Nazanin Alavi Mohsen Omrani Online Cognitive Behavioral Therapy An e-Mental Health Approach to Depression and Anxiety 123 Online Cognitive Behavioral Therapy Nazanin Alavi • Mohsen Omrani Online Cognitive Behavioral Therapy An e-Mental Health Approach to Depression and Anxiety Nazanin Alavi Mohsen Omrani University of Toronto Brain Health Institute (BHI) Centre for Addiction and Rutgers University Mental Health (CAMH) Piscataway, NJ Toronto, ON USA Canada ISBN 978-3-319-99150-4 ISBN 978-3-319-99151-1 (eBook) https://doi.org/10.1007/978-3-319-99151-1 Library of Congress Control Number: 2018960354 © Springer Nature Switzerland AG 2019 This work is subject to copyright. 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This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Acknowledgment To our parents, Vida, Minoo, Mobin, and Behrooz, for all their support and sacrifices through the years; and to our two sons, Kahvian and Dustahn, who light up our lives with their joy and energy! v Contents 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Mental Health Disorders and Treatment Gaps . . . . . . 1 Limited Care Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Inefficient Resource Allocation . . . . . . . . . . . . . . . . . . 4 Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 What Is Depression? What Is General Anxiety Disorder (GAD)? . . . . . . . . . . . . . . . . . . . . . . 9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2 The 12-Step Approach to Online CBT . . . . . . . . . . . . 11 Important Points to Remember in Designing eCBT Modules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 How to Design Modules for Online CBT . . . . . . . . . . 15 How to Give Feedback . . . . . . . . . . . . . . . . . . . . . . . . . 15 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 3 What Is Depression? What Is Anxiety? . . . . . . . . . . . . 17 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Why Take This Course? . . . . . . . . . . . . . . . . . . . . . . . . . 17 What Is Online CBT? . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 What Does the Course Look Like? . . . . . . . . . . . . . . . 18 Discuss Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Introduce the Clinician Facilitating the Course . . . . . 19 Online CBT Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 What Is Depression/Anxiety? . . . . . . . . . . . . . . . . . . . . 20 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Goal of the Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 vii viii Contents Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 22 Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4 What Is the Five-Part Model and How Can It Be Helpful? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 34 How to Summarize the First CBT Session for Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 How to Summarize the First CBT Session for Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 36 What Is the Five-Part Model? . . . . . . . . . . . . . . . . . . . . 37 How to Go Through the Five-Part Model Step by Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 39 Help the Clients with Their Homework . . . . . . . . . . . 40 5 What Is the Connection Between Our Thoughts, Feelings, Behaviour, Physical Reactions, and Environment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 45 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 46 What Is the Connection Between Thoughts and Feelings? . . . . . . . . . . . . . . . . . . . . . . . . . 46 What Is the Connection Between Thoughts and Behaviours? . . . . . . . . . . . . . . . . . . . . . . 47 What Is the Connection Between Thoughts and Physical Reactions? . . . . . . . . . . . . . . . . 47 What Is the Connection Between Thoughts and the Environment? . . . . . . . . . . . . . . . . . 48 Thinking About the Five-Part Model . . . . . . . . . . . . . . 48 Walkthrough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Connection Between Different Parts . . . . . . . . . . . . . . 50 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 51 Contents ix 6 Strategies That Can Be Used in Stressful Situations . . 59 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 59 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 59 What to Do in Stressful Situations? . . . . . . . . . . . . . . . 60 Distracting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Deep Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Why Breathing Is Important . . . . . . . . . . . . . . . . . . . . . 60 How to Do Breathing Exercises? . . . . . . . . . . . . . . . . . 61 Belly Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4 -7-8 Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Roll Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Morning Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Next Week Homework . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Homework 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Homework 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 7 Understanding and Rating Our Feelings, and the Thought Record . . . . . . . . . . . . . . . . . . . . . . . . 69 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 69 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 70 Feelings and Moods . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Rating Moods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Thought Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Summarize the Session . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 72 Homework 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Homework 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 8 What Are Automatic Thoughts? . . . . . . . . . . . . . . . . . . 81 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 81 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 82 What Are Automatic Thoughts? . . . . . . . . . . . . . . . . . . 82 Questions to Help Identify Automatic Thoughts . . . . 83 x Contents What Are Hot Thoughts? . . . . . . . . . . . . . . . . . . . . . . . . 83 Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 84 9 Activity Scheduling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 93 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 94 What Is Activity Record . . . . . . . . . . . . . . . . . . . . . . . . . 94 Learning from Activity Records . . . . . . . . . . . . . . . . . . 97 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 97 10 What Is Evidence and How Can It Help Us Rate Our Thoughts and Feeling? . . . . . . . . . . . . . . 105 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 105 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 106 Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 How to Help the Client Find Evidence That Does Not Support Their Hot Thought . . . . . . . . 107 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 108 11 What Is Alternative and Balanced Thinking? . . . . . . . 117 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 117 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 118 What Are Alternative/Balanced Thoughts? . . . . . . . . 118 Help the Client Find Alternative or Balanced Thinking . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 122 12 Experiments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 131 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 132 Experimenting on the Alternative Thoughts . . . . . . . . 132 Contents xi Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 135 Homework 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Homework 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 13 Action Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Summarize the Previous Session . . . . . . . . . . . . . . . . . . 145 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 146 Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Next Week’s Homework . . . . . . . . . . . . . . . . . . . . . . . . 148 Homework 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Homework 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Homework 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 14 Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 In This Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Welcome Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 What Is This Session About? . . . . . . . . . . . . . . . . . . . . . 157 The Five-Part Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Thought Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Column 1: Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Column 2: Feelings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Column 3: Automatic Thoughts . . . . . . . . . . . . . . . . . . . 159 Columns 4 and 5: Evidence . . . . . . . . . . . . . . . . . . . . . . 160 Column 6: Balanced/Alternative Thoughts . . . . . . . . . 160 Column 7: Rerate Your Mood . . . . . . . . . . . . . . . . . . . . 161 Experiments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Using All the Techniques . . . . . . . . . . . . . . . . . . . . . . . . 161 End of the Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163