Reading B

Your conceptualization provides the framework for treatment. It helps you:

• understand clients, their strengths and weaknesses, their aspirations and challenges;
• recognize how it is that clients developed a psychological disorder with dysfunctional thinking and maladaptive behavior;
• strengthen the therapeutic relationship;
• plan treatment within and across sessions;
• select appropriate interventions and adapt treatment as needed; and
• overcome stuck points.

An organic, evolving formulation helps you plan for efficient and effective therapy (Kuyken et al., 2009; Needleman, 1999; Persons, 2008; Tarrier, 2006). You begin to construct the conceptualization during your first contact with a client and refine it at every subsequent contact. It's important to understand the cognitive formulation for the client's diagnosis(es), the typical cognitions, behavioral strategies, and maintaining factors. But then you need to see whether the formulation fits your specific client. You continually collect data, summarize what you've heard, check out your hypotheses with the client, and modify your conceptualization as needed. For example, I didn't know in the first few sessions that Maria had a belief of worthlessness. It wasn't until she had a shouting match with her mother and sister that this belief came to light.

You confirm, disconfirm, or modify your hypotheses as clients present new information. You continually ask yourself, "Is the new data I've just learned part of a pattern I've already identified—or is it something new?" If new, make a note to check in future sessions to see if these data are part of another pattern.

You share your conceptualization and ask the client whether it "rings true" or "seems right." If your conceptualization is accurate, the client invariably says something like "Yes, I think that's right." If you're wrong, the client usually says, "No, it's not exactly like that. It's more like ___________________." Eliciting the client's feedback strengthens the alli-ance and allows you to more accurately conceptualize and conduct effective treatment. In fact, sharing your conceptualization can itself be therapeutic (Enamel et al., 2015; Johnstone et al., 2011). Abe felt better when I suggested that he really had only one problem: seeing himself as incompetent and a failure.

It's important to put yourself in your clients' shoes, to develop empathy for what they are experiencing, to understand how they are feeling, and to perceive the world through their eyes. Clients' perceptions, thoughts, emotions, and behavior should make sense given their interpretation of past and current experiences, their strengths and vulnerabilities, their values and personal attributes, their biology, and their genetics and epigenetics.

Your conceptualization also helps you understand and build on your clients' positive attributes and skills. Helping clients become more aware of their strengths and resources can lead to better functioning and improved mood and resilience (Kuyken et al., 2009). It also helps you understand how and why obstacles to achieving their goals have arisen and been maintained.

There are many questions you should keep in mind throughout treatment to develop and refine your conceptualization. See Chapter 5 for a description of the evaluation session, in which you'll start to collect a great deal of information: clients' identifying information; chief complaint, major symptoms, mental status, and diagnosis; current psychiatric medications and concurrent treatment; significant relationships; best lifetime functioning; and various aspects of their history. You'll continue to gather data throughout treatment.

CBT is based on the cognitive model, which hypothesizes that people's emotions, behaviors, and physiology are influenced by their perception of events (both external, such as failing a test, and internal, such as distressing physical symptoms).

It's not a situation in and of itself that determines what people feel and do but rather how individuals construe a situation (Beck, 1964; Ellis, 1962). Imagine, for example, a situation in which several people are reading a basic text on CBT. They have quite different emotional and behavioral responses to the same situation, based on what is going through their minds as they read.

The way people feel emotionally and the way they behave are associated with how they interpret and think about a situation. The situation itself does not directly determine how they feel or what they do.

You will be particularly interested in the level of thinking that may operate simultaneously with a more obvious, surface level of thinking. As you're reading this text, you may notice these two levels. Part of your mind is focusing on the information in the text; that is, you are trying to understand and integrate factual information. At another level, however, you may be having some quick, evaluative thoughts about the situation. These cognitions are called automatic thoughts and are not the result of deliberation or reasoning. Rather, these thoughts seem to spring up spontaneously; they are often quite rapid and brief. You may barely be aware of these thoughts; you are far more likely to be aware of the emotion or behavior that follows.

Even if you are aware of your thoughts, you most likely accept them uncritically, believing they are true. You don't even think of questioning them. You can learn, however, to identify your automatic thoughts by attending to your shifts in affect, behavior, and/or physiology. Ask yourself, “ What was just going through my mind?” when

Having identified your automatic thoughts, you can, and probably already do to some extent, evaluate the validity of your thinking. For example, if you have a lot to do, you may have the automatic thought, “I’ll never get it all finished.” But you may do an automatic reality check, recalling past experiences and reminding yourself, “It’s okay. You know you always get done what you need to?”

When people find their interpretation of a situation is erroneous and you correct it, you probably discover that your mood improves, you behave in a more functional way, and/or your physiological arousal decreases. In cognitive terms, when dysfunctional thoughts are subjected to objective reflection, one's emotions, behavior, and physiological reaction generally change.

But where do automatic thoughts spring from? What makes one person construe a situation differently from another person? Why may the same person interpret an identical event differently at one time than at another? The answer has to do with more enduring cognitive phenomena: beliefs.

Beginning in childhood, people develop certain ideas about themselves, other people, and their world. Their most central or core beliefs are enduring understandings so fundamental and deep that they often do not articulate them, even to themselves. The person regards these ideas as absolute truths—just the way things “are” (Beck, 1987). Well-adjusted individuals primarily hold realistically positive beliefs much of the time. But we all have latent negative beliefs that can become partially or fully activated in the presence of thematically related vulnerabilities or stressors.

Adaptive Beliefs

Many clients, like Abe, had been predominantly psychologically healthy before the onset of their disorder; they were reasonably effective, had basically good relationships, and lived in environments that were mostly safe. If so, they most likely developed flexible, helpful, reality-based beliefs about themselves, their worlds, other people, and the future (Figure 3.1). They probably saw themselves as reasonably effective, likeable, and worthwhile. They had accurate and nuanced views about other people, seeing many of them as basically benign or neutral and only some as potentially hurtful (but they most likely believed they could reasonably protect themselves). They saw their world realistically too as composed of a mixture of predictability and unpredictability, safety and danger (but believed they could cope with most things that came their way). They perceived their future as having positive, neutral, and negative experiences (believing they could cope with misfortune—sometimes with the help of other people—and that they would be okay in the end).

FIGURE 3.1. Adaptive (positive) core beliefs about the self. Copyright © 2018 CBT Worksheet Packet. Beck Institute for Cognitive Behavior Therapy, Phila-delphia, Pennsylvania.

The latent negative counterparts to these beliefs might temporarily surface when these clients negatively interpret a setback related to their effectiveness, an interpersonal problem, or an action they took that was contrary to their moral code. But they probably reverted back to their more reality-based core beliefs after a short period of time—that is, unless they developed an acute disorder. When this happens, they may need treatment to help them reestablish their primarily adaptive beliefs. The situation is different for other clients, though, especially those with personality disorders, like Maria. Their positive, adaptive beliefs may have been fairly weak or actually nonexistent when they were growing up and on into adulthood, and they usually need treatment to help them develop and strengthen adaptive beliefs.

Note that some clients hold overly positive beliefs, especially if they're manic or hypomanic. They may see themselves, others, the world, and/or the future in an unrealistically positive light. When these beliefs are dysfunctional, they may need help in viewing their experiences more realistically, which is in a negative direction.

Dysfunctional Negative Beliefs

People who have a history of being less psychologically healthy, or who live in more dangerous physical or interpersonal environments, tend to function more poorly; they may have troubled relationships, and they may hold core beliefs that are more negative. These beliefs may or may not have been realistic and/or helpful when they first developed. In the presence of an acute episode, however, these beliefs tend to be extreme, unrealistic, and highly maladaptive. Negative core beliefs about the self tend to fall into three categories (Figure 3.2):

Clients may hold beliefs in one, two, or all three of these categories, and they may hold more than one belief in a given category.

Case Example

Reader E, who thought she was too unintelligent to master this text, frequently has a similar concern when she has to engage in a new task (e.g., renting a car, figuring out how to put together a bookcase, or applying for a bank loan). She seems to have the core belief "I'm incompetent." This belief may operate only when she is in a depressed state; it may be active some or much of the time; or it may be fairly dormant. When this core belief is active, Reader E interprets situations through the lens of this belief, even though the interpretation may, on a rational basis, be patently invalid.

FIGURE 3.2. Dysfunctional core beliefs about the self.

Reader E tends to selectively focus on information that confirms her core belief, disregarding or discounting information to the contrary. For example, Reader E did not consider that other intelligent, competent people might not fully understand the material in their first reading. Nor did she entertain the possibility that the author had not presented the material well. She didn't recognize that her difficulty in comprehension could be due to a lack of concentration, rather than a lack of brainpower. She forgot that she often had difficulty initially when presented with a body of new information but later had a good track record of mastery. Because her incompetence belief was activated, she automatically interpreted the situation in a highly negative, self-critical manner. In this way, her belief is maintained, even though it’s inaccurate and dysfunctional. It is important to note that she’s not purposely trying to process information in this way; it occurs automatically.

Figure 3.3 illustrates this distorted way of processing information. The circle with a rectangular opening represents Reader E's schema. In Piagetian terms, the schema is a hypothesized mental structure that organizes information. Within this schema is Reader E's core belief: “I'm incompetent.” When Reader E is exposed to a relevant experience, this schema becomes active, and the data, contained in negative rectangles, are immediately processed as confirming her core belief, which makes the belief stronger.

FIGURE 3.3. Information processing diagram. This diagram demonstrates how negative data are immediately processed, strengthening the core belief, while positive data are discounted (changed into negative data) or unnoticed.

But a different process occurs when Reader E encounters an experience in which she does well. Positive data are encoded in the equivalent of positive triangles, which cannot fit into the schema. Her mind automatically discounts the data. (“Yes, the session with my client went well, but that’s because she was so eager to please me.”) These interpretations, in essence, change the shape of the data from positive triangles to negative rectangles. Now the data fit into the schema and, as a result, strengthen the negative core belief.

There are also positive data that Reader E just does not notice. She doesn’t negate some evidence of competence, such as paying her bills on time or helping a friend with a problem. But had she failed to take these actions, she probably would have interpreted her inaction as supporting her dysfunctional core belief. Though she doesn’t discount the positive data, she doesn’t seem to notice or process these positive data as being relevant to her core belief; this kind of data bounces off the schema. Over time, Reader E's core belief of incompetence becomes stronger and stronger.

Abe, too, has a core belief of incompetence. Fortunately, when Abe is not depressed, a different schema (which contains the core belief, “I'm reasonably competent”) is active most of the time, and his belief “I’m incompetent” is latent. But when he’s depressed, the incompetence schema predominates. One important objective of treatment is to help Abe view his experiences (both positive and negative) in a more realistic and adaptive way.

Core beliefs are the most fundamental level of belief; when clients are depressed, these beliefs tend to be negative, global, rigid, and overgeneralized. Automatic thoughts, the actual words or images that go through a person’s mind, are situation specific and may be considered the most superficial level of cognition. Intermediate beliefs exist between the two. Core beliefs influence the development of this intermediate class of beliefs, which consists of (often unarticulated) attitudes, rules, and assumptions. Note that many attitudes indicate clients’ values. Reader E, for example, had the following intermediate beliefs:

• Attitude: “It’s terrible to fail.”
• Rule: “Give up if a challenge seems too great.”
• Assumptions: “If I try to do something difficult, I’ll fail. If I avoid doing it, I’ll be okay.”

These beliefs influence his view of a situation, which in turn influences how she thinks, feels, and behaves. The relationship of these intermediate beliefs to core beliefs and automatic thoughts is depicted below:

How do core beliefs and intermediate beliefs arise? People try to make sense of their environment from their early developmental stages. They need to organize their experience in a coherent way in order to function adaptively (Rosen, 1988). Their interactions with the world and other people, influenced by their genetic predisposition, lead to certain understandings: their beliefs, which may vary in their accuracy and functionality. Of particular significance to the CBT therapist is that dysfunctional beliefs can be unlearned, and more reality-based and functional new beliefs can be developed and strengthened through treatment.

The quickest way to help clients feel better and behave more adaptively is to help them identify and strengthen their more positive adaptive beliefs and to modify their inaccurate beliefs. Once this is accomplished, clients tend to interpret current and future situations or problems in a more constructive way. In most cases we can work both directly and indirectly on positive beliefs from the beginning of treatment. But we usually need to work indirectly on negative core beliefs at first and more directly later on. Even the identification of negative core beliefs can trigger significant negative affect that can lead clients to feel unsafe.

The hierarchy of cognition, as it has been explained to this point, can be illustrated as follows:

It is important to note that the sequence of the perception of situations leading to automatic thoughts that then influence people's reactions is an oversimplification at times. Thinking, mood, behavior, physiology, and the environment can affect one another.

There are also many different kinds of internal and external triggering situations about which clients have automatic thoughts:

• Discrete events (such as failing to get a job offer)
• A stream of thoughts (such as thinking about being unemployed)
• A memory (such as getting fired from a job)
• An image (such as a disapproving face of a professor)
• An emotion (such as noticing how intense one’s dysphoria is)
• A behaviour (such as staying in bed)
• A physiological or mental experience (such as noticing one’s rapid heartbeat or slowed-down thinking).

Individuals may experience a complex sequence of events with many different triggering situations, automatic thoughts, and reactions. (See Chapter 12, pp. 217-218, for an example of an extended cognitive model.)

At intake, it's clear that Abe is suffering from persistent sadness, anxiety, and loneliness. I diagnose hint with major depression, severe, with anxious distress. I ask some specific questions to help me develop an initial conceptualization. For example, I ask Abe when he generally feels the worst—which situations and/or times of day. He tells me that he pretty much feels the same all day long, but perhaps a little worse in the evenings. Then I ask him how he felt the previous evening. When Abe confirms that he was as depressed as usual, I ask, "What was going through your mind?"

Right from the beginning, I obtain a sample of important automatic thoughts. Abe reports that he often thinks, "There's so much I should be doing but I'm so tired. If I even try [to do things like cleaning up the apartment], I'll just do a bad job" and "I feel so down. Nothing will make me feel better." He also reports an image, a mental picture that had flashed through his mind. He saw himself, sometime in the indeterminate future, sitting in the dark, feeling utterly hope-less and helpless.

I also look for factors that maintain Abe's depression. Avoidance is a major problem. He avoids cleaning up his apartment, doing errands, socializing with friends, looking for a new job, and asking others for help. Therefore, he lacks experiences that could have given him a sense of mastery, pleasure, or connection. His negative thinking leads to his being inactive and passive. His inactivity and passivity reinforce his sense of being helpless and out of control.

As a child, Abe tried to make sense of himself, others, and his world, learning from, for example, his experiences, interactions with others, and direct observation. His perceptions were also undoubtedly influenced by his genetic inheritance. Early experiences within the family laid the groundwork for his core belief of competence and incompetence.

Abe was the oldest of three boys. When he was 11, his father left the family and never returned. His mother, a single parent, worked two jobs and relied heavily on him. Once his father left, she often asked Abe to do things that were quite difficult—for example, keeping the house clean, doing the laundry, and taking care of his younger brothers. Abe had a strong value of being a good son, accomplishing what was asked of him and helping others. He expected himself to be able to do everything his mother asked, but he was often not up to the task. He had thoughts such as "I should be doing this [task] better"; "I should be helping Mom more"; and "I should be able to make them [his brothers] behave." On the few occasions when he asked his mother what he should do to control his brothers behavior better, she said irritably, "Figure it out for yourself."

Not all youth in this kind of situation perceive themselves as lacking. Some youth, for example, blame their mothers for expecting too much. Abe's mother did, in fact, expect too much of him, for his age and developmental level. She criticized him when she came home and saw his brothers "running wild" or found the kitchen messy. At these times, she became upset and told Abe, "You can't do anything right. You're letting me down." Abe thought what she said was true, and he felt distressed. He then often retreated to his room and ruminated over his shortcomings.

Over time, Abe's belief that he was reasonably competent began to erode, in the specific context of his home life. He began to notice what he considered to be his failures. Even when he saw he was doing a good job, he tended to discount his accomplishments. "I cleaned up the kitchen, but the living room is still messy"; "I got them [brothers] to do their homework, but I couldn't make them stop fighting." No wonder Abe began to feel incompetent. The result of putting too much weight on his perceived weaknesses and discounting or failing to notice his strengths led to the development of his core belief: "I'm incompetent."

Abe's negative belief was fairly circumscribed to "failures" at home. He received average grades at school, as did his friends. His teachers and mother generally seemed satisfied with his performance, so he was satisfied too. He was an above-average athlete and received praise and support from his coaches. So Abe saw himself as reasonably competent in the context of school and sports. He also saw himself as reasonably likeable and worthwhile.

Abe's beliefs about his world and other people were, for the most part, realistically positive and adaptive. He generally believed that many people were benign—or would be benign as long as he performed well. He saw his world as relatively safe. Influenced by his father's abandonment of the family, he saw the world as potentially unpredictable, but he also thought he'd be able to cope with most circumstances. He viewed his future as unknown but potentially pretty good.

Abe was at his best when he finished high school, became employed, and moved into an apartment with a friend. During this time, his adaptive core beliefs were mostly active. He did well on the job, socialized often with good friends, exercised and kept himself in good shape, and started saving money for the future. He was honest, forthright, responsible, and a hard worker. He was pleasant to be around, often helping family and friends without being asked. He married at age 23, a year after meeting his wife. Although she tended to criticize him, he nevertheless saw himself as basically competent, worthwhile, and likeable. But he had an underlying vulnerability of viewing himself as incompetent when he didn't live up to his self-imposed high expectations. This vulnerability developed primarily as a result of negative interactions with his mother when he was a youth.

Abe became more stressed once his children were born, and he sometimes criticized himself for not spending enough time with them. His wife was stressed too and became more critical of him. But he didn't become depressed at this point. He continued to function well as long as he perceived that he was performing at a high level at work and at home. His related belief was "If I perform highly, it means I'm okay." A problem arose when he perceived himself as functioning at a lower level, associated with his belief "If I don't perform highly, it shows I'm incompetent." It wasn't until he put a very negative meaning on his difficulties at work and on the dissolution of his marriage that his previously latent negative core beliefs became strongly activated. In addition, he saw himself as helpless and out of control (which he described as related to incompetence/failure).

Abe's Intermediate Beliefs and Values

Abe's intermediate beliefs were somewhat more amenable to modifica-tion than his core beliefs. These attitudes (such as "It's important to work hard, be productive, be responsible, be reliable, be considerate to others, honor commitments, do the right thing, and give back to others") reflected his values and his behavior, as did his rules (e.g., "I should work hard"). They developed in the same way as core beliefs, as Abe tried to make sense of his world, of others, and of himself. Mostly through interactions with his family, and to a lesser degree with oth-ers, he developed the following assumptions:

"If I work hard, I'll be okay (but if I don't, I'll be a failure)."
"If I figure things out for myself, I'll be okay (but if I ask for help, it will show I'm incompetent)."

Abe had not fully articulated these intermediate beliefs or values before therapy. But they nevertheless influenced his thinking and guided his behavior.

Abe's Behavioral Strategies

Beginning in adolescence, Abe developed certain patterns of behavior, which were mostly quite functional, to live up to his values and to avoid the activation of his core belief (and the emotional discomfort connected with it). He worked hard when he was at home, when playing sports, and when he got his first job. He set high standards for himself at work and went out of his way to help other people. On the other hand, Abe rarely asked for help, even when it was reasonable to do so. He feared others would criticize him and view him as incompetent. He felt vulnerable at times and tried to make up for what he saw as his weaknesses. While Abe's assumptions were fairly inflexible, he nevertheless got along well in life—until he perceived himself as incompetent and not living up to his values.

Sequence Leading to Abe's Depression

Throughout his life, Abe regularly had some negative thoughts about himself, particularly in situations in which he perceived his performance was subpar. "I should have done that better" was a common thought he had had growing up and later at work and at home, especially after he married and had children. The thoughts usually led to mild dysphoria, but when he resolved to put in more effort, he generally felt better.

These kinds of automatic thoughts became fairly frequent and intense preceding the onset of Abe's depressive episode, in the context of work, marriage, and home life. He had a new boss, Joseph, a man 15 years younger than he. Joseph changed Abe's work responsibilities. Abe had been in charge of customer service at a lighting company. He enjoyed working with customers and interacting with the two employees whom he supervised.

But Joseph moved him over to inventory management, which entailed little interaction with others and required him to use a software program with which he was unfamiliar. Abe started making mistakes and became highly self-critical. He had thoughts such as "What's the matter with me? This shouldn't be so hard." He interpreted his difficulties with his new responsibilities as due to his own incompetence. He became dysphoric and anxious. But he didn't become depressed—not yet.

Abe finally asked for help, but Joseph growled at him, saying that Abe should be able to figure out what to do. Instead of continuing to ask for help, Abe tried harder, but he still couldn't understand how to fulfill some of his new responsibilities. When he even considered asking for help again, he thought, "Joseph will think less of me. What if he says I'm incompetent? I could get fired." His beliefs of incompetence and vulnerability became stronger.

Soon his negative emotions started to spill over at home, as he ruminated over his perceived failures. When he developed symptoms of depression (especially a depressed mood and great fatigue), he changed his activities. He started to withdraw from others, including his wife. At dinner, he would sit almost silently, despite his wife's efforts to get him to open up. After dinner, instead of doing household tasks, he mostly sat in his armchair, ruminating over his perceived failings. On weekends, he sat on the couch for hours at a time, watching television. His wife became very impatient with him when he was reluctant to make social plans, when he helped much less around the house, and when he spoke little to her. She began to nag and criticize him much more than before. His own self-critical thoughts became more and more intense too. His avoidance led to few opportunities for him to feel competent, in control, productive, and connected to others—crucial values of his—and to a dearth of pleasurable or enjoy-able activities that could have lifted his mood.

As he developed stronger symptoms of depression, he started avoiding additional tasks he thought he wouldn't do well, for example, paying bills and doing yard work. He had many automatic thoughts across situations about the likelihood that he would fail. These thoughts led him to feel sad, anxious, and hopeless. He viewed his difficulties as due to an innate flaw and not as the result of encroaching depression. He developed a generalized sense of incompetence and helplessness and curtailed his activities further. His relationship with his wife became quite strained, and they started having significant conflict. He interpreted the conflict as meaning he was failing in the marriage, that he was incompetent as a husband.

Over the course of several months, Abe's problems at work became even worse. Joseph became quite critical of Abe and downgraded him at his yearly performance review. Abe's depression intensified significantly when his wife filed for divorce. He became preoccupied with thoughts of how he had let her and his children and his boss down. He felt like (that is, he had a belief that he was) an incompetent failure. He felt (believed he was) at the mercy of his sad and hopeless feelings ("I'm out of control") and thought there was nothing he could do to feel better ("I'm helpless"). And then he lost his job.

This sequence of events illustrates the diathesis-stress model. Abe had certain vulnerabilities: very strong and rigid values of productivity and responsibility, biased information processing, a tendency to see himself as incompetent, and genetic risk factors. When these vulnerabilities were exposed to relevant stressors (loss of job and marriage), he became depressed.

Abe's depression became maintained by the following factors or mechanisms:

• An ongoing negative interpretation of his experiences
• Attentional bias (noticing everything he wasn't doing well or not doing at all)
• Avoidance and inactivity (which resulted in few opportunities for pleasure, a sense of accomplishment, and connection)
• Social withdrawal
• Increased self-criticism
• Deterioration of problem-solving skills
• Negative memories
• Rumination over perceived failures
• Worrying about the future

These factors negatively affected Abe's self-image and helped maintain his depression. They became important targets in treatment.

Abe's Strengths, Resources, and Personal Assets

Even though Abe was severely depressed when he first came to see me, his life wasn't unremittingly negative. His children and their spouses offered him support. His mood lifted somewhat when he interacted with his grandchildren, especially around sports. He was still doing very basic self-care. Although his funds were dwindling, he had some money in savings. He was able to do a minimal amount of housework and meal preparation. Historically, he had been a highly responsible, hardworking husband, father, and employee. lie had learned many skills on the job that were potentially transferable to other jobs. He had good common sense and had been a good problem solver.

To summarize, Abe's belief that he was incompetent stemmed from childhood events, especially through interaction with his critical mother, who kept telling him that he was doing a poor job (at tasks beyond his abilities) and that he was letting her down. Nonetheless, he had neutral or relatively positive school experiences, and his dominant core belief was that he was okay. Years later, significant stress at work and at home contributed to the activation of his core belief of incompetence and to his use of maladaptive coping strategies, most notably avoidance, which triggered his belief of helplessness. He avoided asking for help, he withdrew from his wife and friends, and he sat on the couch for hours instead of being productive. In addition, he became highly self-critical. Ultimately, Abe became depressed, and his mal-adaptive core beliefs became fully active.

Complex Cognitive Model Sequence

1. Situation: Sally feels exhausted (physiological trigger) when she wakes up.
2. Automatic thought: "I'm too tired to get up. There's no use in getting out of bed. I don't have enough energy to go to class or study."
3. Emotion: Sadness
4. Physiological response: Heaviness in body.
5. Automatic thoughts: "What id [my chemistry professor] gives a pop quiz? What if he won't let me take a makeup quiz? What if this counts against my grade? [image of a failing mark on her transcript]"
6. Emotion: Anxiety
7. Physiological response: Heart starts to beat quickly.
8. Situation: Notices rapid heartbeat.
9. Automatic thought: "My heart's beating so fast. What's wrong with me?"
10. Emotion: Increased anxiety
11. Physiological response: Body feels tense, heart continues to beat rapidly.
12. Automatic thought: "I'd better just stay on bed."
13. Emotion: Relief
14. Physiological response: Tension and heart rate reduced.
15. Behaviour: Stays in bed.

Sally eventually gets up, arrive at class 20 minutes after it started, then has a host of automatic thoughts about being late and missing part of the lecture.