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(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)
(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)
EDITOR-IN-CHIEF
SCIENTIFIC
ADVISORY BOARD
Jack M. Gorman, MD
Therapist Guide
Kelly J. Rohan
1
2009
1
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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
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.
References
viii
Acknowledgments
ix
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Contents
References 135
xi
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Chapter 1 Introductory Information for Therapists
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.
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.
3
2. a treatment that effectively treats acute SAD symptoms in the
initial winter, and
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”).
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).
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.
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
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
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
Evidence Base
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.
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.
Alternative Treatments
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.
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.
11
has not been tested against medications in a head-to-head comparison
to date.
Assessment
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
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Chapter 2 Group Logistics
Forming a Group
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.
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.
16
possible and for the group leaders to call all participants in the event of
a cancellation.
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
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.
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
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Chapter 3 Session 1: Introduction to the Group
Materials Needed
■ Nametags
Outline
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.
Present the following goals of this group using the dialogues in italics.
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.
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 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.
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?
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:
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.
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).
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.
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:
■ Buy a book
■ Get a video
■ Take lessons
■ Practice
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)
28
Chapter 4 Session 2: Symptoms, Prevalence, and Causes
of SAD
Materials Needed
■ Nametags
Outline
29
Setting the Agenda (2 min)
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
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:
3. Some of the changes that participants can expect from this group
include:
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
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?
Symptoms of SAD
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:
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”).
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.
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.
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.
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
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
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.
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.
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!
Homework (3 min)
38
Chapter 5 Session 3: How Activities Relate to Mood
and Thoughts
Materials Needed
■ Nametags
Outline
39
Setting the Agenda (2 min)
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
3. Prevalence of SAD
6. Effectiveness of CBT
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.
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:
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
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.
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.
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?
A positive spiral of mood and activity is also possible. Show Figure 5.2
to illustrate the positive mood–activity level cycle.
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
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.
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 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)
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.
46
Chapter 6 Session 4: Doing More to Feel Better
Materials Needed
■ Nametags
Outline
47
Setting the Agenda (2 min)
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
5. People with SAD often have negative thoughts which make them
feel worse and even less likely to engage in activities.
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?
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: Sometimes people with SAD feel tired after doing a pleasant
activity.
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
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.
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
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
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).
Review the following strategies for creating balance. Prompt for exam-
ples and elicit additional strategies from the group.
53
Plan Ahead
Next, teach the group the steps to activity scheduling: (1) set a specific
goal; (2) plan, schedule, and record; and (3) reward yourself.
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.
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.
Give the group the following general tips (see sample dialogues):
Homework (2 min)
56
Chapter 7 Session 5: What You Think Influences How
You Feel
Materials Needed
■ Nametags
Outline
57
Setting the Agenda (2 min)
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
4. Mood-related activities
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.
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.)
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
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.
Review some events that might put someone at risk for negative
thinking at the B (Belief ) stage:
■ Feeling under-appreciated
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.
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:
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.
Elicit examples from the group and write them out on the board using
the Thought Diary format (see Figure 7.2 for an example).
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.
■ Do you think you could have been thinking about (provide plausible
possibilities)?
You can also ask the other group members for some possibilities of
automatic thoughts in that situation.
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)
65
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Chapter 8 Session 6: Cognitive Distortions
Materials Needed
■ Nametags
Outline
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
67
Review of Session 5 (5 min)
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
■ 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.
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:
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.
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.
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
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.”
Jumping to Conclusions
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.
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.”
Example: A man with SAD thinks, “Winter is horrible! This cold, dark
weather will never go away, and I’ll feel badly forever.”
Emotional Reasoning
You take your emotions as proof of the way things really are. You assume
something is true because you feel it is.
73
“Should” Statements
Example: A person with SAD thinks “I should be able to cope with the
winter season.”
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.”
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.”
74
the worst! I’ll never be able to get out of the house.” You feel sad and
angry.
Cognitive Distortions:
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)
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Chapter 9 Session 7: Evaluating Your Automatic Thoughts
Materials Needed
■ Nametags
Outline
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
77
Review of Session 6 (5 min)
4. Thoughts can affect how one feels emotionally: the A-B-C model.
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
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:
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.
79
2. Review possible outcomes. Ask yourself:
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.
80
Personal Examples
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)
82
Chapter 10 Session 8: Rational Responses
Materials Needed
Outline
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
83
Review of Session 7 (5 min)
Discuss 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
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
■ “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?
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
A = Antecedent event B = Belief C = Consequence
Any event that happens What you think about A An emotional reaction
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.
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.
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%.
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.)
■ 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
Homework (3 min)
90
Chapter 11 Session 9: Core Beliefs
Materials Needed
■ Nametags
Outline
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
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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.
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
Explain that automatic thoughts are the words that actually go through
our minds and are very close to our conscious awareness. This makes
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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.
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:
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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.
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.
Core beliefs about others—Other people reject and hurt me. Other people
remind me of my inadequacies.
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CORE BELIEFS
(Self, Others, World)
A B C
A = Antecedent event B = Belief C = Consequence
(Situation, stream of (Automatic thoughts) (Emotional reaction)
thoughts, or daydream)
Figure 11.1
Core Beliefs and the A-B-C Model
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Core beliefs about the world—The world is a nasty place, full of
opportunities for rejection.
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.
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:
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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)
✎ Have group members keep looking for themes and patterns in their
automatic thoughts so they can begin to learn what their core beliefs
are.
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Chapter 12 Session 10: Evaluating Your Core Beliefs
Materials Needed
■ Nametags
Outline
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
99
Review of Session 9 (3 min)
Discuss 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
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Identifying Core Beliefs (30 min)
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?).
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.
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:
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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.
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.
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)
✎ Have group members keep looking for themes and patterns in their
automatic thoughts to give them more ideas about what their core
beliefs are.
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Chapter 13 Session 11: Maintaining Your Gains and Relapse
Prevention
Materials Needed
Outline
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
107
Review of Sessions 9 and 10 (3 min)
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
Get examples of rational responses from the group and discuss how they
impact mood and the degree of belief in the original automatic thought.
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.
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:
■ “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?”
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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:
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.
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
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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:
Therapist Note
■ If taking trips South comes up, be sure to discuss the consequences of
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.”).
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:
Homework (5 min)
✎ 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.
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Chapter 14 Session 12: Review and Farewell
Materials Needed
■ Nametags
Goals
Begin the session by setting the agenda and writing it on the flip chart.
Refer to the outline at the beginning of this chapter and add any other
topics particular to the group.
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:
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.
117
Beliefs Worksheet (reviewing the evidence for and against it and
coming up with a new, more realistic core belief ).
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?
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.
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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:
Discuss changes that the group members can expect to make (15 min)
Notes:
122
Session 2: Symptoms, Prevalence, and Causes of SAD
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:
Notes:
123
Session 3: How Activities Relate to Mood and Thoughts
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:
Discuss pleasant activities and how they relate to mood and thoughts
(25 min)
Notes:
124
Session 4: Doing More to Feel Better
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:
Notes:
125
Session 5: What You Think Influences How You Feel
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:
Notes:
126
Session 6: Cognitive Distortions
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:
Notes:
127
Session 7: Evaluating Your Automatic Thoughts
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:
Notes:
128
Session 8: Rational Responses
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:
Notes:
129
Session 9: Core Beliefs
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:
Notes:
130
Session 10: Evaluating Your Core Beliefs
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:
Notes:
131
Session 11: Maintaining Your Gains and Relapse Prevention
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:
Notes:
132
Session 12: Review and Farewell
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:
Notes:
133
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About the Author
139