Manual/Protocol Clinic REBT/CBT Pentru Depresie

Managing Depression Using

Rational Emotive Behavior
Therapy (REBT)
To be Used Free for Research, Edcational, and Training !rposes
"c#no$ledgements%
This REBT manual/protocol for depression is based on the rational-emotive &
cognitive-behavioral therapy (REBT/CBT) manuals elaborated at !ount "inai "chool of
!edicine #"$ by a team of psychologists (%r& %aniel %avid %r& !aria 'angas %r& (ulie
"chnur) together and under the supervision of %r& )uy !ontgomery (principal
investigator $merican Cancer "ociety grant *R")+BC++B-,-.-/0)& The e1ternal
consultant for the REBT depression manual/protocol 2as %r& Raymond %i)iuseppe from "t&
(ohns3s #niversity & $lbert Ellis 4nstitute #"$&
To cite this REBT depression manual/protocol5
%avid %& 'angas !& "chnur (&B& & !ontgomery )&6& (7--8)&REBT depression manual;
Managing depression using rational emotive behavior therapy& Babes-Bolyai #niversity (BB#)
Romania&
The preliminary and final Romanian versions of the REBT manual/protocol for depression
2ere used in a randomi9ed clinical trial in Romania5
%avid %& "9entagotai $& :upu ;& & Cosman %& (7--.)& Rational emotive behavior
therapy cognitive therapy and medication in the treatment of ma<or depressive disorder5 $
randomi9ed clinical trial post-treatment outcomes and si1-month follo2-up& Journal of Clinical
Psychology, ! =7.-=80&
To cite the Romanian REBT manual/protocol for depression (used in Romania)5
%avid %& (ed&) (7--0)& Rational Treatment& Tritonic +ress& Bucharest&
%avid %& (ed&) (7--=)& Clinical protocol of rational"emotive therapy for depression# The
treatment of depression by rational emotive therapy& "ynapsis +ublisher& Clu<->apoca&
The ma<or handboo?s and general REBT manuals that are the bac?ground of this REBT
depression manual/protocol are5
@ Ellis $& & )rieger R&!& (,A==)& $andboo% of rational"emotive therapy& >e2
Bor?5 "pringer +ublishing Co&
@ Calen "&R& %i)iuseppe R& & %ryden C& (,AA7)& & practitioner's guide to
rational"emotive therapy (7
nd
ed&)& >e2 Bor? >B #"5 D1ford #niversity +ress&
Fore$ord%
This REBT depression manal&protocol is an evidence'based one tested in
a randomi(ed clinical trial investigating the relative efficacy of rational-emotive
behavior therapy(REBT) cognitive therapy ()T) and pharmacotherapy(flo*etine) in
the treatment of +,- otpatients $ith non'psychotic ma.or depressive disorder
(David et al/, 0--1)& +atients 2ere randomly assigned to one of the follo2ing5 ,8 2ee?s
of REBT ,8 2ee?s of CT or ,8 2ee?s of pharmacotherapy& The continos
otcome measures used 2ere the 6amilton Rating "cale for %epression (2R3D) and the
Bec? %epression 4nventory (BD4)5 the categorical measre 2as 3)4D& 4n the REBT
condition at +6 $ee#s theresponse rates (6R"%E,7) 2ere 789 and the recovery
rates (6R"%E=) 2ere 689& $t si*'month follo2-up theresponse rates (6R"%E,7)
2ere ,89 and the recovery rates (6R"%E=) 2ere 809& >o differences among
treatment conditions at posttest 2ere observed& $ larger effect of REBT (significant) and
CT (nonsignificant) over pharmacotherapy at 0 months follo2-up 2as noted on the 6R"%
only&
REBT DE!RE334:; M";U"<&!R:T:):<
I. Therapists Research Guide
II. Therapist-Patient Interaction Guide
1. Aim of the REBT Depression Manual
. Definitions
(a) Depression Basics
(b) What is Rational Emotive Behavior Therapy?
1) What are Cognitive Techniques?
) What are Behavioral Techniques?
!) What are Emotive Techniques
!. Mana"in" Depression #ith $o"niti%e Techni&ues' The Po#er of (ur Thou"hts
(a) Relearning our "#B#Cs
(b) $o% to Thin& in a 'ore (ositive an) 'ore Rational Way # The "lphabet "pproach ("#
B#C#D#E#*)
). Mana"in" Depression #ith Beha%ioral Techni&ues
(a) "ctivity +che)uling,(lanning
(b) Distraction Techniques
*. Mana"in" Depression #ith Emoti%e Techni&ues
(a) $umorous 'etho)s
(b) +hame#"ttac&ing E-ercises
+. Be,ond REBT Treatment
-APPE.DI/
(1) +tu)y .nstructions
() +pare Copies o/ 0Depression "#B#C#D#E#* +el/ $elp *orm1
(!) E-ample o/ +che)uling *orm
(2) +pare Copies o/ 0+che)uling *orm1
(3) +pare Copies o/ 0Emotive Techniques#'onitoring *orm1
4/ T2ER"!43T RE3E"R)2 =U4DE5
+/ !atients%
The present REBT manal&protocol shold be sed $ith depressed patients
(e/g/, $ho meet criteria for Ma.or Depressive Disorder, according to the D3M'
4>)/ 4n the clinical trial run based on this manual (%avid et al& 7--.) 2e had some
additional inclusion and e1clusion criteria& 4nclusion criteria included a score of at least 7-
on the Bec? %epression 4nventory and a score of ,8 or higher on the ,=-item 6amilton
Rating "cale for %epression& E1clusion criteria included a number of psychiatric disorders
(i&e& bipolar or psychotic subtypes of depression panic disorder current substance abuse
past or present schi9ophrenia or schi9ophreniform disorder organic brain syndrome and
mental retardation)& +atients 2ho 2ere in some concurrent form of psychotherapy 2ho
2ere receiving psychotropic medication or 2ho needed to be hospitali9ed because of the
imminent suicide potential or psychosis 2ere also e1cluded (based on the clinical protocol
of (acobson et al& ,AA0)&
0/ REBT 4ntervention (0- sessions)%
The treatment is based on the techniFues and descriptions in the REBT manuals (Ellis
& )rieger ,A==G Callen %i)iuseppe & %ryden ,AA7)& $fter e1plaining the basic rules of
therapy (scheduling confidentiality etc&) rationale of REBT and the $%C%E model the
goals of REBT are discussed 2ith the patients& The overall elegant REBT treatment is
focused on the irrational beliefs mediating depressive symptoms5 demandingness (%E!)
self-do2ning ("%) a2fuli9ing ($CH) and lo2 frustration tolerance (:HT)& Cognitive (i&e&
disputation) behavioral and emotive techniFues 2ill be used to change the target
irrational beliefs& $utomatic thoughts and faulty inferences are not the focus of
interventions& "lso, distinctive elegant REBT strategies $ill be focsed on% (+)
redcing secondary problems5 (0) promoting nconditional self'acceptance5 and
(?) focsing on the identification and modification of DEM as the central
irrational belief involved in depression& 4n REBT if %E! is not readily recogni9able
among the cognitions collected as home2or? as 2ell as verbali9ations during therapy
sessions its presence is inferred from its derivates (i&e& self-do2ning a2fuli9ing and lo2
frustration tolerance)& The hypothesis regarding the presence of %E! is tested by as?ing
patients about it directly Ie&g& patient5 Jit is a2ful that 4 did not pass the e1am&K
(a2fuli9ing)G therapist5 Jit sounds li?e you had to pass that e1am rightLK (%E!)M&
6o2ever the disputation of inferred %E! is made only if the patient accepts the clinical
conceptuali9ation including %E!&
The REBT intervention consists of a ,8 2ee?s clinical trial I,7 2ee?s of full treatment
and 7 2ee?s of follo2-up meetings (one meeting each 2ee?) focused on therapy
terminationM involving a ma1imum of 7- individual N--minute therapy sessions5
Cee?s ,-8 (initial phase5 7 sessions each 2ee?)
@ "ession , (introduction)
o Clinical diagnosis/assessment and )eneral clinical conceptuali9ation
o Building a therapeutical relationship (i&e& empathy collaboration
congruence unconditional acceptance of patient as person)
o REBT education and Treatment e1pectations
o +roblems list
@ "essions 7-.
o Each problem from the list is approached based on the $BC(%EH)
model of REBT
Cee?s N-. (middle phase5 7 sessions each 2ee?)
@ "essions A-,0
o Cor?ing to2ard strengthening the patients3 rational beliefs and
2ea?ening the irrational beliefs
o Encourage the patients to see the lin?s bet2een problems
particularly those 2hich are characteri9ed by common irrational beliefs
Cee?s A-,7 (final phase5 , session each 2ee?)
@ "essions ,=-7-
o +repare patients for the tas? of becoming his/her o2n future
therapist
o %iscuss dependency problems and relapse prevention
"tructure of the first session5
@ "tarting to build an emphatic and collaborative therapeutic relationship
@ "etting the agenda (and providing a rationale for doing so)
@ %oing a mood chec? including ob<ective scores
@ Briefly revie2ing the presenting problems and obtaining an update (since
evaluation)
@ 4dentifying problems and setting goals
@ Educating the patient about the REBT model
@ Eliciting the patients3 e1pectations for therapy
@ Educating the patient about her/his disorder and psychotherapy process
@ "etting the home2or?
@ +roviding a summary and eliciting feedbac?
"tructure of session t2o and beyond5
@ Chec?ing and maintaining the therapeutical relationship
@ Brief update and chec? on mood (and medication alcohol and/or drug
use etc&)
@ Bridge from previous session
@ "etting the agenda
@ Revie2 of home2or?
@ %iscussion of issue on the agenda setting ne2 home2or? and periodic
summaries
@ Hinal summary and feedbac?
Hundamental aspects to follo2 during REBT intervention5
@ The cognitive conceptuali9ation of the problem based on the $BC model
@ The use of a large repertoire of cognitive behavioral and emotive techniFues
to change the irrational beliefs into rational beliefs
@ The steps of REBT interventions5 (,) behavioral activationG (7) focus on
changing specific irrational/rational beliefsG and (/) focus on changing general
rational and irrational beliefs
@ The use of home2or?
@ $ special focus on %E! promoting unconditional self-acceptance and
reducing secondary disturbances
?/ REBT Manals for Detailed 4ntervention 3trategies%
@ Ellis $& & )rieger R&!& (,A==)& $andboo% of rational"emotive therapy& >e2
Bor?5 "pringer +ublishing Co&
@ (acobson >&"& %obson '&"& Trua1 +&$& $ddis !&E& 'o2ener $&'& )ollan (&'&
et al& (,AA0)& $ component analysis of cognitive-behavioral treatment for
depression& Journal of Consulting and Clinical Psychology, ! 7AN-/-8&
@ Calen "&R& %i)iuseppe R& & %ryden C& (,AA7)& & practitioner's guide to
rational"
emotive therapy (7
nd
ed&)& >e2 Bor? >B #"5 D1ford #niversity +ress&
44/ T2ER"!43T'!"T4E;T 4;TER")T4:; =U4DE
+/ "im of the REBT Depression Manal%
The aim of this manual is to teach you a variety of s?ills to help you manage any
depressive symptoms or depression-related problems you might e1perience& !ore specifically
2e are going to teach you ho2 to use Rational Emotive Behavior Therapy (REBT)&
Research has found that appro1imately =NO of patients 2ho undergo REBT 2ill e1perience an
improvement in their depression symptoms& This manual 2ill teach you ho2 to help yourself
feel less depressed and more energetic and to cope as best as you can 2ith any symptoms
you may e1perience& Research has sho2n that the s?ills 2e3ll teach you are helpful in
managing emotional distress&
0/ Definitions%
(a) Depression Basics
@This brief presentation is based on the free&pblic edcational te*ts
from http%&&$$$/depresion/com (A +BB,'0--1 =la*o3mithCline% paragraphs +, ?,
and 6) andhttp%&&$$$/nimh/nih/gov&health&pblications&depression'a'treatable'
illness/shtml (paragraph 0)D
J"ome people say that depression feels li?e a blac? curtain of despair coming do2n
over their lives& !any of them feel li?e they have no energy and can3t concentrate& Dthers feel
irritable all the time for no apparent reason& The symptoms vary from person to person but if
you feel Jdo2nK for more than t2o 2ee?s and these feelings are interfering 2ith your daily
life you may be clinically depressed&K ()la1o"mith'line)&
J$ depressive disorder is a problem that involves the body mood and thoughts& 4t
affects the 2ay a person eats and sleeps the 2ay one feels about oneself and the 2ay one
thin?s about things& $ depressive disorder is not the same as a passing blue mood& 4t is not a
sign of personal 2ea?ness or a condition that can be 2illed or 2ished a2ay& +eople 2ith a
depressive illness cannot merely Jpull themselves togetherK and get better& Cithout treatment
symptoms can last for 2ee?s months or years& $ppropriate treatment ho2ever can help
most people 2ho suffer from depression&K (>46)&
J!ost people 2ho have gone through one episode of depression 2ill sooner or later
have another one& Bou may begin to feel some of the symptoms of depression several 2ee?s
before you develop a full-blo2n episode& :earning to recogni9e these early triggers
or symptoms and 2or?ing 2ith your therapist 2ill help to ?eep the depression from
2orsening&K ()la1o"mith'line)&
J!ost people 2ith depression never see? help even though most of them 2ill respond
to treatment& Treating depression is especially important because it affects you your family
and your 2or?& "ome people 2ith depression try to harm themselves in the mista?en belief
that the 2ay they feel 2ill never change& %epression is a treatable disorder&K
()la1o"mith'line)&
(b) Ehat is Rational Emotive Behavior Therapy (REBT)F
Rational Emotive Behavior Therapy (REBT) is the first form of cognitive
behavior therapy (CBT) and 2as created by %r& $lbert Ellis in ,ANN& $ccording to the
REBT model people e1perience undesirable activating events about 2hich they have
rational beliefs (RBs) and irrational beliefs (4Bs)& These beliefs then lead to emotional
behavioral and cognitive conseFuences& Rational beliefs lead to functional
conseFuences 2hile irrational beliefs lead to dysfunctional conseFuences& Clients 2ho
engage in REBT are encouraged to actively dispute their 4Bs and to assimilate more
efficient adaptive and rational beliefs 2ith a positive impact on their emotional
cognitive and behavioral responses (Ellis ,A07G ,AA8G Calen et al& ,AA7)& Thus
REBT is a psychological theory and a treatment consisting of a combination of three
different types of techniFues (cognitive behavioral and emotive) you can use to help
yourself feel better physically and emotionally and to engage in healthier behaviors&
(+) Ehat are )ognitive TechniGesF
Cognitive techniFues are specific strategies to change or modify unhelpful and/or negative
thoughts concerning a particular event& (Hor e1ample learning to change one3s thoughts to cope
better 2ith one3s depression)&
(0) Ehat are Behavioral TechniGesF
Behavior techniFues involve learning practical techniFues that help you to cope in
demanding or stressful situations such as depression and/or loss& E1amples of behavioral strategies
include learning ho2 to plan and manage your daily schedule and learning ho2 to distract yourself
from negative thoughts&
(?) Ehat are Emotive TechniGesF
Emotive techniFues are designed to help you change your negative thoughts by emotional
means& 6umorous methods poems songs etc& generate feelings that help challenge and change
negative thoughts&
?/ Managing Depression $ith )ognitive TechniGes% The
!o$er of :r Thoghts%
$lthough 2e may not al2ays be a2are of our thoughts they nevertheless can have a strong
effect on ho2 2e feel and behave in response to a particular situation or event&
(a) Re'learning or "'B')s%
$ccording to the cognitive theory the effect that our thoughts can have on our physical
behavioral and emotional responses to a particular situation can be illustrated using the follo2ing
diagram5
$ P "ctivating event or situation that 2e e1perience
Q
BP Beliefs or thoughts regarding the situation
Q
C P )onseFuence5 6o2 2e feel or act based on these beliefs
:et3s illustrate this model using an e1ample5
E*ample +%
!erson +% & (&ctivating )ituation* + $ friend does not return your phone call
B (Beliefs,Thoughts* + J- must have done something to upset them. -
am such a horrible person./
C (Conse0uence,Effect* + $n1ious upset depressed
!erson 0% & (&ctivating )ituation* + $ friend does not return your phone call
B (Beliefs,Thoughts* + 1They're probably 2ust really busy, and haven't
had time to get bac% to me yet./
C (Conse0uence, Effect* + Content neutral
The above e1ample sho2s ho2 t2o people may e1perience the same situation (e&g& having
a friend not return one3s telephone call) but have very different reactions to the event based on
ho2 they interpret and evaluate the situation according to their thoughts and beliefs&
(b) 2o$ to thin# in a more positive and more rational $ay ' The alphabet approach
("'B')'D'E'F)%
4n this section 2e3ll describe ho2 to use the %epression $-B-C-%-E-H "elf 6elp forms 2e
have included at the end of this manual&
4t might be helpful if you loo? at the form 2e filled out together 2hile you read through this
section in order to revie2 our approach&
Recommendation% :earning to observe and change one3s thoughts ta?es practice& :i?e
any ne2 s?ill 2e learn (e&g& riding a bi?e or learning to program our ;CR) the more 2e practice
the better 2e get& Therefore $e recommend that yo complete at least one of these forms
per day& Blan? copies of this form are located at the end of this boo?let& Dne of our research staff
2ill collect these forms from you during the course of your treatment&
4f you need e1tra forms at any point <ust as? our research staff&
D? no2 let3s beginR
Lets start at the very beginning - As (Activating Events)
Dn the top of the form on the left hand side you 2ill see a bo1 labeled J$ ($ctivating
Events)&K
4n this bo1 2e 2ould li?e you to 2rite about an upsetting event that happened to you
today& Ce have provided some e1amples of upsetting events belo2 the bo1 but you should fill in
e1amples that are personal to you&
Ce 2ould li?e to particularly encourage you to focus on monitoring the times 2hen you feel
particularly sad or 2hen you are tired/fatigued&
4f there is a day 2here nothing particularly upsetting happens 2e 2ould li?e you to fill in
this J$K bo1 2ith either (a) an upsetting event that happened to you in the past or (b) an upsetting
event you3ve made up&
EH"M!<E% J4 feel depressed because of my unsuccessful life and 2onder ho2 4 am
going to get through the rest of the day&K
Before 2e move on to B3s let3s first focus on C3s&
Cs - Consequences following the events
Dn the top of the form on the right hand side you 2ill see a bo1 labeled JC
(ConseFuences)K&
4n this bo1 2e 2ould li?e you to 2rite the conseFuences of the event&
There can be three types of conseFuences& Bou may e1perience one t2o or all three of
them5
o Unhealthy negative feelings& Belo2 the bo1 2e have included a fe2 e1amples
of unhealthy negative feelings (e&g& depressed mood fear rage)& 6o2ever 2e encourage you to
2rite in 2hatever 2ords best describe your e1perience&

o Unhelpful behaviors& Belo2 the bo1 2e have included some e1amples of

unhelpful behaviors& These are things you do that are unproductive or harmful in some 2ay&

o Negative hysical Consequences of !istress& Chen people e1perience an

upsetting event they may e1perience some physical symptoms& Hor e1ample if you argue 2ith a
friend you may find yourself flushed hot or sha?ing& Ce have listed some e1amples of physical
conseFuences belo2 the bo1 but again please 2rite any physical reactions you e1perience&
>ote5 $lthough many physical symptoms can be caused or 2orsened by
stress 2hile you are in treatment all physical symptoms should be ta?en seriously and discussed
2ith your treatment team&
EH"M!<E% J4 feel hopeless and sad 4 have stopped trying to e1ercise and 4 feel even
more fatigued&K
:C, no$ $eIll get bac# to B/
"he #eys to Change - $s (Negative or Unhelpful $eliefs)
$s 2e have sho2n earlier even though it may seem li?e an upsetting event ($) leads you to
feel upset (C) this is not ,--O true&
4n reality it is not the event itself that upsets you it is your negative or unhelpful beliefs
(B3s) about the event that upset you&
"o ho2 do you identify your negative or unhelpful beliefsL
"ee if your beliefs fall into any of the follo2ing categories5
o !e%an&s - Chec? to see if your thoughts contain the 2ords JmustK
JshouldK or JoughtK& Hor e1ample you might thin? J4 mst be able to do all
of my errands todayRK or you might thin? J:ife shold be fair&K
o Awfuli'ing(Catastrophi'ing - Chec? to see if your thoughts involve 2ords
li?e Ja2fulK JhorribleK or Jterrible&K Hor e1ample you might thin? J4 had to
ta?e t2o naps today and that3s"EFU<R 43m usually active all day long&K
o )rustration *ntolerance - Chec? to see if your thoughts include J4 can3t
stand thisRK or the 2ord Junbearable&K Hor e1ample you might thin? J4canIt
stand being depressed li?e thisRK
o +elf-!owning - Chec? to see if you3re calling yourself names being too
critical of yourself or beating up on yourself& $lso chec? to see if you3re
basing your self-2orth on one or t2o minor things& Hor e1ample you might
thin? J4 2as too depressed to ma?e dinner for my ?ids today& 4Im an
insensitive mother and a terrible person/J
o ,ther-!owning - Chec? to see if you3re being too critical of or beating up
on others or basing your entire <udgment of them on one or t2o minor things&
Hor e1ample you might thin? J!y husband isn3t very good at tal?ing 2ith me
about my depression& 2eIs totally insensitive and seless/J
o Life-!owning - Chec? to see if you3re <udging allof your life as bad <ust
because it3s not perfect& Hor e1ample you might thin? J<ife is
$orthlessbecause 4 feel so 2orn out&K
Remember negative thoughts are those thoughts that ma?e us feel and/or behave in a
negative hurtful or unpleasant manner (e&g& feeling depressed or angry and being short-
tempered)&
Dnce you recogni9e the negative belief you have about the situation please 2rite it in the
JBK bo1&
!s - !ebating your Negative $eliefs
$fter you recogni9e your negative or unhelpful thoughts the ne1t step is to DEB"TE or
challenge them& There are lots of different 2ays you can do this&
Hirst you can as? yourself JChere is holding this belief getting meL 4s it helpful or is it
getting me into troubleLK
o Hor e1ample if your belief leads you to feel upset (e&g& to cry to feel depressed)
to do things that are unhelpful or harmful to you (e&g& stop sociali9ing 2ith friends not follo2ing
through on treatment recommendations) or to physically feel 2orse (e&g& to feel more tired) then
you might decide that your belief is unhelpful&
"econd you can as? yourself JChere is the evidence to support my negative beliefL 4s it
logicalLK
o Hor e1ample you may thin? J4 C$>3T "T$>% feeling so tired& But if 4 stop and
really consider this 4 reali9e 4 can stand it& 43m still 2a?ing up every morningG 43m still ta?ing care of
my medical appointments etc& "o even though 4 may not li?e feeling so tired 4 can stand it&K
+lease 2rite in bo1 % 2hat you said to yourself to debate and dispute your negative
thoughts&
Es - Effective(-elpful $eliefs
Dnce you have successfully debated against your negative beliefs you are ready to replace
them 2ith ne2 more effective or more helpful beliefs&
6ealthier beliefs may sound li?e one of the follo2ing5
o references - These are a healthier more rational alternative to demands&
+references are 2hen you 2ish for something or 2ant it very badly but do not demand that it must
be so& Hor e1ample you might thin? J4 really $ish 4 had the energy 4 used to haveK instead of
saying J4 !#"T feel e1actly the 2ay 4 did before 4 got depressed&K
o Anti-Awfuli'ing - This is a healthier more rational alternative to a2fuli9ing& This
is 2hen you can recogni9e that a situation is very bad 2ithout thin?ing it is ,--O $CH#:& Hor
e1ample you might thin? JBeing too tired to go to 2or? N days a 2ee? is really bad but at least 4
#no$ this $onIt last forever and staying at home does give me more time to catch up 2ith my
friendsK instead of thin?ing JHeeling this tired is $CH#:RK
o -igh )rustration "olerance - This is a healthier more rational alternative to
frustration intolerance& This is 2hen you reali9e that even though you may find a situation very
difficult you can stand it& Hor e1ample you might thin? J4 hate feeling so depressed but 4Ill
.st #eep finding ne$ $ays to cope $ith it and 43ll ?eep goingRK instead of thin?ing J4 can3t
stand feeling so depressedR 4t3s unbearableRK
o Anti-+elf-!owning - This is a healthier more rational alternative to self-do2ning&
This is 2hen you are able to accept yourself and approve of yourself even 2hen you3re not perfect&
"o for e1ample you might thin? JD? 4Im not handling the depressed mood as $ell as 4
$old li#e& 43m usually such a strong person and no2 4 find myself often nervous& But 4 recogni9e
that 43m still a good$orth$hile person even if 43m not as strong as 4 thought&K This thought is a
more rational positive alternative than calling yourself names li?e J43m a 2ea? terrible person&K
o Anti-,ther-!owning - This is a healthier more rational alternative to other-
do2ning& This is 2hen you3re able to accept others regardless of mista?es they might have made
or things they might have done to upset you& Hor e1ample you might thin? J43m pretty upset at my
husband for not listening to me& But 4 recogni9e he3s still generally a great guy $ho does lots of
great things& 6e pic?s up the ?ids from day care he ta?es them to the doctor and he ta?es care of
the house&K This is an alternative to thin?ing J6e3s not a good listener and that ma?es him a
horrible person&K
o Anti-Life-!owning - This is a healthier more rational alternative to life-do2ning&
This is 2hen you3re able to be accepting of ho2 your life is even 2hen it is not e1actly as you 2ould
li?e it to be& Hor e1ample you might thin? JThis isn3t ho2 4 planned for my life to be but 4
recogni9e that life is a mi*ed bag full of good as 2ell as bad eventsK instead of thin?ing J:ife is
meaningless and useless no2 that 4 have depression&K
+lease 2rite in Bo1 E your ne2 more helpful beliefs&
Note. Ce are N," as?ing you to replace your negative unhelpful thoughts 2ith
unrealistically positive thoughts& Ce do not e1pect you to 2rite in fantasies or positive thoughts
that are not grounded in reality& 4n order for this techniFue (called cognitive restructuring) to 2or?
you need to really believe the ne2 healthier thoughts you come up 2ith&
)s - New /ore )unctional E%otions an& $ehaviors
>o2 you3re ready to see the results of all your hard 2or?R
By changing your negative beliefs into more helpful ones you should no25
o Heel better emotionallyR
S Hor e1ample you may feel more positive (happier calmer
more rela1ed) or less strongly negative (e&g& disappointed/sad
vs& depressed annoyed vs& furious)&
o Behave in a more helpful 2ayR
S Hor e1ample you may e1ercise or sociali9e 2ith friends or
pursue a hobby&
o Heel better physicallyR
S Hor e1ample you might feel more energetic or have less
muscle tension&
+u%%ary
Remember although 2e cannot al2ays change a particular situation or event (K$K) (e&g&
loosing a close relative) 2e C$> manage and ta?e control of our o2n thoughts& $s a result 2e can
feel better or less distressed about situations 2e may have to confront&
Ce recommend that you complete at least one %epression $-BC-%-E-H "elf-6elp form per
day during your treatment& %oing this 2ill give you practice in catching your unhelpful thoughts in
recogni9ing ho2 they are related to negative conseFuences and most importantly in changing those
thoughts so you can have fe2er depression symptoms and a more positive treatment e1perience&
Ce 2ant to emphasi9e that learning this s?ill can be challenging and it ta?es practice& The
more you practice the easier it 2ill become to change your thoughts and feelings and the better
you 2ill feel&
Blan? copies of this form are located at the end of this boo?let& Dur research staff 2ill
collect your completed forms during the course of your REBT treatment& 4f you need more forms at
any point our research staff 2ill provide you 2ith e1tra copies&
6/ Managing Depression $ith Behavioral TechniGes%
(a) Behavioral TechniGes
"ometimes 2hen 2e have to deal 2ith a stressful or challenging life situation or 2hen 2e
are having a particularly hectic day 2e may not have enough time or energy to focus on using the
cognitive techniFues 2e have <ust revie2ed (i&e& $-B-C-%-E-H model) in order to manage our
negative thoughts&
Dn those days the simple and brief strategies outlined belo2 are alternative techniFues you
can use to help you manage any feelings of distress negative thin?ing fatigue or other symptoms&
(0) Activity +che&uling(lanning
"ome people may begin to feel over2helmed by negative thoughts 2hen undergoing their
REBT treatment as they try to fit in all their usual day-to-day activities& The aim of this section is to
help you plan your daily and 2ee?ly schedule during the course of your REBT treatment& +lanning
your daily and 2ee?ly schedules in advance 2ill help you manage your daily activities decrease
your negative thoughts control your level of fatigue and overall help you feel less depressed and
more in control of your life&
$t the end of this manual a sample copy of a 2ee?ly diary schedule for a 2oman
undergoing depression treatment is provided& This sample copy is intended as a guide to help you
complete your 2ee?ly schedules& Blan? copies of the 2ee?ly diary are also located at the end of this
boo?let for you to use during the course of your REBT treatment&
6ere are the steps 2e recommend for planning a manageable schedule5
(,) Hirst 2e recommend that you 2rite do2n your 2ee?ly depression treatment
sessions& Chen you start your depression treatment you 2ill find that the
therapy team 2ill try to ?eep your 2ee?ly appointments at a regular time each
2ee? (e&g& at ,-am)& Bou 2ill also find that your visit to the therapist3s office
2ill ta?e on average N- minutes& 'eep in mind 2hen planning your day to allo2
e1tra time for traveling to and from the office&
(7) "econd 2e suggest that you plan to give yourself/ daily meal brea?s for
brea?fast lunch and dinner& Bou may also 2ant to include several short (about
,--,N minutes) snac? brea?s during the day&
(/) Third 2e recommend that you also slot in at leastone /--minute daily
physical/recreational activity& +ic? an activity that you en<oy doing such as
2al?ing gardening or attending yoga classes& +revious studies have sho2n that
it is helpful to continue to engage in at least lo2 to moderate levels of
physical/recreational activities (such as 2or?ing out 2al?ing or even
gardening) during the course of your depression treatment& This 2ill ensure that
your fitness level does not considerably decrease during the course of your
treatment&
(8) Hourth 2e suggest that you 2rite do2n on a blan? sheet of paper all the
activities you 2ould li?e to complete during the course of the day& !a?e sure to
list your 2or? activities (if you are employed or self-employed) or your regular
home activities if you 2or? from home as 2ell as your regular daily chores such
as preparing dinner laundry ironing pic?ing up ?ids from school etc&

o Dnce you have made your list of daily activities number each activity in terms of
ho2 important it is to you& That is if you have to go to 2or? that day number your 2or? activities
as *, follo2ed by the ne1t essential tas? you 2ould li?e to accomplish& E1ample ,P 2or? 7 P
pic?ing up child from school / P preparing dinner etc&

o Dnce you have numbered your daily activities 2rite do2n each activity into your
2ee?ly planner ma?ing sure you allo2 yourself enough time to accomplish each tas?&

o Bou may find that you cannot fit in all the activities you 2ould li?e to accomplish in
one day& 4f so 2e suggest that you put off the activities that are less important to you (that is
those activities that 2ere further do2n on your list li?e those you rated a N or a 0) and move them
to another day during the 2ee? 2hen your schedule is less hectic&

o Bou may feel tempted to bypass your daily rest ("tep /) or physical/recreational
activity ("tep 8) on a particular day so that you can fit in another activity& Ce suggest you refrain
from doing this given that ma?ing time for both e1ercise/recreational activities and rela1ation is
important to maintaining a balanced lifestyle& Remember 2e all need to be realistic about 2hat 2e
can and cannot accomplish in one day& "ometimes it is impossible to try to complete the amount of
tas?s 2e 2ould li?e to do in a single day& Therefore set realistic goals for yourself& This 2ay you can
ma?e sure that you do not set yourself up for disappointments&
(b) Distraction TechniGes
%istraction techniFues help ta?e your mind off of your negative thoughts& "ome distraction
techniFues are as follo2s5
(0) *%agining a leasant *%age(+cene

o $ type of distraction techniFue you can use to ta?e your mind off of your negative
thoughts and feelings (including fatigue) is to imagine a pleasant scene& "ome e1amples include5
+lanning a JdreamK holiday& Try to visuali9e 2here you 2ould li?e to go
2ho you 2ould li?e to go 2ith ho2 you 2ould li?e to get there 2hat you 2ould li?e to do there
and ho2 much time you 2ould li?e to spend in your Tdream3 place&
Remembering an en<oyable vacation you have had& 4magine the fond
memories you have of this vacation& Try to recall the details of the place 2here you stayed the fun
activities you pursued&
;isuali9ing a rela1ing scene& Try to imagine a peaceful serene place (e&g&
lying on a beach some2here or meditating in a tranFuil garden setting)&
(1) Listening to rela2ing or en3oyable %usic tapes4 C!s4 vi&eos
o Bou may 2ant to listen to some of your favorite music or 2atch one of your
favorite movies to rela1 you distract you or lift your mood&
(5) "a6e a short wal6
o $nother strategy you could use to distract yourself from unpleasant thoughts
and feelings you may have is to ta?e a stroll& 4f you are at 2or? ta?e a brief
2al? around your 2or?place focusing on the sights and sounds around you
(e&g& pictures music etc&)& 4f you are at home ta?e a stroll around your
neighborhood or garden& +ay close attention to the characteristics of things in
your neighborhood (such as the color shape and si9e of neighboring buildingsG
2hat3s on display in shop 2indo2s etc)&
(7) 8isuali'ing a 9+",: +ign
o Try to imagine a traffic stop sign or even a Tred light3 signal in your mind
2hen you are feeing over2helmed or upset by your negative thoughts and
feelings including fatigue& Hollo2 the instructions of the stop signal by saying
to yourself Jstop thin?ing these negative unhelpful thoughtsK or Jstop d2elling
on the negativeK&
8/ Managing Depression $ith Emotive TechniGes%
@ Emotive techniFues 2ill help you challenge and change your negative thoughts&
(a) 2moros Methods (see http5//2eb&ut?&edu/Uthompson/songs&html)5
o 6umorous methods encourage you to challenge and not ta?ing your
negative thoughts too seriously& The follo2ing is a rational humorous song5
JChen 4 am so BlueK 2ritten by %r& $lbert Ellis to the tune of JThe Beautiful
Blue %anubeK by (ohann "trauss (r&5
Chen 4 am so blue so blue so blue
4 sit and 4 ste2 4 ste2 4 ste2R
4 deem it so a2fully horrible
That my life is rough and scarableR
Chenever my blues are verified
4 ma?e myself doubly terrified
Hor 4 never choose to refuse
To be blue about my bluesR
(b) 3hame'"ttac#ing E*ercises
o Bou should deliberately see? to act JshamefullyK in public in order to learn to
accept yourself and to tolerate the ensuing discomfort& 4n order to avoid
harming yourself only minor infractions of social rules are permitted (e&g&
2earing bi9arre clothes designed to attract public attention calling out the
time in a cro2ded department store)&
Ce recommend that you record the main emotive techniFues Ie&g& humorous methods
(e&g& songs and poems) and shame-attac?ing e1ercises)M you used& Blan? papers for recording the
emotive techniFues are located at the end of this boo?let& Dur research staff 2ill collect your
completed forms during the course of your REBT treatment& 4f you need more forms at any point
our research staff 2ill provide you 2ith e1tra copies&
7/ Beyond REBT Treatment%
The REBT techniFues that have been covered in this manual 2ill help you to manage your
depression symptoms& !oreover these techniFues can be applied to any situation in the future
2hen you may feel over2helmed and/or distressed&
4t is important to note that follo2ing the completion of your REBT treatment you may
occasionally e1perience days 2hen you feel fatigued or distressed& %uring such periods 2e suggest
that you revie2 the contents of this manual and continue to use the REBT s?ills that you have
learned&
Dver time and 2ith practice these REBT s?ills 2ill become natural for you li?e riding a bi?e
or driving a car&
Ce hope that you 2ill find these techniFues valuable and 2e 2ish you every success in the
future&
$++E>%4V (available upon reFuest)
,& "tudy 4nstructions
7& "pare Copies of the %epression $-B-C-%-E-H "elf-6elp Horm
/& E1ample of the "cheduling Horm
8& "pare Copies of the "cheduling Horm
N& "pare Copies of the Emotive TechniFues-
!onitoring Horm