in activity. They should make
sure that the goal is reasonable and attainable. Remind them that the
negative mood–activity level cycle came on gradually over time; revers-
ing it will also be a gradual process that will take some time. They should
select activities that are potentially pleasant for them, but also read-
ily available to them. They may even want to incorporate some local
events, take a class, join a club, develop a new interest, or learn about
something new. The leisure section of the newspaper is full of ideas.
54
Step 2: Plan, Schedule, and Record
Tell group members that they will be using a weekly planner to plan
out their activity levels. This will involve making an appointment with
themselves to do a specific activity at a specific time each day. They will
also record whether or not they followed through and how enjoyable
each activity was. Scheduling activities in advance increases the like-
lihood that group members will actually do a given activity and also
makes it more likely that they will regularly engage in pleasant activi-
ties over time. Just playing it by ear or trying to come up with activities
spontaneously is potentially dangerous because it can easily lead back
into the negative mood–activity level cycle. They should certainly take
advantage of spontaneous activities when they arise (e.g., a friend calls
and wants to meet for coffee today), but always have something planned
in advance as well.
Step 3: Reward Yourself
Encourage group members to use small daily rewards and/or larger

rewards for being active all week. Rewards may include other pleas-
ant activities such as calling a good friend, eating out, making a small
purchase, or seeing a movie.
Weekly Pleasant Activities Plan (20 min)
Next, have group members come up with a specific plan to increase

their activity levels. First, have group members discuss what would be a
reasonable activity level goal (i.e., desired number of activities per week
and amount of time in activities) for now given their current activity
levels. The minimum goal should be to do at least one pleasant activity
per day for a minimum of 10 min everyday. Have group members share
their specific goals with each other to make a public commitment to the
group for increased activity level.
Second, have them fill out the Menu of Pleasant Activities form. They
should use the Pleasant Activities Rating Scale to select target activities
and include some activities that they currently do rarely or not at all,
55
but are highly enjoyable. Then ask them to schedule an appointment
with themselves to do some of these activities using the Weekly Pleasant
Activities Plan. It is generally helpful to have them plan out activities
for the next few days in session to get them started. Have the group
members share their plans for the next few days.
Explain that each day’s planned activity should be scheduled at least

1 day in advance and should be set for a specific time of day. They
should record their activity appointments and follow through and rate
their degree of enjoyment in the activity on the Weekly Pleasant Activ-
ities Plan.
Give the group the following general tips (see sample dialogues):
■ Make a habit of scheduling activities ahead of time
It’s a good idea to make a habit out of planning pleasant activities in

advance; for example, keeping the weekly schedule in a designated
place and planning out the next day’s pleasant activity each night at a
specific time. If you make a ritual out of planning activities, you will
be more likely to do it.
■ Choose activities that are relatively easy to do
Taking a vacation may be enjoyable, but not feasible at the moment.

In the future, you may wish to add some long-range activity goals to
work up to. For now, however, keep it simple. What activities could
you realistically do this week?
Homework (2 min)
✎ Have group members finish developing their Menu of Pleasant

Activities.
✎ Have group members schedule and complete at least one pleasant

activity every day for at least 10 min per activity. They should record
activity appointments, follow-through, and enjoyment ratings on the
Weekly Pleasant Activities Plan.
56
Chapter 7 Session 5: What You Think Influences How
You Feel
Materials Needed
■ Thought Diary—4 Column (additional copies of form

optional)
■ Nametags
Outline
■ Review content of Sessions 3 and 4 (5 min)
■ Review homework (20 min)
■ Discuss the relationship between thoughts and mood

(10 min)
■ Present the A-B-C model (10 min)
■ Review events that may cause negative thinking (10 min)
■ Introduce the concept of automatic thoughts (10 min)
■ Teach group members how to use a thought diary (20 min)
57
Review of Sessions 3 and 4 (5 min)
Briefly review content from Sessions 3 and 4:
1. Categories of SAD symptoms: physical, emotional, cognitive, and

behavioral
2. The negative mood–activity level cycle
3. The positive mood–activity level cycle
4. Mood-related activities
5. Possible problems in doing pleasant activities
6. Importance of balancing unpleasant or neutral activities with

pleasant ones
7. Activity scheduling as a means of increasing pleasant activities
Review group members’ Weekly Pleasant Activities Plans. Ask for

reactions to this assignment using the following questions:
■ What was it like to do an activity for 10 min per day or more?

■ Did you enjoy the activities you practiced?
■ What was your mood like during and after doing the activity?
■ Any problems with finding time to do activities?
■ Did you have difficulty creating balance with responsibilities?
If group members did not enjoy the activities they chose, they could
modify their lists to include more enjoyable activities. If, however, their
58
SAD symptoms include loss of pleasure, they need to just go through
the motions of doing activities; the sense of enjoyment in activities will
come back eventually. Emphasize that activity planning is an important
skill for participants to master in order to reverse the negative mood–
activity level cycle. Encourage group members to stick with it. In the
next week, they should try increasing the amount of time spent on
pleasant activities.
Relationship Between Thoughts and Mood (10 min)
This session focuses on the cognitive symptoms of SAD. Tell the group
that “cognitive” refers to thinking and explain that what we think can
affect how we feel. Ask participants what they might be thinking and
feeling in each of the following situations. (Note: If you get similar
responses, ask for different types of thoughts and feelings that someone
else might experience in these situations.)
Situation 1: You are standing in a slow-moving line at the bank.
Situation 2: You are stuck in a traffic jam.
Note how different people have different thoughts in reaction to the

same situation and, therefore, feel different emotions as a result:
Frustrating or unpleasant things happen to everyone, but not everyone

feels negative emotions in reaction to them. How can this be?
Something comes between the event that is happening and what the
person feels. That something is what the person is thinking (what he
says to himself ). Situations do not directly cause emotions. Instead, a
person’s thoughts directly contribute to the emotions he feels in specific
situations.
The A-B-C Model (10 min)
Present the A-B-C model (Figure 7.1) to the group.
Explain that “antecedent” means coming before; in this model the event
comes before our thoughts and feelings. Use the following example to
illustrate the model:
59
60
A B C
A = Antecedent event B = Belief C = Consequence
Any event that happens What you think about A An emotional reaction
Examples: Examples: Examples:
Being rejected by someone “I’m worthless.” Sad or depressed
Being criticized “I always mess up.” Nervous
Feeling unappreciated “I’ll never get it right.” Angry
Failing at something “I’m stupid.” Frustrated
Making a mistake
Figure 7.1
The A-B-C Model
George and Bill are both on the dating scene. Both men ask the object
of their affection out on a date and get shot down. George thinks to
himself, “I’ll never get a date again. I’m going to be single for the rest
of my life. I’m a total failure at love and sure to be unloved forever.”
Bill says to himself, “Well, this is disappointing. I really liked this
person, but I guess we weren’t meant to be. If I continue to be myself,
I’m bound to find someone I can have fun with.”
Write this out on the board in the A-B-C format as you discuss. Ask
the group how they think George and Bill would feel after this experi-
ence. Prompt for the answer that George’s thoughts are likely to lead to
depressed feelings. Bill, on the other hand, might feel appropriately sad
and disappointed, but he would not be overwhelmed by his emotions.
Then ask the group, based on George and Bill’s thoughts and feelings,
how this experience might affect George’s and Bill’s behavior. That is,
how are they likely to act toward dating in the future? Prompt for the
answer that Bill is more likely to take constructive action (e.g., keep on
searching for a dating partner) whereas George is more likely to give up.
Negative Thinking (10 min)
Review some events that might put someone at risk for negative
thinking at the B (Belief ) stage:
■ Getting rejected by someone
■ Being criticized or disapproved of
■ Feeling under-appreciated
■ Doing more than one’s share of work without receiving credit
■ Performing poorly, failing, or making a mistake
These things are all objectively negative or unpleasant types of events.

However, explain that after a person gets in the habit of negative think-
ing, she may also start to see events that are not really all that bad in a
negative light.
For example, you are at the store and you see a friend. You wave, but
the friend does not wave back. If you are already in the swing of
61
negative thinking, you are likely to have negative thoughts such as,
“He doesn’t like me. He is trying to avoid me because I’m miserable
with my SAD,” leading to negative emotions such as sadness. However,
there are alternative, less negative interpretations of what happened.
For example, it could really be that the friend was distracted and did
not even see you.
Session 6 will introduce different types of negative thinking and their

effects in more detail.
Automatic Thoughts (10 min)
Explain the thoughts or things we say to ourselves at stage B are called

automatic thoughts. These thoughts are called “automatic” because they
happen very quickly; they are an automatic “knee jerk” response to
things that happen. They pop up spontaneously. We do not deliber-
ately try to think them, and they are not the result of reasoning or logic.
Occasionally, automatic thoughts are not preceded by an actual event
or situation, but rather by a stream of thoughts, a daydream, or just
thinking about events from the past.
Tell the group that everyone has automatic thoughts. Most of the time,
we are barely aware of our automatic thoughts because they tend to be
very brief. Usually, we are just aware of the emotion that follows the
thought rather than the thought itself. That is, we recognize feeling sad,
embarrassed, angry, anxious, or irritated, but do not tie these feelings to
a thought. You may want to use an example to illustrate:
For example, as you sit here listening, if you think to yourself, “I am

such a dope. I don’t really understand what the therapists are saying,”
you may feel frustrated or sad. If you think, “This cognitive-behavioral
therapy is too simple and will never work. It does not apply to me. The
problem is not with my thinking and behavior. I just need more light
to feel better,” you may feel frustrated. In contrast, if you say to yourself,
“What the therapists are saying is really making sense. I think my SAD
could be helped by cognitive-behavioral therapy,” you may feel hopeful
and more positive. You may or may not be aware of the automatic
thoughts, but you are probably aware of the emotions you feel.
62
Inform group members that with training, however, they can learn
to become more aware of their automatic thoughts and how they are
related to their feelings.
Explain that automatic thoughts can be either negative or positive. In
individuals with SAD, automatic thoughts are frequently negative dur-
ing the winter, contributing to a sad mood and maintenance of SAD
symptoms. In the summer time, when people with SAD feel best, their
automatic thoughts tend to be more positive, helping them to feel more
satisfied and happier. We do not believe that it is simply a coincidence
that people with SAD have more negative automatic thoughts in the
winter, when they happen to feel their worst, and more positive auto-
matic thoughts in the summer, when they happen to feel their best.
Instead, we believe that the negative automatic thoughts are actually
part of the problem, part of the SAD cycle that keeps them down in the
winter, and that the positive automatic thoughts are part of the reason
why they feel good in the summer.
Using a Thought Diary (20 min)
Elicit examples from the group and write them out on the board using
the Thought Diary format (see Figure 7.2 for an example).
Date Situation Automatic Thought(s) Emotion(s)
Briefly describe situation 1) Write the automatic 1) Specify sad,

(antecedent event), thoughts that accompany anxious, angry,
stream of thoughts, the emotions. etc.
daydream, or image. 2) Rate belief in automatic 2) Rate degree of
thought (0–100%). emotion
(0–100%).
1/24 I was looking over a I am such a dope. (90%) Sad (95%)

report I submitted I messed up again. (90%) Frustrated (85%)
to my boss and He will think I am careless
found a typo. and not a good worker. (80%)
I should do a better job. (95%)
Figure 7.2
Example of Completed Thought Diary—4 Column
63
Go through the following steps with the group:
1. Can you think of some time this past week when you felt sad, down, or
upset in some way? What was happening then?
2. What was going through your mind? While this was happening, how
much did you believe that thought from 0 (not at all) to 100%
(completely, totally believed it to be true)?
3. What else went through your mind? How much did you believe it
(0–100%)? (Make sure to get all the thoughts. Don’t stop with just
one.)
4. After these thoughts, how did you feel? Sad, anxious, angry? How
much did you feel that way? Give each emotion a rating from 0 (not
at all) to 100% (the most intense I have ever felt this).
Ask the group member whether she can see how what she was thinking
influenced how she felt. Also inquire what she thinks would happen to
her emotions if she discovered that her automatic thoughts were not
true or at least not as true as she initially believed they were.
If a group member cannot think of any automatic thoughts, ask:
■ What do you guess you were thinking about?
■ Do you think you could have been thinking about (provide plausible
possibilities)?
■ What did this situation mean to you?
■ Were you thinking (provide a thought opposite to the expected

response)?
You can also ask the other group members for some possibilities of
automatic thoughts in that situation.
If a group member cannot identify a problem situation, ask about gen-

eral areas that have been on her mind (e.g., school, relationships, or
work) and which situations bother her most.
You can ask how eliminating each area one-by-one would affect her
feelings. You might also have the group member use imagery. Ask her to
64
close her eyes and talk about any images that come to mind. Have her
identify what thoughts occur when she visualizes an image.
Homework (3 min)
✎ Have group members continue scheduling activities using the Weekly

Pleasant Activities Plan and modify it as needed.
✎ Encourage group members to try to add some new pleasant activities

to challenge themselves.
✎ Encourage group members to strive for increasing the time for a

pleasant activity to more than 10 min per day.
✎ Have group members complete the Thought Diary—4 Column form

on a daily basis.
65
Chapter 8 Session 6: Cognitive Distortions
Materials Needed
■ Thought Diary—5 Column (additional copies of form optional)
■ Nametags
Outline
■ Discuss SAD-specific automatic thoughts (10 min)
■ Introduce cognitive distortions (15 min)
■ Have group members practice identifying cognitive distortions

(15 min)
67
Briefly review the content of Session 5, which focused on how our

thoughts influence our feelings.
1. A-B-C model (ask “What do A, B, and C stand for?”)
A = antecedent event (any event that happens)

B = belief (what you think about A)
C = consequence (an emotional reaction)
2. Automatic thoughts are rapid, brief, and spontaneous thoughts

that happen at stage B.
3. Everyone has automatic thoughts, but we are not always aware of

them. At first, we may only notice how we feel.
4. Automatic thoughts can be either positive or negative. When

people experience SAD, their automatic thoughts tend to be more
negative during winter, when they feel their worst, than during the
summer, when they feel their best.
5. Negative automatic thoughts tend to lead to blue mood and make

SAD even worse.
Weekly Pleasant Activities Plan
Use the following questions to discuss how group members are

progressing:
■ How is your Weekly Pleasant Activities Plan going?

■ What did you do this week?
■ How did you feel after doing an activity?
■ How enjoyable were your pleasant activities?
■ Have you had to change anything about your plan to make it
work better?
68
■ Have you had any difficulties creating balance with
responsibilities?
■ Is it time to change anything about your plan to challenge yourself
more—add new activities, eliminate some activities that are
becoming more routine, increase your time in activities?
Thought Diary
Instruct group members to take out their Thought Diaries completed

for homework. Go around the room to get some examples of situations,
automatic thoughts, and emotions. Write these examples on the board
in A-B-C format. Ask group members the following:
■ Do you see how what you thought influenced how you felt in that
situation?
■ What do you think would have happened to your emotions if you
discovered that your automatic thought was not correct or at least
was not as accurate as you originally believed?
If a group member did not complete any Thought Diary entries, ask the
following:
■ Can you think of some time this past week when you felt some
type of negative emotion?
■ What emotion or emotions were you feeling then? Sad, anxious,
angry?
■ What was going through your mind?
Have the group member write in the answers on a Thought Diary form
as he speaks.
SAD-Specific Automatic Thoughts (10 min)
Discuss automatic thoughts that people with SAD tend to have about
the winter season in general, environmental cues that the seasons are
changing into fall and winter, weather (e.g., precipitation or cold
69
temperatures), and lack of light (e.g., short days or cloud cover).
Go over the following scenarios and elicit examples of automatic
thoughts from the group. After each scenario, ask group members the
following:
■ What thoughts would you have in this situation?

■ How would you feel?
■ Can you see how your thoughts relate to how you feel emotionally?
You can ask group members to close their eyes and imagine the scenarios
as vividly as possible.
Scenario 1:
Imagine that you are watching the local weather forecast and it shows that
the sunrise is taking place a minute later every day and that the sunset is
taking place a minute earlier every day.
Scenario 2:
Summer is drawing to a close with the arrival of September. You notice the
leaves gradually changing from green to shades of yellow, red, and orange.
Scenario 3:
Imagine that you are just getting out of bed, you feel groggy and tired, and
you look out the window. The sky is dark and overcast, and there is a dusting
of snow on the ground. You can feel the cold air coming in through your
window.
Cognitive Distortions (15 min)
Explain to the group that negative automatic thoughts at stage B tend

to fall into certain categories. We call these thoughts cognitive distor-
tions because they are distorted or extreme in their interpretation of
reality. Once negative thinking is in effect, cognitive distortions help
to keep thinking negative so that most things, even neutral or pos-
itive events, are interpreted in a negative light. It is like putting on
dark glasses through which everything seems pretty bad. With those
dark glasses on, negative thinking can become a magnifying glass that
70
blows up a trivial mistake, small imperfection, or minor event into
a really big deal that makes one upset. Negative thinking can also
downplay or make excuses for positive things that happen so those
things are not experienced as genuinely positive. These cognitive dis-
tortions occur in everyone to some extent, but people with SAD think
this way more than those without SAD, especially during the winter.
It is useful for participants to be familiar with the specific cognitive
distortions so they can recognize when their thinking is unhelpful.
Review the following definitions adapted from Feeling Good: The New
Mood Therapy (Burns, 1999) and illustrated with SAD-specific exam-
ples. Pause after each description and elicit personal examples from the
group.
All-or-Nothing Thinking (Black-and-White Thinking)
You think in black and white terms; there are no gray areas. This type of
thinking is unrealistic because things are seldom all or nothing, all good
or all bad.
Example: A woman with SAD thinks, “Winter is totally bad and sum-
mer is totally good.” In reality, some days are better than others in
summer and winter alike. Some winter days may be more enjoyable
and associated with more cheer than some summer days.
Overgeneralization
You assume that a one-time negative occurrence will happen again and
again. You use words such as “always” or “never” to make generaliza-
tions.
Example: A man with SAD may have a tough day when he is suf-
fering from a lot of pretty severe symptoms (e.g., fatigue, depressed
mood, oversleeping, overeating, and loss of interest in activities). He
may say to himself, “Because this particular day was so bad for me,
every day for the rest of winter until spring arrives will surely be this
terrible.”
71
Mental Filter
You focus exclusively on negative details and ignore anything positive.

As a result of filtering out the positives, you see the entire situation as
negative.
Example: A woman with SAD hears about possible snow for 1 day
in the week’s forecast. She thinks, “The weather for the whole week
is shot.”
Disqualifying the Positive
You turn positives into negatives by insisting they “don’t count.”

This allows you to maintain your negative outlook despite positive
experiences.
Example: A woman with SAD is at a cocktail party. She appears to be

having a good time, smiling, talking, and laughing. Afterward, she tells
herself that she was just faking this because she had to look like she was
having fun or the host would be insulted. A man with SAD spends an
afternoon with his buddies and has such a good time, he forgets about
his SAD. Afterward, he thinks, “That was a fluke. It doesn’t really count.
I still have SAD.”
Jumping to Conclusions
In the absence of solid evidence, you jump to a negative conclusion.

There are two types of this: “mind reading” and the “fortune teller
error.”
Mind Reading
You assume that you know what someone else is thinking. You are so
convinced that the person is having a negative reaction to you, you do
not even take the time to confirm your guess.
72
Example: A woman with SAD is at a holiday party with her family. Her
grandchildren interact very little with her and she thinks, “They don’t
want to talk with me because I am so miserable with my SAD.” Actually,
they are so distracted by their new toys that the children barely talk at
all to anyone.
The Fortune Teller Error
You act as a fortune teller who predicts only the worst for you. You then
treat your unrealistic prediction as if it were a proven fact.
Example: A man with SAD thinks, “I will suffer from SAD symptoms
repeatedly every single fall and winter for the rest of my life.”
Magnification (Catastrophizing) or Minimization
You magnify negative things, blowing their importance out of propor-

tion. The outcome of an event appears catastrophic to you.
Example: A man with SAD thinks, “Winter is horrible! This cold, dark
weather will never go away, and I’ll feel badly forever.”
You minimize positive things, shrinking down their significance. You

make good experiences out to be smaller than they are.
Example: The sun shines brilliantly on a cold December day and a

woman with SAD thinks, “What use is this? It’ll just be dark and dreary
again tomorrow.”
Emotional Reasoning
You take your emotions as proof of the way things really are. You assume
something is true because you feel it is.
Example: Someone with SAD thinks, “I feel overwhelmed and hopeless

during winter, therefore my problems must be unsolvable.”
73
“Should” Statements
You build your expectations with “shoulds,” “musts,” and “oughts.”

When you do not follow through, you feel guilty. When others
disappoint you, you feel angry and resentful.
Example: A person with SAD thinks “I should be able to cope with the
winter season.”
Labeling and Mislabeling
You label yourself or someone else, rather than just identifying the
behavior.
Example: A person with SAD thinks, “I’m a loser for sleeping so much.”
You mislabel an event by using inaccurate and emotionally extreme

language.
Example: A person with SAD sees gray skies and thinks, “The weather
is the pits; it’s impossible to do anything on a totally depressing day like
this.”
Personalization
You take responsibility for things that you do not have control over. You
feel guilty because you assume a negative event is your fault.
Example: A man with SAD thinks, “There’s something wrong with me.
It’s my fault I have SAD.”
Practicing Identifying Cognitive Distortions (15 min)
Have the group practice identifying cognitive distortions in the follow-

ing example:
Imagine that the weather forecast is predicting a major winter storm.

You think, “This is going to be terrible! I can’t stand winter! Winter is
74
the worst! I’ll never be able to get out of the house.” You feel sad and
angry.
Cognitive Distortions:
All-or-nothing thinking—“Winter is the worst!”
Overgeneralization—“I’ll never be able to get out of the house.”
Magnification—“This is going to be terrible!” “I can’t stand winter!”
Fortune Teller Error—“This is going to be terrible!” “I’ll never be able

to get out of the house.”
Notice how some automatic thoughts contain more than one cogni-
tive distortion. Explain that many negative thoughts fit into more than
one category because there is a lot of overlap between the cognitive
distortions.
Personal Examples
Next, have group members try to classify their own automatic thoughts
as specific distortions. You can return to the examples that were
generated from the homework assignments.
Homework (3 min)
✎ Have group members continue with their Weekly Pleasant Activities

Plans. Encourage them to add more pleasant activities and/or increase
the time spent on activities.
✎ Have group members continue to keep Thought Diaries and try to

record at least one example every day. They should also attempt to
classify their thoughts as specific cognitive distortions using the
Thought Diary—5 Column form.
75
Chapter 9 Session 7: Evaluating Your Automatic Thoughts
Materials Needed
■ Automatic Thought Questioning Form (additional copies

optional)
■ Nametags
Outline
■ Discuss how to evaluate thoughts (2 min)
■ Introduce the Automatic Thought Questioning Form (8 min)
■ Discuss examples of questioning thoughts (40 min)
77
Briefly review the contents of Session 6:
1. The vicious SAD cycle: how the different symptoms of SAD

interact with each other to keep a SAD episode going.
2. Four categories of SAD symptoms: physical, emotional, cognitive,

and behavioral.
3. Use of pleasant activity scheduling to turn the negative

mood–activity cycle into the positive mood–activity level cycle in
which one does more and feels better.
4. Thoughts can affect how one feels emotionally: the A-B-C model.
5. Types of cognitive distortions.
Ask how group members are doing with planning and carrying out
pleasant activities and balancing them with responsibilities. Modify
plans as needed. Encourage members to add more activities or increase
the amount of time spent on activities.
Thought Diary
Check to see whether group members completed the “Situation,” “Auto-

matic Thought(s),” “Emotion(s),” and “Distortions” columns of the
Thought Diary with at least one entry per day. Was everyone able to
identify their thoughts? Ask for examples and diagram them on the
board. Discuss any problems with recognizing cognitive distortions.
Evaluating Automatic Thoughts (2 min)
Tell the group that though our initial automatic thoughts occur spon-
taneously, we actually have some control over our subsequent thoughts
78
and the impact of our thoughts on mood. Over the past week, group
members have started to be more aware of their automatic thoughts.
The next step is to learn how to question and evaluate these thoughts to
examine how accurate and useful they are.
Explain to participants that for each automatic thought they have, they
need to consider several things and ask themselves some questions.
Introduce the Socratic method:
Have you ever heard of the famous Greek philosopher Socrates?

Socrates had a style of asking a lot of questions to try and evaluate
things his students said or thought about. This method of questioning
and evaluating is, in Socrates’ honor, named the “Socratic method.”
Automatic Thought Questioning Form (8 min)
Ask group members to identify an important and distressing automatic

thought from their Thought Diaries that they would like to evaluate
using the Socratic method. Refer to the Automatic Thought Question-
ing Form in the workbook. Present the following four steps. You may
want to use the following metaphor to help explain the first step:
To start, imagine that you are both a witness for the defense and an
attorney for the plaintiff at a trial. First you are the witness and your
automatic thoughts are your “testimony.” You want to present the
evidence in support of your testimony in order to convince the jury
what you say is valid. Then you step out of the witness role and act as
the attorney doing a cross-examination of that testimony. In the
cross-examination, you want to logically point out any evidence
against that testimony.
Four Steps to Questioning Automatic Thoughts
1. Review the evidence. Ask yourself:
■ What is the evidence for this thought?

■ What is the evidence against this thought?
79
2. Review possible outcomes. Ask yourself:
■ What is the worst thing that could happen? Could I

survive it?
■ What is the best thing that could happen?
■ What realistically is most likely to happen?
3. Consider the impact of your automatic thought. Ask yourself:
■ What are the results of my belief in this automatic

thought?
◦ How do I feel and act in response to this automatic

thought?
■ What could be the results of changing my thinking?
◦ Would I feel any differently?

◦ Would I do anything differently if I could change the
thought?
4. Problem solve about the situation that brought on your negative

thinking. Ask yourself:
■ What could I do about it? Brainstorm possible solutions and

consider the pros and cons of all options.
■ What would I tell someone else to do? What if a friend of
mine was faced with the same situation?
Examples of Questioning Thoughts (40 min)
George’s Thoughts About Dating
Have the group recall the example of George and Bill from last week
(the two guys who asked someone out and got shot down). George said,
“I’ll never get a date again. I’m going to be single for the rest of my
life. I’m a total failure at love and sure to be unloved forever.” Ask the
group to name George’s A, B, and C. Write them out on the board in
diagrammatic form.
Use the questions listed on the Automatic Thought Questioning Form

to help the group evaluate George’s automatic thoughts.
80
Personal Examples
Return to the group members’ selected automatic thoughts from their

Thought Diary homework. As a group, go through the Automatic
Thought Questioning Form. Have one group member ask the ques-
tions and another answer the questions about her automatic thought.
You and other group members can jump in with follow-up questions
to explore as much information as possible. Be sure that the group does
this in a supportive, objective way to logically evaluate the evidence for
and against the thoughts. Have group members take turns in asking
and answering the questions. Talk about the questioning process with
the group and allow everyone to share their experiences.
Look for opportunities to practice evaluating SAD-specific Thought

Diary entries about the winter season, environmental cues that the sea-
sons are changing, weather, and lack of light. The process of evaluating
SAD-specific thoughts is the same as that of evaluating any negative
automatic thought. In reviewing the evidence, individuals with SAD
tend to have historical evidence in support of these kinds of thoughts
(e.g., “Winter is always a hassle for me,” “I hate winter,” “I can’t func-
tion when the sun is not shining”). However, similar to any negative
automatic thought, these thoughts tend to be global and overly negative
in tone and include cognitive distortions. Examining evidence against
SAD-specific thoughts involves looking for any personal examples that
counter the negative thought (e.g., “Have you ever had a day when you
felt OK in the winter? If not, are some winter days better than others?
What was happening then? What were you doing and thinking then?”).
Point out that the person’s behavior in response to the thought, and
the thought itself, plays a role in resulting feelings (e.g., sitting on the
couch under a blanket rather than going to the gym or calling a friend
in reaction to SAD-specific thoughts contributes to feeling down, above
and beyond the fact that is winter, dark out, snowing, etc.). Pay partic-
ular attention to any thoughts related to external locus of control (e.g.,
thoughts that the season, weather, day length, sunlight availability, etc.
directly and unilaterally determine how one feels) and look for oppor-
tunities to suggest a role for internal locus of control (i.e., what one
thinks and does in response to those environmental cues directly influ-
ences feelings). You can also use this as an opportunity to question the
81
fairness of “feeling like the weather” in a knee-jerk response and to instill
an aggressive stance in participants to exercise the internal control they
have over those external influences to gain control over mood.
Homework (3 min)

Plans.
✎ Have group members continue to keep Thought Diaries using the

5-column form.
✎ Have group members use the Automatic Thought Questioning Form

to evaluate and question at least one important, distressing automatic
thought.
82
Chapter 10 Session 8: Rational Responses
Materials Needed
■ Thought Diary—7 Column (additional copies of form optional)

■ Nametags
Outline

■ Teach how to generate rational responses (10 min)
■ Discuss the importance of believing in one’s rational response
(5 min)
■ Evaluate the impact of rational responses (5 min)
■ Discuss examples of rational responses (30 min)
83
Briefly review the content of Session 7, including using the Socratic

method and the steps to evaluating thoughts:
1. Review the evidence.

2. Review possible outcomes.
3. Consider the impact of your automatic thought.
4. Problem solve about the situation that brought on your negative
thinking.
Discuss how group members are doing with planning and carrying
out pleasant activities and balancing them with responsibilities. Modify
Thought Diary
Check the “Situation,” “Automatic Thought(s),” “Emotion(s),” and

“Distortions” columns on group members’ Thought Diaries. Discuss
examples and diagram them on the board.
Automatic Thought Questioning Form
Review group members’ Automatic Thought Questioning Forms and

discuss how they went about evaluating their negative automatic
thoughts. Address any questions or difficulties.
Generating Rational Responses to Automatic Thoughts (10 min)
Now teach the group how to generate rational responses. Begin with the
following statements:
84
After first identifying negative automatic thoughts that are important
and distressing and then evaluating and questioning those automatic
thoughts to examine how accurate and useful they are, the next step is
to look for alternative explanations. This involves coming up with a
new, more accurate and helpful thought to replace the original
problematic automatic thought.
Explain that we are adding a D to the A-B-C model (see Figure 10.1).
D == Dispute
Explain that at stage D, we try to change our automatic thought to

something more realistic and helpful by asking ourselves:
■ Is there any other way to view or to think about this situation?

■ What would be a more accurate and realistic thought to have?
■ What would be a more helpful thought to have?
If we see words like the following in our automatic thoughts, we

question them:
■ “Should”—Why should I?
■ “Terrible, awful, etc.”—Is it really that bad? What is the worst
thing that could happen? Could I survive it?
■ “Always”—Is it really always or just this time or some of the
time?
The end result of this questioning is a “rational response,” a thought

we generate to take the place of or substitute for our original
automatic thought. Our rational response should be more realis-
tic and more helpful than our original automatic thought. Tell the
group that a rational response is like a rebuttal to an automatic
thought.
Importance of Believing in the Rational Response (5 min)
Explain to the group that with rational responses we are not trying to
come up with something that is rosy and overly positive. Rather we want
85
86
A B C
Any event that happens What you think about A An emotional reaction
This is the new part!!!

After using the Automatic Thoughts Questioning Form to
evaluate your automatic thought, try to actually change
D
your automatic thought to something more helpful.
D = Dispute
Change your automatic thought
from B to a rational response
Is there any other way to view this situation?
Is there another way I can think about this situation?
What would be a more realistic thought to have?
What would be a more helpful thought to have?
Figure 10.1
The A-B-C-D Model
to substitute a thought that is more helpful, while still being realistic.
Use the following examples to illustrate:
For example, if you have the thought, “I failed again,” your rational
response should not be “I always succeed at everything I do” because
that is unrealistic: No one succeeds at everything they do 100% of the
time. Instead, you should come up with something more realistic and
less negative. For example, “I made a mistake this time, but I do most
things well.”
Tell participants that the next step is to rate our belief in the new
thought. After coming up with a rational response, we ask ourselves:
“How much do we believe this rational response?”
Refer to the Thought Diary and explain how to use the 7-column form:
In the “Rational Response” column, you will write down what your
rational response is under number 1 and how much you believe that
rational response under number 2, where 0% is you don’t believe it at
all and 100% is you completely, totally believe it. Don’t tell yourself
something you don’t believe. When you dispute your automatic
thought, make sure you end up with statements you can accept. If you
end up with a statement you don’t have any faith in, keep on
challenging your automatic thoughts until you arrive at a better
rational response.
Explain that the higher the belief rating for a given rational response, the
more effective it will be in countering our original automatic thought.
For each automatic thought, it is recommended that we generate sev-
eral rational responses that we believe highly in order to have a strong,
convincing rebuttal to our original automatic thought.
Evaluating the Impact of Rational Responses (5 min)
Tell the group that if we have generated a series of good, helpful rational
responses, this process should reduce our belief in negative automatic
thoughts and make us feel better. The next step is to evaluate the impact
87
of our rational responses on our original automatic thought and on our
emotions.
The impact on our original automatic thought is indicated in the last

column of the Thought Diary. Under “Outcome,” we re-rate our belief
in the original automatic thought. In other words, now that we have
challenged the automatic thought and generated a rational response,
how much do we believe that automatic thought we had in the first
place? 0% is we do not believe it at all, and 100% is we still totally, com-
pletely believe it. If we have generated a good, helpful rational response,
our degree of belief in the original automatic thought should go down.
The impact on our emotions is also indicated in the “Outcome” col-

umn. Under number 2, we list any emotions we feel now. In other
words, what was the impact of coming up with a rational response to
our automatic thought on our emotional state? We may still have some
of those same emotions we had in the original “Emotion(s)” column.
However, they should now be less in degree. We may also experience
new emotions after generating a rational response, maybe even some
positive emotions such as hopefulness or happiness.
Use the following example to illustrate:
If you originally had the automatic thought “I failed again” and your
rational response is “I made a mistake this time, but I do most things
well,” you should believe in that rational response and see a noticeable
change in those original emotions. For example, if you first had the
emotion of sadness rated 85% in the “Emotion(s)” column, after
evaluating your automatic thought and coming up with a rational
response, we would hope your sadness would be reduced, maybe to a
degree of 35%.
Examples of Rational Responses (30 min)
George’s Rational Response
Have the group recall the example of George and Bill from last week (the
two guys who asked someone out and got shot down). Review George’s
A, B, and C.
88
A = the person he asked out declined his invitation
B = “I’ll never get a date again. I’m going to be single for the rest of my
life. I’m a total failure at love and sure to be unloved forever.”
C = felt depressed
Discuss with the group what George’s “D” (rational response) could be:
“How could he dispute each automatic thought at B to make his think-
ing more realistic and feel less down?” “What could he say to himself
to view the original situation (A = being rejected by someone) in a less
negative and more helpful light?” Give an example if needed:
Is it really that bad? No, I guess not. This is only one person in a huge
sea of people that I could ask out. I’m sad at being turned down, but I
doubt I’ll really end up never getting a date again. In fact, chances are
that I will date again. I’m not really a failure at love. I’ve had plenty
of dates before. And I’m not unlovable. My family loves me.
Personal Examples
Take another look at group members’ Thought Diaries from the past
few days. Ask them to try to generate rational responses to one of
their automatic thoughts. Diagram out the “Situation,” “Automatic
Thought(s),” “Emotion(s),” “Distortions,” “Rational Responses,” and
“Outcome” columns on the board. (Note: You can also return to the
previously diagramed Thought Diary examples from the homework
review at the beginning of this session.)
Help the group members to go through the questions that occur at

D (listed on the A-B-C-D model) to come up with some appropriate
rational responses. Write the rational responses, how much the group
member believes each rational response, and the outcome (belief in orig-
inal automatic thought and remaining emotions) on the board; also ask
the group member to write these into his Thought Diary. During the
exercise, ask each participant the following:
■ What rating would you give that rational response for amount of
belief (i.e., belief in rational response from 0 to 100%)?
89
■ What is the outcome for your belief in the original automatic
thought (0–100%)?
■ What emotions do you feel now and at what intensity (0–100%)?
Note: You may not have time to review examples from every participant.
The other group members should benefit vicariously from observing
the process and can also participate in generating potential rational
responses for the examples reviewed.
SAD-Specific Examples
Either in this session or in upcoming sessions, look for opportuni-

ties to practice generating rational responses to SAD-specific Thought
Diary entries about the winter season, environmental cues that the
seasons are changing, weather, and lack of light. Refer back to the
contents of Session 7 for suggestions regarding evaluating SAD-specific
thoughts. Draw from this evaluation process to generate possible ratio-
nal responses. Look for ways to rephrase thoughts that reflect global
negativism about winter (e.g., “I hate winter”) into rational responses
that are more helpful (e.g., “I prefer summer to winter”). Point out the
impact on feelings and likely subsequent behavior in reaction to the
original thought versus the rational responses.
Homework (3 min)

Plans.
✎ Have group members keep Thought Diaries using the Thought

Diary—7 Column form, which includes columns for rational
responses and the outcome.
✎ Ask group members to try to look for patterns in their automatic

thoughts as they complete the Thought Diaries.
90
Chapter 11 Session 9: Core Beliefs
Materials Needed
■ Nametags
Outline
■ Introduce core beliefs (10 min)
■ Discuss the difference between core beliefs and automatic

thoughts (10 min)
■ Have group practice identifying core beliefs (10 min)
91
Review of Previous Sessions (5 min)
Briefly review the contents from previous sessions, beginning with the
categories of symptoms: physical, emotional, cognitive, and behavioral.
Remind the group that these areas all interact. Treatment of one will
likely improve other areas as well.
So far, the group has learned techniques to help depression on two

important levels:
■ Behavioral—pleasant activity scheduling
■ Cognitive—evaluating negative automatic thoughts and replacing

them with rational responses
Thought Diary
Review all the columns of participants’ Thought Diaries (“Situa-

tion,” “Automatic Thought(s),” “Emotion(s),” “Distortions,” “Rational
Responses,” and “Outcome”). Check that they have recorded at least
one entry a day. Discuss how it went and problems, if any. Go around
the room and get examples and diagram them on the board. Pay special
attention to the rational responses and their impact (on emotions and
belief in the original automatic thought). Suggest additional rational
responses as needed. Emphasize any positive outcomes.
Introduction to Core Beliefs (10 min)
Explain that automatic thoughts are the words that actually go through
our minds and are very close to our conscious awareness. This makes
92
it possible to identify, evaluate, and question automatic thoughts and
reframe them as rational responses in order to experience some relief.
There is, however, a deeper, less conscious level to our thinking that
influences what we think about, what we do, and how we feel. This
deeper level of thinking is made up of our core beliefs. In this session
and the next, the group will focus on core beliefs, in particular, what
core beliefs are, how they develop, how to identify them, and how to
change negative core beliefs to make them more helpful.
Defining Core Beliefs: How They Are Learned and Maintained
Discuss with the group how, during childhood, people learn certain
ways of thinking about themselves, other people, and the world. This
learning is important so we can make sense of things as we grow up.
Core beliefs are our most central, fundamental, important beliefs. They
are the things we wholeheartedly believe to be true about ourselves,
other people, and the world in general. We consider our core beliefs
as absolute truths or just “the way things are.”
For most of our lives, our core beliefs tend to be positive (e.g., “I am
likeable,” “I am competent,” “I am in control,” “Other people are
trustworthy,” “The world is a good place,” and so on).
When people feel depressed, their negative core beliefs tend to surface
(e.g., “I am a failure,” “I am unlovable,” “Other people are critical,”
or “The world is a dangerous place”). During winter, when individ-
uals with SAD are feeling their worst, we expect that their negative
core beliefs are activated and wreak havoc on their thinking, helping
to maintain the symptoms of SAD. During summer, when individuals
with SAD are feeling their best, we expect that their positive core beliefs
are activated, helping to contribute to good mood and sense of well-
being. People with SAD may not believe their negative core beliefs in
the spring or summer, when they are not feeling depressed. However,
it is to be expected that they believe their negative core beliefs almost
completely when they are feeling depressed in the winter. You may want
to use the following dialogue in your discussion:
Once a negative core belief is activated (when you are feeling

depressed), you easily notice any evidence that seems to support it, but
93
ignore or discount any evidence that contradicts it. It’s like having a
screen around your head that allows anything that fits with the
negative core belief through and stops anything that doesn’t fit.
For example, a college student who is depressed may have the core
belief, “I’m inadequate.” He would, therefore, ignore that he got an A
on a recent biology exam (maybe saying, “The test was easy”). Instead,
he would pay special attention to getting a C on a calculus exam
because this would confirm his negative core belief of inadequacy.
Core Beliefs Versus Automatic Thoughts (10 min)
Explain to the group that core beliefs are different from our automatic
thoughts. Our core beliefs are not as close to our conscious awareness,
but they certainly do affect our day-to-day and moment-to-moment
automatic thoughts. Our core beliefs influence the way we view daily
situations and, therefore, influence the way we think, feel, and behave.
Core beliefs actually are what drive our automatic thoughts; they are
like the root of our automatic thoughts. Core beliefs are the reason why
different people have different automatic thoughts in reaction to the
same situation.
Core beliefs fit into the A-B-C model as shown in Figure 11.1. Diagram
this out on the board for the group. You can tell participants that the
idea of core beliefs is a difficult concept to understand. To clarify, return
to the example you’ve been using throughout this group (George and
Bill are both on the dating scene. Both men ask the object of their
affection out on a date and get shot down). Discuss what George’s and
Bill’s core beliefs may possibly be or the way these men may generally
think about themselves, other people, and the world. Give the following
examples if needed.
George’s Core Beliefs
Core beliefs about self—I am unlovable. I am inadequate.
Core beliefs about others—Other people reject and hurt me. Other people
remind me of my inadequacies.
94
CORE BELIEFS
(Self, Others, World)
A B C
(Situation, stream of (Automatic thoughts) (Emotional reaction)
thoughts, or daydream)
Figure 11.1
Core Beliefs and the A-B-C Model
95
Core beliefs about the world—The world is a nasty place, full of
opportunities for rejection.
Bill’s Core Beliefs
Core beliefs about self—I am competent and worthwhile. I am lovable.
Core beliefs about others—Other people are generally good. Others

accept me.
Core beliefs about the world—The world is a safe, accepting place where
I can find happiness.
Reiterate that core beliefs are the reason why different people have
different automatic thoughts in reaction to the same situation. Empha-
size that this higher level of thinking influenced the specific automatic
thoughts that these men had in reaction to the same situation.
Identifying Core Beliefs (10 min)
In the last session, you asked participants to try to look for pat-
terns in their automatic thoughts as they completed their Thought
Diaries. Explain now that one way to identify our core beliefs is to
look for themes in our automatic thoughts because, again, our core
beliefs actually drive our automatic thoughts. Ask group members the
following:
■ Do any of your automatic thoughts occur again and again?

■ Does there seem to be any common theme among your automatic
thoughts?
■ Do your automatic thoughts suggest any ideas about how you
think about yourself, other people, and the world?
Note: Other ways to help participants identify core beliefs include

(1) using the downward arrow technique to identify the underlying
meaning associated with an important automatic thought that you
hypothesize stems from a core belief (J. S. Beck, 1995) and (2) asking
96
participants to complete a questionnaire that measures the extent to
which a person has certain attitudes or core beliefs, such as the Dysfunc-
tional Attitudes Scale (Weissman & Beck, 1978) or the Young Schema
Questionnaire (J. Young & Brown, 2003).
Homework (3 min)

Plans.
✎ Have group members continue to keep Thought Diaries using the

7-column form.
✎ Have group members keep looking for themes and patterns in their
automatic thoughts so they can begin to learn what their core beliefs
are.
97
Chapter 12 Session 10: Evaluating Your Core Beliefs
Materials Needed
■ Core Belief Worksheet (additional copies of form optional)
■ Nametags
Outline
■ Identify core beliefs (30 min)
■ Discuss evaluating and changing core beliefs (3 min)
■ Introduce the Core Belief Worksheet (10 min)
99
Briefly review the content from Session 9:
1. Core beliefs are our most central, fundamental, important beliefs

about ourselves, other people, and the world.
2. We consider our core beliefs as absolute truths or simply “the way

things are.”
3. We learn most of our core beliefs during childhood.
4. Core beliefs are different from automatic thoughts:
◦ Automatic thoughts are the words that actually go through

our minds and are very close to our conscious awareness.
◦ Core beliefs happen at a deeper, less conscious level of
thinking. They are at the root of our automatic thoughts.
Discuss how group members are doing with planning and carrying
out pleasant activities and balancing them with responsibilities. Modify
Thought Diary
Review all the columns of participants’ Thought Diaries (“Situa-

tion,” “Automatic Thought(s),” “Emotion(s),” “Distortions,” “Ratio-
nal Responses,” and “Outcome”). Diagram examples on the board,
paying particular attention to rational responses that were generated
in response to automatic thoughts. Suggest alternative or additional
rational responses as needed. Emphasize the positive impact of ratio-
nal responses on belief in the original automatic thought and on
emotions.
100
Identifying Core Beliefs (30 min)
Examining Automatic Thoughts
Reiterate that we can learn what our core beliefs are by examining our
automatic thoughts for indications of how we generally think about our-
selves, others, and the world. Ask participants whether they noticed any
patterns or themes in their automatic thoughts suggestive of underlying
core beliefs. Discuss group members’ observations in reviewing their
Thought Diaries. If a group member is struggling with this, consider
using the downward arrow technique (J. S. Beck, 1995) to examine the
meaning of an important, distressing automatic thought (e.g., Assum-
ing that automatic thought is true, what would that mean to you or
about you?).
Common Core Beliefs
Explain that core beliefs often fall into two broad categories: core beliefs
surrounding themes of being helpless and core beliefs surrounding
themes of being unlovable (J. S. Beck, 1995). Have group members give
examples of these kinds of core beliefs.
Challenging and Changing Core Beliefs (3 min)
Now that participants have some ideas about what their core beliefs
are, it is important to work on making any negative core beliefs
they have more realistic and accurate, more helpful, and less nega-
tive and more positive in tone. You may want to use the following
metaphor:
Think of your core beliefs as an iceberg. They are really important

beliefs you have and wholeheartedly believe to be true. It’s difficult to
logically evaluate and eventually change them. However, by gradually
chipping away at the iceberg, it is possible to change your core
beliefs.
101
Tell the group that the process of evaluating our core beliefs is simi-
lar to how we evaluated and questioned our automatic thoughts using
the Socratic method. However, it is usually a lot more difficult to log-
ically evaluate our core beliefs because they are a lot more important
to us and we believe them more than our automatic thoughts. The
process of replacing an unhelpful, negative core belief with a more
helpful, positive core belief is somewhat similar to replacing a nega-
tive automatic thought with a rational response. Again, it is usually
harder and more time consuming to replace core beliefs because they are
more central and are more strongly believed by us than our automatic
thoughts are.
Core Belief Worksheet (10 min)
Introduce the Core Belief Worksheet to the group. Say that it is an

organized way of working on our core beliefs and is similar to a Thought
Diary, but is made for core beliefs instead of automatic thoughts. The
Core Belief Worksheet combines the steps of evaluating, questioning,
and generating new, more helpful core beliefs.
Provide participants with copies of a blank Core Belief Worksheet.

Have them refer to the completed example in their workbooks (same
as Figure 12.1). Explain how they will be completing the form as part of
this session’s homework. At the top, they will write in a core belief that
seems important, as determined from their Thought Diaries. They will
write down how much they believe that core belief right now from 0
to 100%. Then they will think about that core belief in the past week
and write down the least and most they have believed that core belief
from 0 to 100% in the spaces provided in the worksheet. Refer to the
completed example worksheet:
The core belief in the example is, “I am a failure.” This depressed

young woman believes that she is a failure 80% right now, but
believed it as much as 90% and as little as 70% at some other times
this past week.
Next, group members will look at the evidence for and against their core
beliefs.
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Core Belief Strength Evidence for with Evidence against New Belief Strength(0–100%)
(0–100%) BUT statements
I am a Current: Growing up, my mother often made I maintained excellent grades I perform most things I do very New Belief:
failure. 80% statements comparing me to my sister, throughout my education and well, but, like most people, I do 95%
suggesting that I was not as good as my received lots of praise from my not reach my top goal all of the
sister (not as smart, not as likeable, not instructors. time.
as pretty, etc.) BUT that was only her Old Belief:
Most things I wrote under
opinion and today I understand that 60%
nurturing parents do not say such things “evidence for” are specific times
when I did not reach some top goal.
to their kids.
I do reach my desired goal the vast
Most (past week): During my senior year of high school, I majority of the time. Even when I
90% did not make a sports team that I do not reach my top goal, things
really wanted to be part of BUT I did work out for me and I do not end
make this team every other year of up as a total failure. I at least
high school and more students tried partially succeed.
out at that year than ever before.
I obtained a very good job that I
Least (past week): I did not get into the top college of perform well and continue to enjoy.
70% my choice BUT that was a highly
selective school and I ended up Achieving things is not the only way
attending an excellent college. to define success or failure—having
good relationships is important, too. I
During college, I really struggled to
have good relationships with my
pass my biology courses BUT many
family and friends.
students struggled with biology and I
earned high grades in all of my other
courses.
Figure 12.1
Example of Completed Core Belief Worksheet
Note: Adapted from Cognitive Therapy: Basics and Beyond, by J. S. Beck, 1995, New York: The Guilford Press.
103
On the left-hand side of the worksheet, they should list any evidence
that supports the core belief. After they list something, instruct them to
add a “BUT” statement with one or more other explanations for why
that might have occurred (other than the core belief being true). Refer
again to the example on the worksheet:
This young woman thought through her life and recorded specific
events when she strongly held the belief, “I am a failure.” There were
multiple times when her mother made comments about how she did
not measure up to her sister, which she recorded as evidence that
supports her belief of being a failure. She follows this up with a
“BUT” statement (other reasons, other than being a failure that her
mother made these comments) that this was only her mother’s opinion
and that these comments may have been inappropriate and were
certainly unhelpful for a parent to express.
On the right-hand side of the worksheet, instruct group members to

write down any evidence that contradicts the core belief. In the next
column, after considering all the evidence, they will generate a new,
more helpful, less negative, more positive core belief. Return to the
example:
In the example, the depressed women cites various things that suggest
she is, indeed, at least partially successful and certainly not a total
failure. After considering the evidence for her core belief with “BUT”
statements and after considering the evidence against her core belief,
the woman generates a new, more realistic, helpful core belief, “I
perform most things I do very well, but, like most people, I do not
reach my top goal all of the time.” She believes this new
belief 95%.
Instruct group members to rate how much they believe their new beliefs
from 0 to 100%. Tell them that just like they should believe in their
rational responses, they should also highly believe their new core beliefs.
Finally, they will re-rate how much they believe in their original core
belief from 0 to 100%. They should see a decrease here from their initial
rating. If they don’t, they will probably want to add more evidence to
review. Go back to the metaphor of chipping away more and more at
the iceberg.
104
Homework (2 min)

Plans.
✎ Have group members continue to complete all the columns of the

Thought Diary—7 Column form on a daily basis.
✎ Have group members keep looking for themes and patterns in their
automatic thoughts to give them more ideas about what their core
beliefs are.
✎ Have group members complete the Core Belief Worksheet and be

prepared to talk about this process with the group in the next session.
105
Chapter 13 Session 11: Maintaining Your Gains and Relapse
Prevention
Materials Needed
■ Personal Goal Planning Sheet

■ Nametags
Outline

■ Review content of Sessions 9 and 10 (3 min)
■ Discuss how to maintain gains (10 min)
■ Introduce relapse prevention (5 min)
■ Give tips for relapse prevention (20 min)
■ Discuss setting new personal goals (5 min)
107
Review of Sessions 9 and 10 (3 min)
Review the concept of core beliefs. Emphasize the following points:
1. Core beliefs occur at a very deep, higher level of thinking. Core

beliefs are different from automatic thoughts (or the words that
actually go through our minds) in that they are less conscious.
2. We learn both positive and negative core beliefs based on the

experiences we have had in life from childhood to the present. For
most of their lives, most people tend to have positive core beliefs.
When people become depressed, their negative core beliefs tend to
surface.
3. During winter, negative core beliefs are activated among people

with SAD. Once negative core beliefs are activated, they influence
a person’s automatic thoughts, making them more negative.
Thought Diary
Get examples of rational responses from the group and discuss how they
impact mood and the degree of belief in the original automatic thought.
Core Belief Worksheet
Elicit examples of what the process of evaluating and changing core

beliefs was like. Check that all participants were able to generate “BUT”
108
statements and new, more realistic core beliefs. Discuss any difficulties
with the process.
Remind the group that core beliefs are like an iceberg-sized thought. We
really believe them to be true, so evaluating and changing them can be
difficult and takes time; we have to keep chipping away at the iceberg.
Encourage participants to keep working through their core beliefs until,
eventually, they get through the process of evaluating and changing all
the negative core beliefs they have.
Maintaining Your Gains (10 min)
Tell participants that you hope that they have experienced some
improvements in their SAD symptoms and in their quality of life since
they started attending this group 5 weeks ago. However, there are still a
number of weeks of winter left and it is important for group members
to maintain the gains they have made. Use the following dialogue to
introduce the concept of maintenance:
At the beginning of the group, we told you to think of this group as

your driving instructor. Just like a driving instructor teaches you the
basic skills necessary to be a good driver, this group was meant to teach
you some basic skills to cope with winter more effectively. Although it’s
true that the group is not going to meet anymore after this week, you
don’t need to stop “driving.” You now have the knowledge for how to
drive on your own. You are in the driver’s seat, so to speak, for coping
with your SAD.
Explain to group members that maintaining gains involves asking

themselves several questions:
■ “What can I do to maintain the gains I’ve made in this group?”
■ “What can I do to make sure I continue to improve even more

after the group stops meeting?”
■ “Is this as good as it’s going to get for me during the winter with
my SAD or do I want to try and make it even better?”
■ “If I want it to be even better, what can I do to try and make this
happen?”
109
Stress to participants that it is best to think about maintaining gains
ahead of time and have a plan in place for how to do it. They might
be tempted to just “play it by ear” or “see what happens.” However, if
these strategies don’t work, they may find themselves back in the depths
of a SAD episode with no plan for how to get out of it. People who
are successful at making a major life change (e.g., quitting smoking
or drinking alcohol, or losing weight) tend to have a plan in place for
how to maintain their gains. Conclude the discussion with the following
dialogue:
We have asked you to make a major life change in this group—to

change your old habits (the ways you used to cope with winter) to more
helpful, adaptive ways of coping with winter. If you don’t plan ahead,
you may fall back into your old habits that contributed to making
your SAD worse (e.g., low activity level and negative thinking).
Introduction to Relapse Prevention (5 min)
Use the example of a forest ranger firefighter to introduce the concept

of relapse prevention:
What is a forest ranger firefighter’s job? To sit on top of a tower and

monitor the forest for signs of a fire. Why do they do that? Chances are
good that a forest fire will occur sooner or later (e.g., when the weather
is dry, when someone gets careless). The goal of the forest ranger
firefighter is then to identify fires quickly, have a plan in place, and
put the fire out. This is similar to the position you are in now (or will
be in once your SAD improves)—you’ve got to watch out for future
SAD episodes. This is called relapse prevention.
Emphasize the importance of having a relapse prevention plan in place.

After all, we cannot prevent winter from happening; winter will recur
year after year. A good relapse prevention plan will help participants
be ready for winter next time it rolls around so they’ll be prepared to
cope with it. Inform the group that people who have had repeated SAD
episodes in the past are actually at greater risk for SAD episodes, and
for depression in general, in the future, which makes relapse prevention
especially important.
110
Have the group recall that in the first week, you told them that
cognitive-behavioral therapy (CBT) has been found to be more effective
than other types of therapy in preventing relapse.
Reiterate that people who successfully complete CBT are less likely
to have future episodes of depression. We expect that this is because
people who go through CBT continue to use the skills they learned
to cope with stress and changes in mood. Stress that only if they
continue to use the skills they have learned in this group can they
expect some improvements in how they cope with future fall or win-
ter seasons. If they go back to their old habits and ways of coping,
they will likely fall back into the same patterns and experience SAD
again.
Tips for Relapse Prevention (20 min)
1. Be alert to signs and symptoms of SAD.

Remind group members that they know what to watch out
for—the signs and symptoms of SAD. They should monitor their
mood on a regular basis. They can ask themselves, “How have I
been feeling over the past week? How have I been handling things
lately?” If they notice they are falling back into some of the same
old negative patterns (e.g., low energy, sleep problems, negative
thinking, do not feel like doing anything, appetite changes), this
should alert them.
2. Take early action.

Group members will need to identify any changes in their moods
and behaviors, have a plan in place, and take action before they are
feeling so badly that they cannot get motivated to do anything
about it. Emphasize that they should try to identify early signs of
SAD and depression because prevention is easier than treatment
for a full-blown SAD episode.
3. Be aware that major life events can set you up for depression.
Mention that people with a history of SAD are also more
vulnerable to depression, in general, at any time of the year. Major
life events often come before depression so it is important for
111
group members to be aware of this. Negative life events can occur
at any time of the year and often lead to depression. If a major
stressful life event were to happen during winter, it could serve as a
“double whammy,” making SAD worse. Group members should
think ahead about ways stressful events may affect them. They will
need to monitor their moods more closely when they are under
stress and prepare for these events with a plan. Give examples of
life events associated with depression:
■ Social separations: moving away from loved ones or loved ones

relocating, divorce or separation or end of a relationship,
death of a loved one, etc.
■ Health-related problems: injury or illness, a new medical
problem, etc.
■ New responsibilities and adjustments: change in career,
becoming a caretaker for someone, going back to school, etc.
■ Work-related changes: promotion, getting laid off, etc.
■ Financial and material changes: decrease in income, cutting
back on spending, etc.
4. Have a relapse prevention plan in place.

Ask group members what strategies would improve their moods if
they had a relapse (i.e., if they begin to experience SAD symptoms
again next fall or winter). Discuss how they can remind themselves
to use what they have learned in this group if they start feeling
down again. Elicit other ideas that may help them cope with
winter (other than things they have learned in this group).
Therapist Note
■ If taking trips South comes up, be sure to discuss the consequences of
that: immediate positive consequence (i.e., individuals with SAD

typically feel better when they travel South in the winter) versus
delayed negative consequence (i.e., upon returning home, a crash is
common due to the sudden contrast in climate). ■
5. Remember that your thoughts play a role in relapse and

relapse prevention.
Group members need to be careful of negative thoughts that can
get in the way (e.g., “I must be a failure. I went through this SAD
treatment program and I’m depressed in the winter again.”). They
112
should replace these with positive, empowering thoughts (e.g., “I
can do something to help myself feel better. I can increase my
activity level and work on making my thoughts more
positive.”).
Setting New Goals (5 min)
Tell the group that we can think of coping more effectively with winter
as making a major life change. After all, their old ways of coping with
winter were well-formed habits that may have become “comfortable” in
some ways. Sometimes making one positive life change can lead to other
positive life changes in other areas. Encourage participants to keep the
positive momentum going.
Now that they have worked hard to improve their SAD, they may want
to generate new goals for themselves. Such goals can include:
■ Individual goals: educational plans, vocational choices, exercise and

physical activity level, economic pursuits, recreational and creative
activities
■ Interpersonal goals: goals related to family, friends, and romantic

relationships; joining a group; becoming a leader
Have group members begin to generate short- and long-term goals

and record these on the Personal Goal Planning Sheet in the
workbook.
Homework (5 min)
✎ Have group members come up with a personal plan for maintaining

any gains they have made in this group and for coping with future fall
or winter seasons.
✎ Have group members think about any other areas of their lives they
would like to change for the better and generate goals.
113
✎ Instruct group members to use the Personal Goal Planning Sheet to
develop their plans and goals and be prepared to share these with the
group at the last meeting.
114
Chapter 14 Session 12: Review and Farewell
Materials Needed
■ Nametags
Goals
■ Review the past 5 weeks (30 min)
■ Encourage group members to reflect and share comments about

the group (20 min)
■ Bring the group to a close (3 min)
115
Review of Past 5 Weeks (30 min)
As you have given group members a lot of information over the past
5 weeks, it is often helpful to end the group with a summary and review
of what has been covered. This can help to refresh participant’s mem-
ories and see the big picture of what they have learned. Organize the
review around important things you hope group members will take with
them and remember. You may find the following summaries helpful:
1. SAD and SAD symptoms are a very common experience. SAD is a

clinical depression that follows a seasonal pattern of onset (in the
fall and winter) and remission (in the spring and summer). SAD
prevalence increases with latitude. In general in the United States,
the farther away from the equator, the higher the prevalence of
SAD and SAD symptoms. SAD symptoms happen on a
continuum, where most people experience some changes in mood
and behavior during fall and winter. Those with mild-to-moderate
SAD symptoms are said to have subsyndromal SAD or S-SAD.
2. SAD symptoms fall into four main categories—physical,

emotional, cognitive, and behavioral. (Ask for examples from each
category.) These different types of SAD symptoms interact or
influence each other in a depressive cycle that could start with any
symptom. Each year, SAD episodes actually start with the
appearance of one or two symptoms. These one or two symptoms
alone may be unpleasant, but manageable. These few early
symptoms then lead to the development of more and more
symptoms until a person has many symptoms of SAD and feels
overwhelmed by them. We call this the vicious SAD cycle, which
works to keep SAD symptoms going and gets in the way of feeling
better.
3. Our level of pleasant activities relates to how we feel, and doing

more can make us feel better. Week 2 focused on skills that could
help us feel better on the behavioral level. A high frequency of
pleasant activities is associated with satisfaction and happiness. A
low frequency of pleasant activities is associated with depressed
mood. Activity level and mood act in a negative cycle, where
feeling depressed can cause a person to engage in fewer pleasant
116
activities and becoming less active can cause a person to feel more
depressed and so on. The negative mood–activity cycle can start
with either depressed mood or a decrease in activity level. To break
the negative cycle we must start a positive mood–activity level
cycle, where we do a few more pleasant activities and then feel
better, which makes us want to do even more activities and so on.
4. What we think about relates to how we feel, and changing

unhelpful, negative thoughts into more positive ones can make us
feel better. Weeks 3, 4, and 5 focused on skills that could help us
feel better on the cognitive level. During Week 3, the A-B-C
model showed us how different people can have different reactions
to the same situation. We defined thoughts at stage B as automatic
thoughts—spontaneous thoughts that just pop into our heads.
Automatic thoughts can be positive or negative. Negative
automatic thoughts tend to fall into certain categories called
cognitive distortions. Cognitive distortions are unhelpful ways of
thinking that are common in depression, which tend to make a
person feel even worse.
5. In Week 4, we learned how to evaluate our automatic thoughts

using the Socratic method. This process involved reviewing the
evidence for and against the automatic thought, thinking about
the worst/best/most realistic outcome, and problem-solving about
the situation that brought on our negative thinking. Then, we
added a D to the A-B-C model. D = dispute (change the
automatic thought to a rational response). We practiced
generating a new, more realistic and helpful thought (a rational
response) to replace the original automatic thought. A good
rational response is one that we highly believe and that reduces any
negative emotions we feel.
6. During Week 5, we began talking about core beliefs. Core beliefs

are basic ideas we have about ourselves, other people, and the
world in general. Our core beliefs are learned during childhood
and are much deeper and less conscious than our automatic
thoughts. We worked to identify our core beliefs by looking for
patterns or themes in our Thought Diaries. Then, we began to
work on evaluating and changing our core beliefs using the Core
117
Beliefs Worksheet (reviewing the evidence for and against it and
coming up with a new, more realistic core belief ).
7. Hopefully, even though we did not directly target the emotional

and physical symptoms, we experienced some change in those
symptoms, too. We should feel less depressed following a pleasant
activity, after evaluating negative thoughts, and after thinking
rational responses. Activity scheduling should give us a little more
energy and focusing on positive rather than negative thoughts
should take attention away from any negative physical states (pain,
fatigue).
8. In Session 11, we emphasized the importance of having a plan in

place for how we will maintain any gains we have made in
treatment and prevent relapse. We also broadened our perspective
a bit to think about other life areas we may like to improve upon.
As with any other lifestyle change (quitting smoking or drinking,
losing weight, going through rehab for some health problem, etc.),
improving SAD symptoms will take time and effort. We have to
keep practicing and building on the skills we have learned to make
a difference in our lives.
For the last homework assignment, you asked group members to

complete the Personal Goal Planning Sheet. Members should have
developed their own personalized plans for how to maintain any gains
they have made in this group for the rest of this winter, how to cope with
future fall–winter seasons to make the seasons even better for them, and
how to improve any other areas of their lives. Have group members
share some of their goals and plans with each other.
Reflection and Group Sharing (20 min)
Tell participants that sometimes when a therapy group is coming to a

close, it is helpful to share any feelings group members have about the
group with one another. Give each group member the opportunity to
118
share comments about the group. The following questions can be used
to encourage discussion:
■ Out of the skills that you’ve learned, which have been most helpful
to you?
■ What do you see as the biggest change you’ve made from this
group?
■ What do you think is left to improve upon?
■ Who is responsible for any improvements you’ve made in this
group? Is it the group, the group therapists, or you? Or maybe it’s
that the days are getting longer and warmer?
People with SAD tend to do the opposite of personalization when

it comes to explaining their improvement. For example, a participant
might say, “I felt better because the group was helpful or because spring
is on its way.” Remind participants about their own involvement in their
improvement. Use the following dialogue for reinforcement:
Remember, you didn’t just sit here passively and listen to the material.
You interacted with the group, asked questions, thought about the
material between sessions, and did a homework assignment after every
session. Even though other factors may be partially related to any
improvements you’ve made, you deserve the majority of the credit.
Don’t discount your own contribution to your feeling better.
Group Closing (3 min)
At the end of the session, congratulate group members on completing

the program. Have them say their good-byes and answer any remaining
questions. Emphasize that it is important for them to keep practicing
the skills learned in group on their own. Remind them to review their
workbooks and seek out additional resources as needed (see suggestions
in the workbook).
119
Fidelity Checklists
121
Session 1: Introduction to the Group
Fidelity Checklist
Group: Date:
Rate your fidelity to each session element on a scale of 1 to 7, with 1 indicating poor fidelity and
7 indicating high fidelity.
Actual Time:
Set agenda (5 min)
Introduce group leaders and members (15 min)
Review the goals of this group (15 min)
Explain the purpose of this group (5 min)
Discuss the issue of confidentiality (5 min)
Introduce cognitive-behavioral therapy (15 min)
Discuss changes that the group members can expect to make (15 min)
Present the rationale for homework (10 min)
Assign homework (5 min)
Notes:
122
Session 2: Symptoms, Prevalence, and Causes of SAD
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Review content of Session 1 (5 min)
Discuss SAD and its symptoms (40 min)
Introduce the vicious cycle of SAD symptoms (10 min)
Explain the prevalence of SAD (5 min)
Present possible causes of SAD (15 min)
Discuss the importance of psychological factors in maintaining SAD

(10 min)
Notes:
123
Session 3: How Activities Relate to Mood and Thoughts
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Review Pleasant Activities Rating Scale homework (20 min)
Discuss pleasant activities and how they relate to mood and thoughts
(25 min)
Teach the group how to reverse the depressed mood–activity level

cycle (5 min)
Teach the group how to change thoughts in order to increase activity

level (10 min)
Help group members choose positive self-statements and plan a

pleasant activity (20 min)
Notes:
124
Session 4: Doing More to Feel Better
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Review pleasant activities completed for homework (20 min)
Discuss important mood-related activities (5 min)
Review possible problems in doing pleasant activities (10 min)
Discuss how to get started on a balanced activity plan (8 min)
Review strategies for creating balance (10 min)
Introduce steps to activity scheduling (10 min)
Have group members create an activity plan (20 min)
Notes:
125
Session 5: What You Think Influences How You Feel
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Review content of Sessions 3 and 4 (5 min)
Review homework (20 min)
Discuss the relationship between thought and mood (10 min)
Present the A-B-C model (10 min)
Review events that may cause negative thinking (10 min)
Introduce the concept of automatic thoughts (10 min)
Teach group members how to use a thought diary (20 min)
Notes:
126
Session 6: Cognitive Distortions
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Discuss SAD-specific automatic thoughts (10 min)
Introduce cognitive distortions (15 min)
Have group members practice identifying cognitive distortions

(15 min)
Notes:
127
Session 7: Evaluating Your Automatic Thoughts
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Discuss how to evaluate thoughts (2 min)
Introduce the Automatic Thought Questioning Form (8 min)
Discuss examples of questioning thoughts (40 min)
Notes:
128
Session 8: Rational Responses
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Teach how to generate rational responses (10 min)
Discuss the importance of believing in one’s rational response (5 min)
Evaluate the impact of rational responses (5 min)
Discuss examples of rational responses (30 min)
Notes:
129
Session 9: Core Beliefs
Fidelity Checklist
Group: Date:
7 indicating high fidelity
Actual Time:
Set agenda (2 min)
Introduce core beliefs (10 min)
Discuss the difference between core beliefs and automatic thoughts

(10 min)
Have group practice identifying core beliefs (10 min)
Notes:
130
Session 10: Evaluating Your Core Beliefs
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Identify core beliefs (30 min)
Discuss evaluating and changing core beliefs (3 min)
Introduce the Core Belief Worksheet (10 min)
Notes:
131
Session 11: Maintaining Your Gains and Relapse Prevention
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Review content of Sessions 9 and 10 (3 min)
Discuss how to maintain gains (10 min)
Introduce relapse prevention (5 min)
Give tips for relapse prevention (20 min)
Discuss setting new personal goals (5 min)
Notes:
132
Session 12: Review and Farewell
Fidelity Checklist
Group: Date:
Actual Time:
Set agenda (2 min)
Review the past 5 weeks (30 min)
Encourage group members to reflect and share comments about the

group (20 min)
Bring the group to a close (3 min)
Notes:
133
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138
About the Author
Kelly J. Rohan, PhD is Associate Professor of Psychology at the Univer-

sity of Vermont, where she also directs the Mood Disorders Laboratory
and Seasonality Treatment Program. She has also been on the faculty of
the Uniformed Services University of the Health Sciences in the Depart-
ment of Medical and Clinical Psychology. Dr. Rohan received her BA from
Saint Bonaventure University and her PhD in clinical psychology from the
University of Maine. She completed her residency and a 2-year postdoc-
toral fellowship at the University of Mississippi Medical School/Jackson
Veterans Affairs Medical Center Consortium. Dr. Rohan’s area of interest is
mood disorders, with specialization in seasonal affective disorder (SAD) and
cognitive-behavioral treatments. Dr. Rohan has received research funding
from the National Institute of Mental Health and was awarded the Young
Investigator Research Award from the Society for Light Treatment and
Biological Rhythms for her work on cognitive-behavioral therapy for SAD.
139

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Coping With the Seasons

David H. Barlow, PhD

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Oxford New York

Published by Oxford University Press, Inc.

Oxford is a registered trademark of Oxford University Press

All rights reserved. No part of this publication may be reproduced,

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America

Stunning developments in healthcare have taken place over the last

Of course, the major stumbling block for clinicians everywhere is the

The manuals and workbooks in this series contain step-by-step detailed

In our emerging healthcare system, the growing consensus is that

This therapist guide applies cognitive-behavioral therapy (CBT) for

David H. Barlow, Editor-in-Chief,

Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59,

First, I would like to acknowledge the contribution of all of the

Chapter 1 Introductory Information for Therapists 1

Chapter 2 Group Logistics 15

Chapter 3 Session 1: Introduction to the Group 21

Chapter 4 Session 2: Symptoms, Prevalence, and Causes

Chapter 5 Session 3: How Activities Relate to Mood and

Chapter 6 Session 4: Doing More to Feel Better 47

Chapter 7 Session 5: What You Think Inﬂuences How

Chapter 8 Session 6: Cognitive Distortions 67

Chapter 9 Session 7: Evaluating Your Automatic Thoughts 77

Chapter 10 Session 8: Rational Responses 83

Chapter 11 Session 9: Core Beliefs 91

Chapter 12 Session 10: Evaluating Your Core Beliefs 99

Chapter 13 Session 11: Maintaining Your Gains and Relapse

Chapter 14 Session 12: Review and Farewell 115

Fidelity Checklists 121

About the Author 139

Background Information and Purpose of This Program

This guide presents a cognitive-behavioral group treatment for seasonal

The session-by-session protocol for conducting 1.5-hr CBT sessions

This treatment was designed as a group program, and this guide is

Seasonal Affective Disorder

SAD is a subtype of recurrent depression that involves a regular tem-

DSM-IV-TR MDE criteria represent the spectrum of SAD symp-

SAD characterizes 10–20% of recurrent depression cases (Blazer et al.,

Available data suggest that the long-term course of SAD is variable. In a

The cause of SAD is yet to be established, but several hypotheses

Development of This Treatment Program

The central public health challenge in the overall management of SAD

1. a time-limited treatment (i.e., acute treatment completed in a

3. a treatment that shows effects that endure beyond the cessation of

There would be no need to develop a treatment with these three qual-

Cognitive-Behavioral Model of SAD