12

Processes of Thought and Occupation

Bonnie Kirsh, PhD, OT Reg (Ont)

Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any
given set of circumstances. (Viktor E. Frankl, 1905-1997: Austrian psychiatrist, Man’s Search for Meaning)

What you believe you experience. (J. Krishnamurti, Commentaries on Living, Volume 1, p. 88)

Our life is what our thoughts make it. (Marcus Aurelius Antoninus, Meditations, Book IV)

The objectives of this chapter are as follows:

» Describe the core tenets of cognitive behavioral therapy (CBT).
» Identify the major contributors to CBT.
» Detail the process and outcomes of CBT applied to practice.
» Describe the alignment of CBT with occupational therapy principles and the application of CBT
principles to occupational therapy practice.

Krupa, T., Kirsh, B., Pitts, D., & Fossey, E. Bruce & Borg’s
Psychosocial Frames of Reference: Theories, Models, and Approaches for
Occupation-Based Practice, Fourth Edition (pp 191-210).
© 2016 SLACK Incorporated.
192 Chapter 12
hand, is seen as faulty thinking patterns resulting from
dysfunctional thought processes. When people process
information in such a way that their thoughts do not align
with existing evidence or logic, the result is psychological
disturbance that is characterized by irrational beliefs. This
The behavioral approach, outlined in the previous
can have a significant impact on occupational performance
chapter of this book, conceptualizes human behavior as
and experience, the focus of occupational therapy.
a response to environmental stimuli, but the absence
of human control and volition within this model was
seen to be insufficient to explain human behavior. Many
theorists took issue with the stimulus-response condition-
ing approaches of behaviorists, arguing that they are too
passive and simplistic. These theorists promoted a shift Within cognitive approaches, three levels of cognition
in focus from environmental antecedents and behavioral have been identified and targeted for intervention: full
consequences toward cognitive factors, and specifically consciousness, automatic thoughts, and schemas (Clark
processes of thought, promoting the notion that what et al., 1999). Consciousness is a state in which rational deci-
people think, believe, expect, remember, and attend to sions are made with full awareness. Automatic thoughts are
influence how they behave (O’Leary & Wilson, 1987). the more autonomous, often private cognitions that flow
People’s conscious thoughts, wishes, and ideals have been rapidly during everyday thinking and may not be carefully
increasingly considered important contributors to behav- assessed for accuracy or relevance (Wright, 2006). There
iors. These factors became incorporated into new models, has been considerable attention directed to understanding
forming the basis of cognitive and cognitive behavioral the nature of automatic thought processes associated with
therapies. particular health conditions. For example, in depression,
Cognitive approaches to therapy concern them- automatic thoughts typically center on themes of negativity,
selves with cognitive structures and thought processes, low self-esteem, and ineffectiveness. In anxiety disorders,
such as beliefs, thinking styles, problem-solving styles, automatic thoughts often include overestimates of risk in
and coping styles (Meichenbaum, 1977). They aim to situations and underestimates of ability to cope (Wright,
correct faulty conceptions and self-signals (Beck, 1976) as Beck, & Thase, 2003). Cognitive schemas are fundamen-
a means of alleviating psychosocial distress and changing tal rules or templates for information processing that are
behavior. These approaches may be viewed as existing on shaped by developmental influences and other life experi-
a continuum from purely cognitive to a combination of ences. As individuals process information from the envi-
cognitive-behavioral. ronment, they interpret it based on schemas that they have
In many ways, cognitive and cognitive-behavioral developed. This interpretation then influences self-worth
approaches are a good match with occupational therapy and behavioral coping strategies (Wright, 2006). In depres-
principles and practice because of the emphasis on client sion, schemas are usually concerned with loss, worthless-
perceptions and meanings, and a belief in the individual ness, defeat, and deprivation.
to exercise control. Occupational therapy theory and The aim of cognitive behavioral approaches is to alter
cognitive-behavioral theory both value cognitive awareness cognitions and cognitive processes at any or all of the three
and the person’s ability to problem solve. Both recommend levels described above to facilitate behavioral and emotional
a collaborative relationship between client and practitioner, changes. The general term for this treatment approach is
and both integrate activity or tasks into the intervention cognitive restructuring. Specifically, cognitive restructuring
process. involves helping individuals recognize errors in thinking
and eliciting rational alternative thoughts, and reapprais-
ing beliefs about themselves and the world (Thrasher,
Lovell, Noshirvani, & Livanou, 1996). Therapists encourage
individuals to monitor their daily thoughts—often daily
thought diaries are used—and then evaluate them through
Within a cognitive framework, healthy thinking is the
reasoning, Socratic questioning, collecting evidence for
focus. People are seen as capable of creating and guid-
and against each thought, and delineating pros and cons of
ing their own lives through formulating their thoughts that
their way of thinking (Marks, Lovell, Noshirvani, Livanou,
influence their behaviors and emotions. They engage in
& Thrasher, 1998).
activities that provide feedback for healthy thinking, and
In cognitive restructuring, individuals learn to replace
for experiencing pleasure in their lives. Rational, healthy
negative beliefs and self-statements with positive ones. Two
thoughts enable people to act in ways that are compatible
commonly used techniques are self-talk, which involves
with life satisfaction and positive social interaction (Barris,
creating a new internal dialogue characterized by positive
Kielhofner, & Watts, 1988, p. 92). Disorder, on the other
self-statements; and cognitive rehearsal, which involves
 Processes of Thought and Occupation 193

TABLE 12-1

imagining positive interactions or experiences. As posi- and to develop more functional responses (Neimeyer &
tive, rational thoughts replace negative, irrational ones, Feixas, 1990) and has been shown to increase the efficacy
new behaviors can be experienced and coping skills are of CBT. For example, a study examining the relation-
developed. For example, negative self-statements (such as ship between treatment outcome and the extent to which
“If I do that I will fail”) may lead to avoiding particular cocaine-dependent individuals completed CBT homework
situations, but when such negative statements are replaced assignments reports that participants who completed more
with more positive ones (such as “It will be difficult but I homework assignments demonstrated significantly greater
can do it”), an individual may actually confront an anxiety- increases in the quantity and quality of their coping skills
provoking situation, learn to cope with it, and develop and used significantly less cocaine during treatment and
new thoughts around it. A two-way relationship between through a one year follow-up (Carroll, Nich, & Ball, 2005).
cognition and behavior is established in which cognitive These data suggest that the extent to which participants are
processes influence behavior, and behavioral change influ- willing to complete extra session assignments may be an
ences cognitions. important mediator of response to CBT. For examples of
Cognitive approaches not only aim to change dysfunc- CBT homework, see Table 12-1.
tional thinking, they also aim to broaden individuals’ The environment is an important domain in cogni-
knowledge (so that new thinking is possible), strengthen tive behavioral approaches, and there is a need for careful
the application of knowledge in skill-building, and improve assessment of antecedent events or stimuli that may act as
the ability to problem solve. To this end, psychoeducation triggers to negative thoughts or behaviors. For example,
is a commonly used approach. It aims to broaden and researchers have determined a number of situations in
deepen one’s knowledge base and prepare clients to respond which substance use is more likely to occur for people
to life’s daily challenges through increasing awareness, struggling with substance abuse disorders (Marlatt, 1996).
improving functional skills and teaching problem-solving While these situations, which may involve an interaction
strategies. In doing so, new perspectives are gained and with someone else or reactions to nonpersonal environ-
thoughts about oneself are changed from incapable to mental events, are seen to pose a general risk, it is the
capable. individual’s appraisal of the situations that determines the
Homework assignments are frequently used with cogni- actual risk for the individual (Myers, Martin, Rohsenow, &
tive and cognitive-behavioral approaches, to supplement Monti, 1996). CBT can be useful in helping clients modify
skills learned in sessions with the therapist. Homework beliefs about these environmental situations as a means of
is used to disconfirm dysfunctional thinking patterns trying to cope with these situations.
194 Chapter 12
The notion of schemas, mentioned briefly in an earlier
part of this chapter, was originated by Beck, who defined
them as cognitive structures “for screening, coding and
evaluating stimuli that impinges on the organism” (Beck,
1967/1970, p. 283). Beck postulated that in depression,
The cognitive-behavioral frame of reference takes the
idiosyncratic schemas involving themes of personal defi-
position that a person’s cognitive function and beliefs medi-
ciency, self-blame, and negative expectations dominate
ate or influence behaviors. Specifically, the approach is
the thinking process. Beck believed that activation of the
based on a number of assumptions with regard to person/
schemas leads to negative automatic thoughts and cognitive
cognition, environment/context, and activity/occupation.
errors and is the mechanism by which depression develops.
Table 12-2 summarizes these assumptions within the broad
Although Beck’s focus was on depression, he expanded his
domains of person, environment, and occupation.
approach to anxiety and in the years that followed, Beck’s
work inspired a perspective on human cognition, emotion,
and behavior that has wide application to a host of psycho-
logical conditions.
Bandura was discussed in another chapter for his con-
Key theorists who contributed to the development of tribution to learning theory, specifically observational
CBT and practice are Aaron Beck, Albert Bandura, Albert learning. However, by the 1970s, Bandura was becoming
Ellis, and Donald Meichenbaum. aware that a key element was missing, not only from the
Aaron Beck’s early writings focused primarily on prevalent learning theories of the day, but also from his
pathology in information processing styles in people with own social learning theory. In 1977, with the publication
depression or anxiety, but he also incorporated behav- of Self-Efficacy: Toward a Unifying Theory of Behavioral
ioral methods to activate, reverse helplessness, and counter Change, he identified the important piece of that miss-
avoidance among these people. Beck’s initial formulation ing element—self-beliefs. According to Bandura (1995)
of the cognitive theory of depression identifies a negative self-efficacy is “the belief in one’s capabilities to organize
cognitive triad, which includes a negative view of the self, and execute the courses of action required to manage pro-
the world, and the future (Beck, 1970). Beck proposed that spective situations” (p. 2). In other words, self-efficacy is a
the negative cognitive pattern leads to other symptoms of person’s belief in his or her ability to succeed in a particular
depression. For example, a negative view of self or world situation. The basic principle behind self-efficacy theory is
results in a depressed mood or sadness, whereas a negative that individuals are more likely to engage in activities for
view of the future leads to the loss of motivation, a sense which they have high self-efficacy and less likely to engage
of hopelessness, and pessimism (Beck, 1970). Beck noted in those they do not. In Bandura’s view of human behavior,
that cognitions involving low self-esteem, deprivation, self- the beliefs that people have about themselves are critical
criticism, and suicidal wishes were common in depression. elements in the exercise of control and personal agency—
Beck also introduced the notion of cognitive errors these beliefs are determinants of how people think, behave,
(Box 12-1), which emerged from his finding that depressed and feel. Bandura’s work emphasized that cognition plays a
patients distorted reality in a systematic manner that result- critical role in people’s capability to construct reality, self-
ed in bias against themselves. He described a number of regulate, encode information, and perform behaviors.
cognitive errors commonly made in depression, including Albert Ellis developed rational emotive therapy in the
arbitrary inference, or drawing a specific conclusion in the 1950s, which proposed that people become unhappy and
absence of evidence or when the evidence is contrary to the develop self-defeating habits because of unrealistic or faulty
conclusion; selective abstraction, or focusing on a detail out beliefs. These unrealistic beliefs usually originate from one
of context while ignoring more salient features of the situ- of three core ideas: (1) I must perform well to be approved of
ation; overgeneralization, or drawing a conclusion on the by others who are perceived as significant; (2) you must treat
basis of one or more isolated incidents; and magnification/ me fairly—if not, then it is horrible and I cannot bear it; and
minimization, or exaggerating or minimizing the signifi- (3) conditions must be my way and if not, I cannot stand to
cance or magnitude of an event. Beck subsequently added live in such a terrible and awful world. In Ellis’ view, these
personalization, or a tendency to relate external events to irrational thoughts lead to psychological distress.
oneself, and dichotomous thinking, or a black-and-white Ellis developed the ABC theory of personality, which
way of thinking that places experience in one of two cat- was later expanded to the ABCDE model, to explain the
egories. Beck acknowledged that most individuals show relationship among thoughts, feelings, and behavior. In
such cognitive errors but what characterizes the distortion this model, A is the activating event; B is the belief system,
in depression is the systematic negative bias against the self which may be rational or irrational; C refers to emotional
(Clark et al., 1999).
 Processes of Thought and Occupation 195

TABLE 12-2
196 Chapter 12

1. Filtering—Taking negative details and magnifying them, while filtering out all positive aspects of a situation
2. Polarized thinking—Thinking of things as black or white, good or bad, perfect or failures, with no middle
ground
3. Overgeneralization—Jumping to a general conclusion based on a single incident or piece of evidence;
expecting something bad to happen over and over again if one bad thing occurs
4. Mind reading—Thinking that you know, without any external proof, what people are feeling and why they act
the way they do; believing yourself able to discern how people are feeling about you
5. Catastrophizing—Expecting disaster; hearing about a problem and then automatically considering the
possible negative consequences (e.g., “What if tragedy strikes?” “What if it happens to me?”)
6. Personalization—Thinking that everything people do or say is some kind of reaction to you; comparing
yourself to others, trying to determine who’s smarter or better looking
7. Control fallacies—Feeling externally controlled as helpless or a victim of fate or feeling internally controlled,
responsible for the pain and happiness of everyone around you
8. Fallacy of fairness—Feeling resentful because you think you know what is fair, even though other people do
not agree
9. Blaming—Holding other people responsible for your pain or blaming yourself for every problem
10. Shoulds—Having a list of ironclad rules about how you and other people “should” act; becoming angry at
people who break the rules and feeling guilty if you violate the rules
11. Emotional reasoning—Believing that what you feel must be true, automatically (e.g., if you feel stupid and
boring, then you must be stupid and boring)
12. Fallacy of change—Expecting that other people will change to suit you if you pressure them enough; having
to change people because your hopes for happiness seem to depend on them
13. Global labeling—Generalizing one or two qualities into a negative global judgment
14. Being right—Proving that your opinions and actions are correct on a continual basis; thinking that being wrong
is unthinkable; going to any lengths to prove that you are correct
15. Heaven’s reward fallacy—Expecting all sacrifice and self-denial to pay off, as if there were someone keeping
score, and feeling disappointed and even bitter when the reward does not come
Adapted from Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: Meridian.

consequences (such as anxiety) created by B; D is the dis- performed (Barris et al., 1988, p. 94). All of these approach-
putation or rational challenges to B, which may eliminate es aim to replace self-defeating thoughts with more positive
disturbing Cs; and E is the new effects or “a more rational ones.
philosophy” (Ellis, 1973). According to Ellis, it is not A that Donald Meichenbaum is best known for stress inocula-
causes C but rather B, the beliefs and meanings attributed tion training, an approach that helps individuals cope with
to the event, that is the causative factor. Rational emotive the aftermath of exposure to stressful events and that is
therapy focuses on the influence of the belief system on used on a preventative basis to inoculate individuals to
emotions and behavior. future and ongoing stressors. This form of CBT aims to
Rational emotive therapy is an active therapy, with the empower individuals to expand their repertoire of cop-
therapist taking a challenging and directive stance. A num- ing skills and to use existing ones. It uses a three phase
ber of strategies may be used to change irrational beliefs intervention. In the first conceptualization phase, a col-
and promote rational self-talk: (1) client self-monitoring laborative relationship is established between the client
of thoughts; (2) reframing of situations to view them from and the therapist. Clients are educated about the role of
a more positive angle; (3) therapist modeling of rational the appraisal processes with regard to stress, and that they
thinking; (4) use of straightforward feedback, challenge, may be—perhaps unknowingly—exacerbating the level of
and confrontation of client thoughts and beliefs; and stress they experience. Stresses and threats are reframed
(5) use of homework assignments and practice sessions as problems to be solved and stressors are broken down
in which new rational self-statements and behaviors are with short-, intermediate-, and long-term coping goals
 Processes of Thought and Occupation 197
in mind. The second phase of stress inoculation training control intervention and were carried out under blind con-
focuses on skills acquisition and rehearsal that follows ditions. The two largest studies (Lewis et al., 2002; Sensky
naturally from the initial conceptualization phase. Coping et al., 2000) showed no significant advantage for CBT over
skills are learned and practiced and may include emotional the control intervention.
self-regulation, self-soothing and acceptance, relaxation CBT has been used with individuals with psychosis, not
training, self-instructional training, cognitive restructur- only to address symptoms, but also to help people move
ing, problem-solving, interpersonal communication skills forward with their recovery and realize their potential in
training, attention diversion procedures, using social sup- domains such as work. It is this application that has greater
port systems, and fostering meaning-related activities. The relevance to occupational therapy. Lysaker et al. (2005)
final phase of application and follow-through provides developed an intervention that was an adjunct to a work
opportunities for clients to apply the coping skills across therapy program which had, as its overarching purpose,
increasing levels of stressors. Techniques such as imag- helping participants identify and correct dysfunctional
ery and behavioral rehearsal, modeling, role-playing, and beliefs about work. The intervention was aimed at helping
graded in vivo exposure are used in the form of personal people with schizophrenia change dysfunctional beliefs
experiments. about themselves. In this randomized, controlled trial,
participants in the intervention group worked significantly
more weeks than those in the standard support group and
the intervention group also maintained baseline levels of
hope and self-esteem, whereas the control group did not.
While CBT was originally thought to be suitable pri- The authors surmise that these improvements relate to
marily for people with depression and anxiety, it has since the increased ability of intervention group participants to
been applied increasingly to people experiencing a range of problem solve and avoid making negative self-attributions.
health conditions. It is being used widely, for example, with Cognitive behavioral approaches are being delivered to
individuals who have difficulty adjusting to significant individuals across the lifespan. Lopez and Mermelstein
physical illnesses and disabilities, and when these physical (1995) administered a cognitive behavioral intervention
illnesses are accompanied by depression and anxiety. Spe- program to participants at a geriatric rehabilitation unit of
cific CBT strategies have even been developed for people a large metropolitan medical center. Patients with elevated
who experience psychosis (e.g., with a diagnosis of schizo- depression and anxiety scores participated in a program
phrenia), a health condition where the primary impairment based on CBT principles and were compared to a control
is a disorder in thought. In this situation, where an indi- group who scored within normal limits on the depression
vidual may be absolutely convinced that his or her thoughts and anxiety measures. The intervention program relied
are true (even when to other people they seem very irratio- heavily on a broad-based, cognitive-behavioral, and coping
nal), CBT has been applied with the intent of reducing the skills/problem-solving framework. Interventions included
distress experienced in response to these thoughts and to (1) making graphs of progress and goals and having team
increase coping options (Smith, Nathan, Juniper, Kingsep, members reinforce the participant’s progress, (2) encourag-
& Lim, 2003). ing patients to seek information about their conditions and
Research over the past decade has shown that CBT helps to talk more openly and realistically about their diseases
people with schizophrenia spectrum disorders reduce posi- and disabilities, (3) relaxation training where appropriate,
tive and negative symptoms (Drury, Birchwood, Cochrane, (4) helping patients in making social comparisons and in
& Macmillan, 1996; Haddock et al., 1998; Kingdon & Turk- perspective taking, and (5) increasing patients’ pleasant
ington, 1991; Sensky et al., 2000; Tarrier et al., 2001). Tarrier activities (e.g., getting them involved in unit social activities
(2005) reviewed the evidence from 20 controlled trials of and events). The overall therapeutic approach was active
CBT in schizophrenia in which 739 patients were included and focused on goals. Cognitive restructuring was useful
and concluded that there is evidence that CBT reduces in helping patients to realign their expectations and to
persistent positive symptoms in patients with chronic dis- increase their confidence. Findings indicated that, com-
ease and may have modest effects in speeding recovery in pared with patients who were psychologically healthier at
acutely ill patients. However many questions still need to admission, participants in this program achieved compara-
be answered about the efficacy of CBT with schizophrenia. bly low levels of distress by discharge, except for anxiety. In
Critiques of research methods in many of the studies have addition, both groups achieved their rehabilitation goals to
been issued, calling for replications and further research. similar degrees. A side benefit of the program identified by
For example, in an article debating the issue, Turkington the authors was that this approach enabled staff to become
and McKenna (2003) pointed out that of the 13 trials of advocates, helping patients identify problems and areas of
CBT in schizophrenia included in a Cochrane meta-anal- strength on which to build from admission onward. This
ysis (Cormac, Jones, & Campbell, 2002), only four used a was an improvement over the previous, and more common
198 Chapter 12

approach, of having problem patients referred for psycho- trials also found that these benefits last after 12 months
logical treatment while passive, often depressed patients (MoodGYM, n.d.). These tools are showing great promise;
were overlooked. indeed a review of eight studies of supported Internet- or
Perhaps one of the most significant advances in the area computer-based CBT, six of which were randomized con-
of CBT is its adaptation to online formats that enable self- trolled trials, indicate that these programs are potentially
help and easy delivery. A number of specific Internet-based more effective than usual care (Høifødt, Strøm, Kolstrup,
CBT programs have been developed and evaluated. Beating Eisemann, & Waterloo, 2011).
the Blues is a program aimed at “people feeling stressed,
depressed, anxious or just down in the dumps” (Beating the
Blues, 2006). The course is made up of eight online sessions
that help people understand the link between thoughts,
feelings, and behaviors, and which teach coping strategies. As part of the assessment process, the individual’s
The effects of this tool on emotional distress in employees perceptions, thoughts, attitudes, values, and beliefs are
with stress-related absenteeism were evaluated through solicited. An ABC assessment (Box 12-2) is commonly
a randomized controlled trial in which 48 public sector carried out in which antecedents, behaviors, and conse-
employees were randomized equally to Beating the Blues quences are documented. This assessment can point out the
plus conventional care, or conventional care alone. At the interactions between situations, thoughts, emotions, and
end of treatment and 1 month later, adjusted mean depres- day-to-day behavior.
sion scores and adjusted mean negative attributional style
scores were significantly lower in the intervention group.
One month post-treatment, adjusted mean anxiety scores
were also significantly lower in the intervention group. The
study concludes that this online CBT tool may accelerate
psychological recovery in employees with recent stress-
related absenteeism (Grime, 2004). Another online pro- CBT is one of a range of strategies that can be used in
gram from Australia, called MoodGYM, is designed to pre- addressing the focus of concern in occupational therapy;
vent depression in young people. Using flashed diagrams that is, occupational performance and experience. For com-
and online exercises, MoodGYM teaches the principles of plex occupational problems, CBT may be combined with
CBT to work through such issues as stress and relation- other approaches so that the range of factors—for example,
ship break-ups, and also teaches relaxation and meditation skill deficits, social and family influences, environmen-
techniques. Scientific trials evaluating MoodGYM have tal barriers, and other factors—may be addressed. While
shown that using two or more modules is linked to signifi- not the exclusive intervention for complex occupational
cant reductions in depression and anxiety symptoms. The problems, CBT holds an important place in occupational
 Processes of Thought and Occupation 199
therapy. Occupational therapy offers an opportunity to test ending conversations, using gestures and nonverbal com-
the validity of negative assumptions through involvement munication, and adjusting tone of voice, are important
in activities that are pleasurable and that promote a sense to learn. Similarly, assertiveness training can be broken
of self-efficacy. Activities are used to refute clients’ auto- into cognitive skills and behavioral skills. Cognitive skills
matic thoughts and help change behavior. For example, a include recognizing the differences between aggression,
client working on broadening his social activities with the assertion and passivity, recognizing personal rights and
help of his occupational therapist may attend a social club, the rights of others, and reducing cognitive and affective
and through this experience may replace negative thoughts obstacles to acting assertively. Examining such beliefs as
such as, “I won’t know anyone and no one will want to “If I say no, I won’t be liked” can be examined so that they
talk to me,” with more positive ones such as, “I can talk to can be replaced with thoughts that enable more control
people I don’t know and enjoy it.” In CBT, changes are made and assertive behavior. Assertiveness training also includes
through homework, practicing, and experiencing—that behavioral skills such as role playing and homework assign-
is, “doing”—the unique domain of the profession. With ments aimed at helping people express how they feel and
expertise in occupational and task analysis combined with what they want.
knowledge of cognitive principles, occupational therapists Occupational therapists have found that cognitive
are able to help clients schedule and perform specific activi- behavioral approaches provide a solid foundation for
ties related to problem areas. They help clients to monitor resolving the emotional and physiological symptoms of
daily activities and pay attention to the degree of pleasure post-traumatic stress disorder (PTSD) because this frame
and accomplishment each activity yields. As awareness of reference articulates how beliefs about events and behav-
increases, clients can gradually increase participation in ioral, emotional, and cognitive consequences evolve after
meaningful and pleasurable activities and feel rewarded traumatic events (Bruce & Borg, 1993). Its concepts of
by them. To help clients connect their beliefs to their cognitive restructuring, assertiveness training, and stress
engagement in activity, they can be asked to predict how inoculation training are effective in reducing anxiety
much pleasure or mastery they will achieve with sched- and gaining mastery over trauma (Bruce & Borg, 1993;
uled activities, then compare their predictions with actual Meichenbaum, 1994; Stein & Cutler, 1998). Creative visu-
results. At the same time, clients can anticipate obstacles, alization can be used for behavioral rehearsal, practicing
problem-solve their way around them, and develop contin- alternative solutions to problems, or to create safe places
gency plans. A weekly review of the pleasurable activities in to use to elicit a relaxation response in times of high stress
which the client engaged can disconfirm negatively biased (Meichenbaum, 1994; Parham & Fazio, 1997; Stein & Cutler,
recall such as, “My week was terrible.” Occupational thera- 1998).
pists are skilled in grading tasks and assignments according Davis (1999) describes how occupational therapists can
to the client’s ability to perform; graded activities that target use this approach to help children who are victims of
the needs and interests of the individual enable clients to trauma, and to facilitate mastery over the trauma. In this
act on their environments and at the same time monitor case, occupational therapists can help a child acquire func-
thoughts that influence feelings and behaviors. The thera- tional skills that enhance the ability to recognize feelings,
pist can help the client experience success by helping break eliminate cognitive distortions about the event, problem
down large, unrealistic goals into smaller, more manageable solve, and identify more rational options for coping. The
pieces. With success, negative thoughts such as “I can’t do occupational therapist can begin eliciting irrational beliefs
anything well” can be examined and replaced. about the event and help to replace them with more rational
Occupational therapists have been using cognitive beliefs. In doing so, guilt and anxiety about the event may
behavioral principles in their work for some time. In 1987, be reduced, enabling the child to move forward in his or
Mary Johnston published an article titled “Occupational her occupational roles. Stress management skills and asser-
therapists and the teaching of cognitive behavioral skills,” tive communication skills could be incorporated to enable
in which she reviewed established and longstanding occu- the child to communicate feelings and needs in an effec-
pational therapy interventions such as communication tive manner. In addition, occupational therapists can help
skills training, assertiveness training, problem solving and survivors of PTSD learn to handle anger and internalized
management of depression. In the area of communica- rage, which is vital to recovery from trauma. Meichen-
tion skills, she explains that the cognitive skills needed baum’s stress inoculation training has been used success-
to converse more effectively include looking at units of fully to teach survivors and their families to manage these
interaction and examining assumptions and beliefs about powerful and often overwhelming feelings (Meichenbaum,
what has taken place. Recognizing faulty beliefs regarding 1994).
these interactions is an important step that can then be Psychoeducation is an important cognitive behavioral
followed by replacing them with new and more construc- strategy that is often used by occupational therapists
tive ones. In addition to examining underlying beliefs (Padilla, 2002). A basic assumption of psychoeducation is
and assumptions, behavioral skills, such as beginning and that information can enhance understanding of the illness,
200 Chapter 12
identify needed treatment resources, and the supportive compliance and motivation. Outcome evaluations of this
services available (Greenberg et al., 1988). This strategy approach show that self-report measures at pre-, post-, and
has been shown to increase clients’ awareness of their ill- 12-month follow-up suggested clinical improvements for
ness and treatment (Pekkala & Merinder, 2001), to increase five of the seven patients.
daily living skills and adaptive capacities, and create more Another example of CBT incorporated into occupational
productive alliances among clients, families, and mental therapy practice can be found in the work of Yakobina,
health professionals, making treatment more efficient and Yakobina, and Tallant (1997), who applied the approach to
cost-effective (Dixon, Adams, & Lucksted, 2000). Occupa- the treatment of dysthymic women. Here, the occupational
tional therapists bring a unique focus to psychoeducational therapist helps the client in three ways: (1) to alter a negative
strategies because they combine skill building, information, view of self in which the woman sees herself as worthless,
and activity to empower clients to make healthy choices in incompetent, and undesirable; (2) to change the negative
their lives. Davis (1999) suggests that for children suffer- interpretation of her life experiences; that is, a perception
ing PTSD, psychoeducation can be used to teach them and that the world is a difficult, demanding, and self-defeating
their families signs and symptoms and help them recognize place where she can only expect failure and punishment;
how to gain mastery over intense feelings. She suggests that and (3) to counteract a negative view of the future in which
occupational therapists can act as resource guides and pro- the depressed individual expects continued hardship, suf-
vide children and families with books, websites, handouts, fering, and failure (Andreasen & Black, 1995; Kaplan,
and articles on PTSD to help them learn about the disorder Sadock, & Grebb, 1994). The initial step in enabling a client
and to teach basic problem solving and stress management. to achieve these goals is to help her increase her awareness
Other occupational therapy interventions that incorporate of the negative thoughts she uses. This may be done by dis-
psychoeducation have been documented within acute men- cussing how thoughts affect behavior, by teaching her how
tal health units (Cowls & Hale, 2005; Eaton, 2002) and in to identify and record her negative automatic thoughts, and
community settings where practical tasks help clients with by introducing her to the concept that she can control her
severe and persistent mental illnesses optimize community thoughts and thereby change her behavior. The second step
functioning (Crist, 1986). involves helping the client analyze, dispute, and critique her
Addressing adolescents with obsessive compulsive disor- negative cognitions through discussion. The occupational
ders, Söchting and Third (2011) demonstrated how occupa- therapist attempts to refute the client’s automatic thoughts
tional therapists can incorporate CBT into a group format. through the use of activities that will reinforce more appro-
The group protocol included four main components. In the priate thoughts and help to change the client’s behavior
first, psychoeducation, obsessions, and compulsions were (Bruce & Borg, 1993). In so doing, she may be able to assess
defined, and a model of their connection was outlined and her daily functioning more realistically. Mastering activi-
illustrated with patients’ own examples. Second, the con- ties that are meaningful and pleasurable enables the client
cept of cultivating mindful detachment (March & Mulle, to test the validity of her negative assumptions (Andreasen
1998) was introduced and practiced using Schwartz’s idea & Black, 1995). Activities provide cognitive, affective, and
of relabeling. Relabeling teaches patients that their obses- behavioral learning experiences to teach skills, strategies,
sions are not ordinary thoughts but rather the symptoms and methods of coping. With this goal in mind, the occu-
of obsessive-compulsive disorder and, therefore, must be pational therapist, together with the client, must initially
relabeled and referred to as what they are, namely obses- select activities that will maximize success, but activities
sions. Clients are encouraged to distance themselves from can be graded so that dealing with failures in a way that
these obsessions and view them as bizarre “messages” does not employ faulty thinking can become a skill.
that “do not belong to me.” The third component involves While the examples provided thus far use CBT princi-
building a master treatment plan in the form of an exposure ples that are directed at particular diagnostic groups, these
hierarchy to guide a systematic approach to the exposure principles can also be used to address functional limitations
and response prevention exercises to be practiced both in or behaviors across diagnostic groups, and they can under-
the group sessions and between them. In each session, the lie health promotion as well as treatment programs. For
group first reviews homework together, and then breaks example, Herning, Cook, and Schneider (2005) describe a
out for individual exposure and response prevention as group CBT intervention that focuses on helping older adults
planned by the facilitators ahead of time, with the group identify and change negative or unrealistic thoughts about
reconvening at the end of the session to review the session exercise so that they can more effectively maintain their
and receive homework assignments. Last, the concept of exercise behavior. In this program, participants are asked
refocusing as developed by Schwartz (1996) is integrated as to keep a log of their thoughts about exercise, the situa-
a way of increasing tolerance for response prevention. The tions in which the thoughts occurred, and their subsequent
aim of refocusing on an alternative behavior is to facilitate behavior. The authors provide the example of a participant
response prevention. The facilitators strive to work with exercising at home in front of a window who may think,
the established interests of the patients, as this increases “I am so relaxed, I am actually enjoying my exercise while
 Processes of Thought and Occupation 201
viewing all the beauty of spring.” At the beginning of each experience, she reports how engagement in mindfulness
group session, participants share their thought logs with the meditation that had a focus on self-observation of thoughts,
group and through the group discussion, and in doing so, feelings, judgments, and sensations allowed her to see her
gain a broad picture of how unrealistic thoughts may stand persistent pain objectively and observe other sensations in
in the way of exercise. They then practice generating alter- her body, without holding onto the pain. Once she devel-
native thoughts and develop a plan of action to use these oped this skill, she applied the same principles to her every-
new thoughts to guide new behaviors. Herning et al. (2005) day life to learn how to manage her health and engage more
point out that some older adults may, for example, believe fully in meaningful occupations. A specific example of how
that they should be able to exercise for longer periods than CBT approaches can be incorporated into occupational
their stamina allows. Participants learn to recognize these therapy practice is provided in Box 12-3.
negative thoughts, put them in context, and think of other,
more realistic thoughts such as “Yes, I would like to exercise
longer. However, I am making progress. Last week I could
only exercise for 5 minutes.” After participants become
familiar with basic CBT concepts, group sessions focus on
setting short- and long-term goals and eliminating barriers
to goal achievement. Here, participants are able to share Advancement of CBT strategies has relied on measures
problem-solving strategies (e.g., scheduling to maximize to assess irrational beliefs and other cognitively related
energy), share information (e.g., free local walking groups), constructs. One commonly used measure is the Automatic
and learn from one another. Thoughts Questionnaire (Hollon & Kendall, 1980), which
Cognitive approaches are being applied across numer- was developed to assess spontaneous negative self-state-
ous contexts, including the workplace. Gardner, Avolio, ments and intrusive cognitions experienced by depressed
Luthans, May, and Walumba (2005) employed a cognitive persons. The questionnaire lists 30 items, each of which
intervention to determine whether it is effective in helping is a negative thought. The respondent is to rate how often
employees modify their appraisal of stressful situations and the thought has surfaced in the past week on a scale from
lower the effects of stress. The cognitive intervention was one (not at all) to five (all the time). This questionnaire is
compared with a traditional stress management training an inventory of an individual’s negative cognitions and
program that emphasized behavioral coping skills. The addresses issues such as low self-esteem, hopelessness,
cognitive groups received teaching and practice in the cog- negative self-concept, and negative expectations. Good con-
nitive model, identification of negative automatic thoughts, current validity has been reported and Automatic Thought
thought challenging, beliefs and attitudes, positive self-talk, Questionnaire scores are correlated in the moderate-to-
distraction, and relaxation using imagery. Both the cogni- high range with such measures of depression as the Beck
tive and the behavioral intervention were found to reduce Depression Inventory and the Depression scale of the
symptom ratings at the 3 month follow-up but improve- Minnesota Multiphasic Personality Inventory (e.g., Bisno,
ment at follow-up was greater for participants who attended Thompson, Breckenridge, & Gallagher, 1985; Dobson &
the cognitive intervention. Breiter, 1983; Dobson & Shaw, 1986; Eaves & Rush, 1984;
Finally, there is a growing body of literature pointing to Harrell & Ryon, 1983).
the health benefits of mindfulness, which draws on CBT Thought records enable individuals to document
principles (Baer, 2003; Grossman, Niemann, Schmidt, & what was going through their minds under particular
Walach, 2004). Mindful awareness is the ability to con- circumstances when they felt a particular emotion. Com-
sciously observe one’s habitual thoughts and actions that pleting thought records enables people to identify what
are transferred to daily activities (Stroh-Gingrich, 2012). antecedents in the environment may be triggers, and
Being mindful increases engagement with the present helps people identify the thought that may be automati-
moment and allows for a clearer understanding of how cally called up in response. As a result, automatic thoughts
thoughts, feelings and emotions influence health and qual- become accessible for questioning, evaluation, and cogni-
ity of life (McCorquodale, 2013). In her paper on occupa- tive restructuring.
tional engagement as it relates to mindfulness, Elliot (2011) Additional tools include core belief logs that can track
states that mindfulness is “a means by which to ‘wake day-to-day evidence that suggests a core belief is not
up,’ more fully and openly participate in the surround- 100% true (Beck, 1995) and life review, which involves
ing world, and assume responsibility for one’s choices” re-evaluating a core belief’s historical underpinnings. In
(p. 368). Occupational therapists are beginning to incor- each of these cases, the occupational therapist and client
porate mindfulness meditation in their practices—for can examine evidence that supports the core belief and
example, Stroh-Gingrich (2012) describes its application reframe the evidence in a more “rational” manner.
to help people living with persistent pain. Drawing on her
202 Chapter 12

Joan, age 29 years, was referred to the community mental health team by her family doctor. She had been complain-
ing of ongoing and persistent depressive symptoms and relationship difficulties with her husband. Joan thought her
problems had arisen following the birth of her latest baby.

An occupational therapist from the community mental health team visited Joan at her home. At the assessment
interview, Joan described low mood, increased irritability, difficulty carrying out simple tasks, reduced libido, reduced
memory, anhedonia (loss of pleasure), reduced concentration, and reduced energy levels. She was very tearful when
talking about her problems. She expressed some fleeting suicidal ideas but had no plans to act on them as she felt she
was too much of a coward. She denied that she wanted to harm herself. She felt that she was no longer in control of her
life and had no time for herself with the pressures of full-time employment, children, and housework. Her reluctance to
take antidepressants was due to being unsure of the benefits.

Background Information
Joan graduated from college with a diploma in Business Studies. She has been married for 7 years. She worked full time
as an administrator at a local health center and had just returned to work following maternity leave but felt unable to
cope and went on sick leave. Joan was ambitious and regularly took work home to cope with the high demands but still,
she was facing the possibility that she could be laid off due to reorganization at work. Joan believed that her colleagues
in the administrative team underperformed and she thought she was expected to do additional work to compensate for
this. Before the children were born, Joan had been active, and had enjoyed cycling and swimming with friends.

In the first CBT session, the occupational therapist assessed the relationship among thoughts, feelings, and behaviors.
It was also important to establish a collaborative rapport to maximize engagement in therapy and introduce the CBT
model.
Joan described herself as having “always been shy” and lacking in confidence, particularly when getting to know
people. She considered herself to be a “terrible mother” and was concerned that her feelings for her husband had
lessened. She also thought that her parents did not care about her. Joan told the occupational therapist that she had
decided to go on sick leave following an incident at home when she had lost her temper and had used excessive force
while trying to bathe her daughter Sarah who was being uncooperative. She was very distressed about her inability to
control her daughter’s behavior and upset at her own aggressive behavior.
Following Joan’s description of her problems, the therapist described the CBT model and explained how it might
be helpful to Joan. The therapist and Joan identified the links between thoughts, feelings, and behavior. Joan and her
therapist completed a Five Areas of Assessment form that captures a specific situation (Figure 12-1).
During this process, the therapist asked questions that helped Joan identify her thoughts, feelings, and actions.
The aim was for Joan to feel understood and to engender a sense of hopefulness that therapy might be help-
ful. The therapist explained to Joan that she was expected to take work away from sessions and to try things out to see
if they might be helpful.
Together, Joan and the occupational therapist discussed Joan’s situation and arrived at a formulation of Joan’s
problems, as follows: Joan’s unhelpful thinking may have been activated when her performance at work was scrutinized.
Joan believed that she would be exposed as a failure and this fear was applied to other major areas of her life, such as
her role as a mother and relationship with her husband. For example, Joan had thought “My boss thinks I am a failure,”
“I am a rotten mother,” and “My husband does not care for me.” All her unhelpful thoughts are reinforced by the way
she processes information; she has a negative thinking bias and tends to select certain negative aspects and uses this
 Processes of Thought and Occupation 203

Figure 12-1. Joan’s initial five areas of assessment. (Reprinted from Donaghy, M., Nicol, M., and Davidson, K.M. (Eds.), Cognitive-
behavioural Interventions in physiotherapy and occupational therapy, Edinburgh, New York ButterWorth-Heinemann. Copyright ©
2008 with permission from Elsevier Health Sciences.)

to interpret the whole situation. These thoughts link very powerfully to her feeling; a low mood and irritability. When
she feels like this she can behave in unhelpful ways such as withdrawing from her daughter and focusing on unpleas-
ant tasks. She avoids pleasure, which increases how badly she feels. The occupational dysfunction resulting from her
depression manifested as reduced ability to perform the tasks and activities that are required for her major occupational
life roles as wife, mother, and worker.

Session 2
In the second session, Joan discussed some information she had read on depression, on the advice of the occupational
therapist. She said she was relieved to find that other people felt the same way. She discussed her roles and daily activi-
ties and the occupational therapist noticed that Joan focused only on tasks that needed to be done and spoke little
about pleasurable activities, including pleasure time with her children. Joan held the belief that “it’s good to be active
and get things done” and had very little insight into how having little pleasure had affected her mood, and in turn her
ability to get things done, thereby creating a vicious cycle (Figure 12-2).
The occupational therapist asked Joan to keep an activity log as homework, to determine which activities and
occupational roles made her happiest.

Sessions 3 to 5: Increasing Pleasurable Activities

Sessions 3, 4, and 5 began by reviewing an activity schedule in which Joan listed her daily activities alongside the level
of pleasure (on a scale of 1 to 10) and sense of achievement she derived from each (on a scale from 1 to 10). This helped
the occupational therapist and Joan identify pleasurable and valued activities.
Joan’s ratings of pleasure and achievement helped her see that there was an overall lack of pleasure in her life and
that she had become overly task-oriented with childcare, with little time for herself in the day. It was decided to rein-
troduce pleasurable activities, broken down into step-by-step action plans. For example, Joan would try to re-establish
204 Chapter 12

Figure 12-2. Joan’s vicious circle of behavior. (Reprinted from Donaghy, M., Nicol, M., and Davidson, K.M. (Eds.), Cognitive-behavioural
Interventions in physiotherapy and occupational therapy, Edinburgh, New York ButterWorth-Heinemann. Copyright © 2008 with permis-
sion from Elsevier Health Sciences.)

cycling with friends at quiet times and build up to using off-road cycling tracks. The work that Joan agreed to carry out
between sessions would put these plans into action. The occupational therapist and Joan were able to set some initial
goals for therapy:
• Increase awareness of the thoughts Joan has about Sarah, and the impact they have on her depression
• Increase the pleasurable activities in Joan’s life

Sessions 6 and 7: Increasing Awareness of Negative Thoughts

Sessions 6 and 7 focused on increasing awareness of negative thoughts. The occupational therapist recommended using
a dysfunctional thought record (Greenberger & Padesky, 1995) to focus on increasing Joan’s awareness of the impact of
her negative thoughts by looking at a specific time when Joan felt particularly low. An example is provided in Table 12-3.
Joan was encouraged to look at specific situations and identify her thoughts, feelings, physical symptoms, and
behavior. She was asked to rate her emotions as a percentage (feeling low 90%) and look for negative automatic
thoughts. Together, the occupational therapist and Joan identified that Joan was thinking in unhelpful ways that either
lowered her mood or made her feel anxious—she tended to focus on the negative in a situation, would mind-read what
other people thought of her, would make catastrophic predictions about how her children would “turn out,” and would
ruminate on personal standards she had set. Looking at the impact of these thoughts identified that she had begun to
“withdraw into herself” and that this was also unhelpful.

Session 8: Review of Main Goals of Therapy

The eighth session focused on reviewing Joan’s remaining goals in therapy:
• Improving her relationship with her husband
• Exploring her return to work
The occupational therapist and Joan agreed these were long-term goals and split them into short-term and
medium-term goals. For example, the goal of improving her relationship with her husband included the short-term
goal of planning regular time together apart from the children, and the medium-term goal of exploring images that
suggest alternative approaches to their marriage. The goal of return to work included the short-term goal of establishing
a routine at home that would enable her return and a medium-term goal of meeting with her boss to establish working
 Processes of Thought and Occupation 205

TABLE 12-3
’

Reprinted from Donaghy, M., Nicol, M., and Davidson, K. M. (Eds.), Cognitive-behavioural Interventions in physiotherapy and occupational therapy,
Edinburgh, New York ButterWorth-Heinemann. Copyright © 2008 with permission from Elsevier Health Sciences.

TABLE 12-4

Reprinted from Donaghy, M., Nicol, M., and Davidson, K.M. (Eds.), Cognitive-behavioural Interventions in physiotherapy and occupational therapy,
Edinburgh, New York ButterWorth-Heinemann. Copyright © 2008 with permission from Elsevier Health Sciences.

terms and conditions. All the while, Joan would need to work on changing the unhelpful thinking patterns that stood
in the way of these goals.

Sessions 9 to 12: Challenging Negative Thoughts

In the set of sessions that followed (sessions 9 to 12), Joan began to challenge some of the negative thoughts that
contributed to her low mood. She used dysfunctional thought records to guide her in evaluating the evidence for and
against negative thoughts. She noticed that evaluating her thoughts, or looking at them in a different way, did make
a difference to the way she felt. Table 12-4 documents the process of challenging the negative thoughts that were
presented earlier in Table 12-3.
Joan noticed that believing thoughts such as “I am a terrible mother” prevented her from letting her daughter Sarah
have positive experiences with her. Joan went on to use thought records to help her identify and challenge negative
thoughts related to returning to work. Table 12-5 illustrates this process.
206 Chapter 12

TABLE 12-5

Reprinted from Donaghy, M., Nicol, M., and Davidson, K.M. (Eds.), Cognitive-behavioural Interventions in physiotherapy and occupational therapy,
Edinburgh, New York ButterWorth-Heinemann. Copyright © 2008 with permission from Elsevier Health Sciences.
 Processes of Thought and Occupation 207

Alternative conclusions to her unhelpful thoughts were obtained through looking at the evidence for and against her
thoughts. Beliefs and assumptions such as “If I were good at my job, I would not make mistakes” are replaced with “I am
making too much of a simple mistake.”

Session 13: Final Session

The final session focused on reviewing Joan’s progress in therapy to help her to identify what had been helpful or
unhelpful, and what “new life rules” she could develop to help her maintain her progress. Joan came to appreciate the
value of keeping a record of her achievements, and having a review day when she stopped to take stock of all the things
she has done that were acceptable to her or had given her pleasure. Joan and the occupational therapist documented
her new life rules:
• I know I tend to see the negative in everything—it would be helpful to challenge this with my thought records
and positive event log.
• To be a good mother, I also need to make time to enjoy myself.
• It is good to be active and get things done, but not to the exclusion of pleasurable time for myself.
• I do not need to rely solely on other people’s opinion of my work.

Reprinted from Donaghy, M., Nicol, M., and Davidson, K. M. (Eds.), Cognitive-behavioural Interventions in physiotherapy and occupational therapy,
Edinburgh, New York ButterWorth-Heinemann. Copyright © 2008 with permission from Elsevier Health Sciences.

CBT outcome studies have concluded that this treatment

approach is highly effective for depression and anxiety dis-
Outcomes of CBT interventions have typically been orders (Butler & Beck, 2000; Gaffan et al, 1995; Wright et
captured through measurement of symptomatology, but al., 2003). Studies typically show CBT to be as effective as
there are some examples of evaluation processes that go antidepressant medication for the treatment of depression,
beyond illness indicators. Davis, Ringer, Strasburger, and but there are mixed results regarding the effectiveness of
Lysaker (2008) describe a participant evaluation of a CBT combined treatment (CBT and medication) for depression.
program for enhancing work function in schizophrenia. The most robust evidence of CBT as an efficacious treat-
The survey included questions regarding how well partici- ment can be found in large-scale studies of people who had
pants liked the intervention, what program elements CBT chronic or severe depression; these studies show that com-
participants found beneficial, and what program improve- bined treatment gives better results than either treatment
ments they would suggest. The researchers compared their alone (DeRubeis, Gelfand, Tang, & Simons, 1999; Hollon et
level of satisfaction with that of participants in a control al., 2005; Keller et al., 2000). The overall results of studies of
group receiving support alone. The CBT intervention was patients with depression or anxiety disorders indicate that
associated with greater participant satisfaction than sup- CBT may be used alone as an effective treatment for these
port alone, particularly the perception of the overall quality conditions and that for severe or chronic depression, com-
of services and assistance with problem solving. During bined therapy with medication is recommended.
the interviews, CBT participants reported that they found CBT also has research support in the treatment of other
connection with other participants and program staff to be disorders such as bulimia nervosa and schizophrenia, where
beneficial, as well as assistance with cognitive restructur- it can be used as an adjunct to pharmacotherapy (Rector &
ing, problem-solving, and providing/ receiving work-relat- Beck, 2001; Turkington, Dudley, Warman, & Beck, 2004;
ed feedback. The authors conclude that participant evalua- Wright et al., 2003) or to increase the attainment of work
tions can function as a source of useful data for evaluation goals. CBT has also been shown to reduce the risk for
of CBT interventions for persons who have schizophrenia. relapse in bipolar disorder (Lam et al., 2003) and to help
208 Chapter 12
patients with medical disorders cope with pain and disabil- 2. You and your client are discussing her goal of working
ity (Sensky, 2004). CBT has been found in at least one study at a paid job, when she states, “I will never be able to
to significantly reduce the frequency of subsequent suicide do this; I fail at everything.” What are some strategies
attempts among people who had previously attempted sui- you can draw on to help her think differently about her
cide (Brown et al., 2005). potential for work?
Some research exists on the effectiveness of CBT 3. Discuss how mindfulness can be used in occupational
approaches as applied to occupational therapy. A critical therapy to enhance occupational performance and
review of the published literature on cognitive-behavioral experience.
interventions with people with chronic pain was conducted
by the McMaster group on evidence-based practice. Their 4. Discuss how activity can be incorporated into a
primary question was, “What is the effectiveness of cog- cognitive behavioral approach.
nitive-behavioral interventions in improving occupational
performance (function) for people with chronic pain?” They
included studies of CBT that included at least three of the
following modalities: relaxation, stress management, goal
setting, self-monitoring/self-talking, assertiveness train- Andreasen, N. C., & Black, D. W. (1995). Introductory text-
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Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New
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has demonstrated their application to occupational therapy come following an intervention for controlling depression.
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CBT, and the strong alignment of its principles with occu-
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pational therapy principles, makes this approach an appeal- the prevention of suicide attempts: A randomized controlled
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rated into everyday occupational therapy practice are yet to therapy: Frames of reference for intervention. Thorofare, NJ:
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