CBT microskills

The negative triad

Behaviour cycle

  • Identify vicious cycles > avoidance
  • Behavioural experiments
  • Positive behaviour log
  • Challenge unhelpful thinking
    • Different way of looking at it eg Responsibility pie chart
    • What would your best friend say?
    • Have you talked to others about it? What do they say?

Dealing with worries and concerns

Type of worry or concern Realistic Unrealistic
  • Problem insoluble
  • Out of control
  • Unlikely to change
  • Problem potentially soluble
“Depressive thinking” (may pre-date episode or be maintaining it or both)
Strategies Coping strategies Problem solving Cognitive strategies

Stages of problem solving


Enable the patient to:

  • define the goal;
  • brainstorm options;
  • explore the pros and cons of each option;
  • choose the desired option;
  • go through the steps required to carry out option and achieve goal;
  • consider the “worst case scenario” (stress inoculation).

Get the patient to do the work (patient-centred). If he/she cannot think of options try to avoid suggesting alternatives yourself. It may be easier if, when the patient is severely depressed, he/she is on medication. Problems may not be soluble (see coping strategies).

Counselling depressed patients

Dealing with realistic worries

Coping Strategies

  • Focus on the positive as much as possible;
  • Help the patient to realistically adjust his or her expectations;
  • Offer appropriate reassurance;
  • Provide empathy, encouragement and support. Empathy should be verbalised to be most effective (see above).
  • At all times remember to use a negotiatory style.
  • What are the potential sources of outside help and support?
  • How can they be used?
  • How has he/she managed on previous occasions?
  • What do they want to achieve this time?
  • What steps can be taken to ensure that this does not happen again? (relapse prevention).

Ways of increasing or modifying activity

  • Task assignments;
  • Activity scheduling: – make a record of the present activity level;
  • Rating sense of PLEASURE and/or ACHIEVEMENT:
    • A for achievement;
    • P for pleasure;
    • score out of 5 for all activities;
  • Re-scheduling: – work to expand activities particularly those with promising A and P ratings.

Automatic Thoughts

  • “There is nothing I can do about”
  • “I’ll never be any good about it”
  • “It’s always my fault”
  • “Everybody hates me”

Thinking errors in depression

  • All or nothing thinking: “Unless I do it perfectly there is no point in trying…”
  • Overgeneralization: “I’m always making mistakes…”
  • Mental filter: “Nothing ever goes right at work …” Discounting the positive: “She was only feeling sorry for me…”
  • Mind reading: “Everyone thinks I’m a wimp …”
  • Personalization: “They always pick on me…”
  • Catastrophizing: “Failing my driving test will be a disaster and I’m bound to fail…”

Eliciting negative automatic thoughts

  • Work through an example:
    • ask about thoughts which come into mind
    • link thoughts to feelings
  • Ask what thoughts come to mind here and now in the consultation when you are talking about a difficult topic – link thoughts to feelings
  • Keep a record of thoughts
  • Willingness to keep a record can be a good test of motivation.

Intervening with automatic thoughts

  • Stay neutral when exploring evidence for and against the thought
  • Your role is to ask questions, not to provide answers
  • Ask “How?” and “What?” questions rather than “Why?”
  • Use a negotiating style
  • Emphasize the joint role in finding the best way of examining the evidence and challenging the automatic thoughts

Failing to do the above may mean that your well-intentioned efforts come across as “pull yourself together”.

Key Strategies:

  • Questioning the evidence
    First of all question the evidence for the accuracy of the thought:

    • “What leads you to think this?”
    • “What’s the evidence for and against?”
    • “What other factors might be playing a part?”
  • Hypothesis testing
    Is there any way that you can test out your hypothesis?
  • Generating alternatives
    What are the alternative explanations?

    • “Can you think of another way that you can look at this thought?”
      This is called generating a rational response in cognitive therapy jargon.
  • Reattribution
    Challenge tendency to relate external events to self. Encourage correct apportioning of “blame” rather than blaming self for everything.

Provide as much support and encouragement as you can. Encourage appropriate assertiveness. Encourage taking credit for the positive aspects of life where this is clearly due.

Five areas assessment tool


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