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Conceptualizing mode deactivation therapy as a moodle-based online program for adolescents and adults to relieve belief-oriented distress.

MODE DEACTIVATION THERAPY (MDT) is a third wave cognitive behavioral therapy that has proven effective in multiple randomized controlled trials for the treatment of adolescents with complex problems (Swart & Apsche, 2014b). A meta-analysis that combined the results of 12 different studies with a combined number of 699 participants found that MDT consistently produced statistically significant improvement in the symptomatology of subjects. The MDT protocol is based on the core principles of mindfulness, acceptance, cognitive defusion, and redirection. It utilizes the unique process step Validation-Clarification-Redirection, or VCR, as major therapeutic change element. In VCR the client's unhelpful core beliefs are validated as reasonable and logical in the realm of their circumstances and experiences. By exploring the "grain of truth" in the client's beliefs, private experiences (e.g. thoughts, feelings, memories, and moods), and behaviors, its context and impact is clarified. The client is guided to develop functional alternative beliefs instead and coaxed to redirect their cognitions accordingly. This approach has proven successful even among resistant clients with complex comorbidity.

Traditionally the MDT program is conducted during individual or family face-to-face sessions that usually extends over about 18 sessions. The purpose of this paper is to examine two questions that will have important implications for the continued development and improvement of a new delivery mode and applications of MDT.

Can the MDT protocol be delivered effectively in an assisted online mode?

MDT's logical basis was developed by Dr. Jack Apsche in the late 1990s using the cognitive principles set forth by Drs. Aaron Beck and Albert Ellis from the 1950s onward. He conceptualized the link between core beliefs and behavior as the primary basis of psychological distress. Based on this understanding the need for mindfulness, validation, and redirection was identified and evolved into a structured methodology that is both robust in application, but specific in delivery. As an effective treatment for troubled adolescents was much needed at the time, MDT was established within this population, proving to be an effective evidence-based approach in many empirical research studies. But, especially in the past decade, the need for brief, accessible, and robust treatments for behavioral and mood disturbances at all ages has become even more apparent.

With the Internet now used by almost 40 percent of the world population and more than three of every four people in the developed world, the realization has come that it could be a viable modality to deliver mental health services cost-effectively and without geographical limitations for providers and patients. Research has already demonstrated success in various modes of "e-therapy", often with little distinction in outcomes compared to face-to-face deliveries. It is reasonable to assume that MDT will realize equally positive results through an online mode, and the potential benefits warrant exploration.

Is MDT expected to be effective as a treatment approach for adults with behavioral, personality, and mood-related issues?

In the traditional face-to-face modality MDT has proven to be more effective than treatment-as-usual and other cognitive behavioral protocols when treating adolescents with behavioral and complex comorbid conditions. The theory is based on cognitive principles of modes and schemas that are underpinned by deep-seated core beliefs. By creating a mindful awareness MDT targets problematic beliefs and modes in order to redirect them to functional alternatives. This is the premise of MDT in a nutshell, and it is logical to conclude that the same philosophy is valid for adults with behavioral, personality, and mood-related issues, at least to the point that invite further work.

Therefore, this paper is to be considered as the first step in a process to adjust and expand the Mode Deactivation Therapy methodology to be able to provide a cost-effective psychotherapy service to more people in need.

* A review of the status of online therapy

Since the advent of online therapy about 10 years ago, there has been a continued debate in favor or opposition to the practice. There are several possible advantages and challenges that continue to shape the development, which include the circumstances, types of clients, and their particular needs that determine their match for online therapy (Rochlen, Zack, & Speyer, 2004). As the technology robustness, availability, and access continues to expand rapidly, frequent reviews are helpful to reexamine causes for concern as well as potential benefits for therapists and clients.

Potential benefits of online therapy

Access and convenience. Perhaps the most cited benefit of Internet-based therapy is the increased access and convenience for both therapist and client. It can remove geographical imbalances of therapist-patient ratios. According to the World Health Organization (who), the global burden attributable to mental and substance abuse disorders increased 37.6% between 1990 and 2010 (Whiteford et al., 2013). A study by Bruckner et al. (2013) found that all low-income countries and almost two-thirds of middle-income countries have far fewer mental health professionals that they need to deliver only a core set of interventions to cope with this growth. The need is only becoming greater with the number of armed conflicts and failing states increasing, as well as continued rapid urbanization globally that stresses stability and resources. Therefore, there is an overall shortage of cost-effective and affordable interventions in these countries, but also an inequitable distribution of mental health resources in many other areas compared to the proportionate burden of mental health disorders (Saxena, Thornicroft, Knapp, & Whiteford, 2007).

Disinhibition and internalization. The mode of online communication has been found to encourage therapeutic expression and self-reflection (Rochlen, Zack, & Speyer, 2004). According to Suler (2004), this online disinhibition effect causes more intense self-disclosure as people instinctively feel anonymous and dissociated, which lessens the fear of an immediate negative response and judgment. People are therefore able to move into themselves as the effects of transference are not as pronounced as the fears and perceived expectations are often experienced in diminished forms. The power differential between therapist and patient is also minimized as the compounding effects of body language, appearance, and environment are eliminated. Online platforms have the distinct effect of leveling the playing field, which increases the sense of a peer relationship with less apprehension of disapproval and punishment.

Self-reflection and ownership. The asynchronous and faceless nature of an email or online forum-based therapeutic interaction stimulates more intense self-reflection and disclosure. It is possible to promote feelings of empowerment and autonomy in the therapeutic process as patients are able to enact a natural rhythm of writing based on their needs and preferences. People do not feel as obligated to respond on the spot to online comments and questions compared to face-to-face real-time communications.

They can utilize time to think, evaluate, and compose their reply (Suler, 2010). It is referred to as a "zone of reflection" (p. 28) that is utilized to mediate potentially awkward or emotional situations in an interaction. It has the benefit of strengthening emotion regulation by cultivating a new temporal perspective before formulating a response. As such, their reaction is often more rational and mature instead of an unthoughtful and impulsive reply.

Therapeutic value of writing. Evidence that writing about emotional experiences has generally helpful value has been offered by Pennebaker (1997). This notion has spawned more than 200 studies in the past two decades, which provided a better sense of the positive influence of expressive writing. These studies highlighted that writing about emotional issues for a minimum of 15 minutes for at least three times, ideally separated by one to two days in between, works best in a clinical setting (Pennebaker, 2010). However, "writing immediately after an emotional upheaval is not recommended." (p. 24). Expressive writing should instead be encouraged when a person ruminates about an issue outside of a range that is reasonably considered normal. Although forms of expressive writing has been used as homework within psychotherapy for over 50 years, its application must be customized for each individual client. Regular monitoring and feedback is used to determine effectiveness. Many online therapy practices are naturally inclined to depend on expressive writing and encourage its use beyond homework assignments.

Telepresence. The concept of telepresence has been described as the "feeling (or illusion) of being in someone's presence without sharing any immediate physical space" (Rochlen, Zack, & Speyer, 2004, p. 272). This effect is obviously not as pronounced in asynchronous text-based communication than interactions occurring in real-time via video, telephone, or even live chat. While such a sense of real-time presence can be comforting and validating, it can also introduce distracting and superficial aspects such as subconscious monitoring the behavior of others around them and adapting their own behavior accordingly. In comparison, text-only communication eliminates these factors. Some online supporters even claim that it connect the person "more directly to the other's psyche" (Kraus, Stricker, & Speyer, 2010, p. 152).

Multimedia. In email and online forum applications such as Moodle rooms there is an added advantage that the facilitator can quickly and seamlessly link or make supplementary information available to clients. Such material may include educational website links, video clips, documents, and assessment tools. A context with limitless resources is created that is highly adaptive and responsive to the client's unique needs at any time. It is similarly valuable to enhance the therapist's knowledge whenever required.

Therefore, the benefits of online therapy are varied and promising; especially suitable for anyone with basic computer savvy and access to email and Internet. With attention to detail, timing, and expert linguistic use, a good rapport can be built with almost any patient in a short span of time. The geospatial distance provides an additional buffer to promote personal reflection and minimize anxiety.

Challenges and concerns of online therapy

However, in addition to the many benefits and opportunities that online therapy offers, there are also challenges and concerns to consider and navigate. It is likely that Internet-based therapy does not suit all providers and patients equally well. Careful reflection on the part of the therapist and conscientious assessment of the abilities and attitudes of the patient is required to ensure that the benefits of online therapy can be realized instead of allowing problems and incompatibilities to prevent progress.

Visual and verbal cues. A well-known standard for understanding the importance and impact of nonverbal communication was proposed by Mehrabian (1972): The 55/38/7 percentage formula represents the percentages of importance that varying communication channels have with the belief that 55% of communication is body language, 38% is the tone of voice, and 7% is the actual words spoken. Many of these interpretations occur rapidly and instinctively on a subconscious level. With little conscious thought the recipient/observer adapts their own behavioral and emotional response to the perceived meaning of the inputs. Therefore, the nonverbal behavior of a patient and other visual cues provides important information to the therapist that may otherwise have gone unnoticed. Therapists are usually skilled observers who draw inferences from all behavioral clusters, which are utilized in the therapeutic alliance and treatment process. Although it is subjective and can be misinterpreted, nonverbal signals that contradict or support verbal messages present an additional window to the patient's thoughts and feelings, which they may not choose to expose intentionally. This is commonly referred to as leakage. Similarly, the therapist is able to employ body language in a face-to-face interaction with a client to enhance perceptions of empathy, alliance, and treatment credibility. Examples are high eye contact and forward trunk lean (Dowell & Berman, 2013). The lack of visual contact in text-based therapy also rule out some experiential therapeutic techniques that require in-person presence (Rochlen, Zack, & Speyer, 2004).

Misinterpretation and reassurance. In online therapy, especially asynchronous text-based modalities, there is an absence of spontaneous and immediate clarification (Rochlen, Zack, & Speyer, 2004). Patient with certain characteristics such as dependency and attachment issues, poor self-esteem, and paranoid features, may benefit from direct reassuring visual and verbal cues. In text-based communications a therapist has to have heightened awareness of how their messages could be interpreted. Therefore, they must be especially skilled in conveying messages and their emotional content accurately and sensitively. By using the appropriate tone and level in written communication, the therapist can enhance the motivation and receptiveness of a patient.

Solipsistic introjection. It refers to the sense in online interactions that the view of the self is the only tangible reality. This can cause heightened self-absorption that alters self-boundaries. Although the other person in online communication may be largely unknown and anonymous, they can become a character within the person's own "intrapsychic world, a character shaped partly by how the person actually presents him or herself via text communication, but also by one's internal representation system based on personal experiences, wishes, and needs." (Suler, 2004, p. 323). As a result, there is a sense that the introjected character becomes more elaborate and subjectively real, often significant parts are imagined, or subconsciously fabricated and embellished. Such a blurring of reality and fantasy can become like a stage that may unleash undesired psychological effects such as abusive and inconsiderate online behavior, or increased dissociation.

Time delay. All communication that are not real-time or live is intrinsically asynchronous to a larger or lesser extent, depending on the participants' routines and habits. Although some temporal buffers can be beneficial in providing both the patient and therapist time to reflect, unexplained delays can increase anxiety and feelings of emptiness and disconnect, which is sometimes referred to as the "black hole phenomenon, i.e. the ambiguity in the no-reply can become a blank screen where easily we can project our own expectations, emotions, and anxieties" (Richards & Vigano, 2012, p. 704). The therapist must again be aware of and attuned to the patient's expectations in order to manage it effectively. Time delay can also be utilized by the therapist to relieve perceptions of pressure that the patient may have, as well as an effective observation and response to counter-transference issues. The crux of therapy approaches, and especially text-based communication, is to know and manage the patient's expectations, in part by creating rules, guidelines, and habits that enhance stability and predictability.

Online skills. As has become evident by now, both the therapist and patient is required to have adequate online and writing skills and etiquette, including computer literacy and a familiarity with and willingness to use the required technology. Schulenberg and Yutrzenka (2004) underscored the importance that the therapist is attentive to the patient's attitude towards computers and the Internet, know whether they have any aversion and anxiety that may hinder their ability and willingness to participate in online activities--this may include uncertainty about confidentiality and privacy--or any other issues and limitations that could be relevant. Therapists using any online or computerized tools have the responsibility to establish the specific competence and take all reasonable steps to ensure the security of a patient's data and communications, and their wellbeing. This includes multicultural competence as relating to online interaction, as well as consideration of social systems and values, and time zones. Ease and cost-effectiveness of access can easily be offset by perceived or real biases and misunderstandings. Therefore, communicate readily, regularly, and accurately.

Crisis intervention. One concern that is almost always raised about online therapy is the inability to deal effectively and timely with a crisis such as homicidal and suicidal thoughts or behavior. As it is also the responsibility of an online therapist to help patients manage crises, they should ensure to have the infrastructure and protocols in place to respond to emergencies. Guidelines should be provided and readily available to patients from the outset, and in cases of more serious and pressing emergencies, therapists should revert to procedures that are consistent with face-to-face relationships, including providing patients with a toll-free number for use in such cases, contacting the appropriate authorities in the proximity of the patient, and having details of an emergency contact person available (Mitchell & Murphy, 1998). This implies meticulous and up-to-date recordkeeping of a patient's location, and primary and secondary contact channels. According to Fenichel et al. (2004), there is no reason why the handling of a patient emergency should be less effective in an online therapy relationship compared to traditional therapy, given that the appropriate procedures are put in place.

Cultures and values. The importance of considering cultural and other values, beliefs, and practices has been highlighted in various respects before, including the therapists responsibility to ensure that s/he is multiculturally competent, considers the patient's unique position, their familiarity and propensity to use computers to navigate and communicate online, in addition to other characteristics that may be equally relevant in conventional therapeutic relationship. In practical terms, their knowledge of computers and online access may be such that their ability to process certain tasks is compromised. Examples are large files, unusual formats, and unfamiliar software. The delivery of an online service should be adapted to the patient's ability. The same principles applies to writing and linguistic skills.

Privacy and security. The issue of online privacy and security of patient information and communication has already been briefly highlighted. It is the therapist's duty to put all reasonable measures in place to ensure that all data storage and transactions are secure and that the patient is informed of these steps, possible limitations, and responsibilities.

Although the challenges and concerns pertaining to online therapy seem limiting to the effective application of this modality, the potential benefits of cost-effectiveness and reach in increasingly technologically savvy societies offer exciting possibilities. Essentially, the playing field is leveled in terms of affordability and availability of therapy at any time and any place.

Evidence of the effectiveness of online interventions

A meta-analysis conducted by Azy Barak and his colleagues found that the mean weighted overall effect size of the included studies was similar to the average effect size of traditional, face-to-face approaches (Barak, Hen, Boniel-Nissim, & Shapira, 2008). Their analysis included 92 studies involving a total of nearly 10,000 clients who were treated for a range of psychological problems using various Internet-based interventions, including self-help therapy, guided online therapy, and online communication-based therapy. Barak et al. concluded that Internet-based interventions seem better suited to treat problems of a psychological nature involving dysfunctional thoughts, feelings, and behavior, rather than problems that are primarily physiological or somatic.

Focusing only on panic, anxiety, depression, and PTSD, the weighted average effect size is 0.62, which is considered medium. In the 33 studies that measured effectiveness at later follow-up, the mean effect size was not significantly different (0.59), which implies that Internet-based therapy is effective and durable. Three main approaches were considered: (1) CBT that focused on cognitive changes, (2) psychoeducation primarily aimed at providing information and explanations on a problem area, and (3) behavioral interventions that focused on the modification of target behaviors. Significant differences were found in the respective outcomes, with CBT performing the best (average effect size 0.83), and behavioral approaches the worst (ES 0.23). In terms of age, adults between the ages of 19 and 39 seem to gain more from online therapy than younger and older clients. However, Barak et al. cautioned that only a few studies reported specific ages.

In terms of mode of delivering therapy, the effectiveness of web-based therapy was found to be similar compared to online communication methods such as email, voice and video calls. Web-based individual therapy was found to be more effective than group therapy, and an interactive delivery achieved better results than static sites. The former is more typical of CBT approaches, while the latter is often used for psychoeducation content. It was also found that some form of pre-screening or assessment enhanced online therapy outcomes, arguably by optimizing the patient fit and elevating commitment and motivation. No statistically significant difference could be established between synchronous (i.e. voice or video chat) and asynchronous (i.e. email or forum) communication modes. Furthermore, in general, multi-channeling of communication appeared to hinder rather than enhance effectiveness of the overall intervention. Therefore, Barak et al. concluded web-based self-help therapy is at least as effective as conventional face-to-face therapy, and is enhanced by pre-screening and authorizing patients.

Another, more recent study, by Hedman, Ljotsson, and Lindefors (2012), agreed that Internet-based therapy is a promising treatment that may benefit the availability and cost-effectiveness of psychological interventions. A total of 1,104 studies were reviewed, with 108 meeting criteria for inclusion, and applications for depression, social phobia, and panic disorder the best established. Hedman et al. found that effect sizes were large in the treatment of depression and anxiety disorders, with at least equal effectiveness compared to conventional cbt, but with a significantly higher cost-effectiveness. Nearly all included studies relied on "fairly simple text-based treatments with minimal therapist support using e-mail-like messaging systems" (p. 757). In their conclusion, Hedman et al. noted the "general emerging picture is that ICBT produces about the same effects as conventional CBT does for each specific clinical disorder" (p. 759), but that it may be less optimal for certain patient groups such as patients with Borderline Personality Disorders, severe forms of Obsessive-Compulsive Disorder, or disorders with psychotic features. Nevertheless, it is expected that Internet-based therapies will increasingly become part of routine psychiatric care as the reach is far improved, with much less therapist time involved--often less than 20 minutes per patient per week--without compromising effectiveness.

* The scope of the current study

The current study conceptualizes the adoption of the existing face-to-face Mode Deactivation Therapy (MDT) protocol into a briefer, online program designed to utilize the same theoretical principles. Compared to the usual program that is conducted over 18 sessions or more for about eight months, it is proposed that the online schedule be shortened to comprise 12 sessions that are conducted at a suggested rate of one per week. Depending on the personal circumstances and needs of the patient the tempo can be slowed down at preferred stages. At a later stage, after preliminary tests, the number of sessions could even be condensed to six or eight, which may be beneficial for certain patients and conditions, but could compromise effectiveness and durability of improvements. The online MDT program will, at least for initial tests, be based on a Moodle platform, which is a technology that allows web-based forums, virtual interactions, easy sharing of information and resources, and email to supplement online communication.

Technology framework and accessibility

The design of the online program is proposed in accordance with Moodle capabilities. Moodle--the acronym for Modular Object-Oriented Dynamic Learning Environment--is an open-source software e-learning platform with a focus on interaction and collaborative constructions of content. It is a relatively new technology, with the first version of Moodle released in August 2002. In November 2014, there were more than 54,000 registered sites in 231 countries. Countries with more than 2,000 site registrations each are the United States, Spain, Brazil, United Kingdom, Mexico, and Germany. At the same time there were more than 69 million individual users on Moodle sites. The platform is also sometimes referred to as a Learning Management System (LMS), or Virtual Learning Environment (VLE).

Moodle has several features that are useful on an e-learning platform, including announcements, files download and sharing, assignment submission, instant messaging, online scored quizzes, surveys, authentication and other security measures. It also allows for a self-help or instructor-led functionality. In addition to online learning, these features are practical and easy-to-use for application in online therapy, counselling, or coaching for well-being and performance improvement.

Users can install Moodle from source and use customized plugins, but this requires a fair deal of technical proficiency. Alternatively, many web hosting services facilitate a "one-click install" service via commercial script libraries that automates the installation of web applications such as Moodle to a private website. For the purpose of this study Fantastico was used to install Moodle. All capabilities and themes used are part of the standard Moodle 2.7 version. No customization was done. Moodle rooms can be accessed through the Internet, via pc, tablet, smartphone, or any other Internet-enabled device.

One of the main advantages of Moodle room and other Internet-based applications is that access to the Internet has had an incredible growth--from an estimated 10 million users in 1993, to 670 million in 2003, to 2.7 billion in 2013--and is continuing to grow rapidly in developing countries in Asia, Africa, Latin America, the Caribbean, and the Middle East. Already, an estimated 77% of people in the developed world and 33% in the developing world have access to the Internet. Lack of mental health services is most critical in areas that are hard to reach or have a lack of services.

It is in particular these populations, as well as those wishing to engage from the privacy and convenience of their own homes, that can be fruitfully served by online mental health services. Not only does online platforms have the ability to reach people and populations in need, but guidance can be provided by a provider who is based anywhere, and Moodle courses can also be employed to provide training to local mental health providers and other information to its users. In addition, a Moodle site can easily be installed and operated in a language other than English. At this time language packs are available to facilitate Moodle site design in 86 different languages.

As The Moodle platform is open sourced, extremely affordable, easy to use and design, and already in use in thousands of online classrooms by millions of students and service users, it is a suitable choice for this application. Next, the manualized methodology that are applied in the 18 sessions or so of the typical MDT schedule are "deconstructed" into its distinct instruments and techniques, namely:

* Psychoeducation and goal-setting

* Personality beliefs and compound core belief assessment

* Assessment of fears and avoids

* Understanding and monitoring thoughts and feelings

* Mindfulness

* The role of situations and beliefs in thoughts and feelings

* Triggers, Fears, and Avoids worksheet

* Conglomerate of Beliefs and Behaviors worksheet

* Validation

* Clarification

* Redirection

* Reinforcement and wrap-up

Each of these instruments and techniques are assigned to a module in the program and presented in the format and sequence of definition, education, review of previous homework assignment, practical exercise to illustrate the relevant principles and techniques, and assignment of a new homework exercise. Ideally, the patient submits assignments on a weekly basis, which are reviewed and commented upon by the provider who acts as mentor and collaborator. The necessary administration, guidelines, informed consent and security protocols are also put in place before the start of a program. After completion of the assigned sessions progress is reviewed and a decision made regarding the patient's best options for the future.

* Session 1: Introduction and the importance of thoughts and beliefs

Mode Deactivation Therapy (MDT) combines psychoeducation with cognitive techniques and behavioral exercises--similar to most other CBT-based approaches. The objective of the first session is to start engaging in discussion with the patient in order to obtain and dispatch information. At this time the online registration and informed consent process has been completed and establishment of a therapeutic alliance is underway and further solidified by continued personal contact. The patient is encouraged to share any concerns or questions regarding the process or any aspect thereof.

The first online session covers a description of the MDT theory, primarily the principles of cognitive theory--how thoughts, feelings, physical sensations, and behavior relate. The concept of core beliefs, including their subconscious purpose and how they are generated by cumulative life experiences, is explained. As the result of each person's cumulative life experiences to date, core beliefs are designed to help a person cope with and assign meaning to events and situations. Also called personality beliefs, it can be quite persistent in influencing persons' attitudes and views about themselves, others, and the world in general. There are positive beliefs such as that others are trustworthy and one's own esteem is healthy and justified, but it is the negative beliefs that are often problematic by causing distress and undesirable behaviors. As indicated in the diagram, unhelpful core beliefs can cause worry and anxiety when triggered by an upsetting situation. Negative feelings, emotions, and physical symptoms are linked to negative thoughts, which often lead to unhelpful actions such as withdrawal, aggression, excessive eating, drinking, or other problems that negatively influence one's functioning and social interactions and relationships.

By emphasizing the role of thoughts in psychological well-being, MDT uses a systematic, goal-oriented procedure. There is a specific number of steps with a beginning and an end that better enables the patient to work towards specific and well-defined personal goals. There are twelve sessions in total, which all center on a practical exercise with explanation of the relevant principles and goals that it is based on. It is entirely self-paced, and can take as much, or as little, time and repetition as required to extract the most benefit. In the next session, problems that the patient believe interfere with achieving their long-term goals will be identified. These will be explored and analyzed further in subsequent sessions to devise an improvement action plan.

As a homework assignment before the second session the patient is asked to think about, identify, and formulate personal goals and expectations of the online process by being as much realistic, concrete, and specific as possible instead of too optimistic, abstract or vague.

The patient is reminded to consider categories such as family, friends, work or school, health and body, psychological well-being, and spirituality to formulate their desired goals; be sure to start small, be patient, and don't think in all-or-nothing terms. In preparation of the next session, the patient is expected to list at least three to five things that they want to achieve in the next month, year, or five years. The patient posts the list to the Moodle room forum where it is reviewed by the MDT therapist for comments and preparation of the subsequent steps.

* Session 2: Personality beliefs and CCBQ assessment

In the second online session the patient will complete the Mode Deactivation Therapy (MDT) Compound Core Belief Questionnaire-Short Version, or CCBQSV. They will make a note of belief items that they endorsed with a "3" (almost always) or "4" (always). The CCBQ-SV has 96 items that are rated on a 4-point Likert scale. The results provide a personality profile of the patient in terms of eight personality clusters, namely antisocial, avoidant, borderline, dependent, histrionic, narcissistic, paranoid, and passive aggressive. According to the CCBQ's developer, Dr. Jack Apsche, obsessive compulsive and schizoid types were not included as none of the criteria pertaining to these clusters have ever been endorsed in clinical trials and there was a need to shorten the long-form questionnaire to make it more practical, user-friendly, and cost-effective (personal communication, July 12, 2014). Each item in the questionnaire is related to one of the personality types and 12 items make up one cluster. In face-to-face MDT practice the CCBQ is completed by hand or computer, and analyzed by computerized scoring. In the online program, the questionnaire will be completed online by the patient during the second session, but will not be scored immediately. The items will either be scored by hand or input into computerized scoring by the online therapist or an administrator/assistant, which will yield a personality cluster analysis, highlight individual items that are highly endorsed, as well as identify potentially life-threatening or treatment-interfering beliefs.

There are 9 items that, when highly endorsed, provide a warning of a potential life-threatening situation that may develop based on a particular belief. Examples are:

"When I am angry, my emotions are extreme and out of control."

"When I hurt emotionally, I do whatever it takes to feel better."

"Unpleasant feelings usually escalate and then get out of control ... and get worse"

In general, life-threatening beliefs are related to very poor emotion regulation or a high internalization of unpleasant thoughts and feelings. Similarly, there are 17 items that, when highly endorsed, alert the MDT therapist to personality characteristics that are likely to interfere with the effective delivery of therapy. Examples are:

"Everyone betrays my trust. I cannot trust anyone"

"I am inadequate; I will do whatever I must to hide it"

"I would rather not try something new than fail at something"

"If other people get any information on me, they will use it against me."

I can do what I want; consequences don't affect me directly unless I am caught."

In general, treatment-interfering beliefs are those related to avoidant and dependent behavior, antisocial and paranoid tendencies. Grandiose beliefs and low self-esteem can also interfere with the delivery of effective treatment as the individual typically has an unrealistic self-concept that is not in balance with their environment. They will either adopt a resistant/confrontational/dismissive approach to the therapist, or be submissive and cling to the therapist while taking all steps to get approval and avoid unpleasant situations and confrontation. The results of the CCBQ-sv are very useful to the online therapist to determine the style and approach of communication that will suit the individual patient best. The patient is reminded to print a copy of the completed CCBQ-sv, which s/he reviews and makes notes of the higher endorsed and more problematic beliefs and what it means in his/her life. A copy of the CCBQ (including scoring instructions) is available online at http://www.apschecenter.com/pdfs/Pg1.pdf (Swart & Apsche, 2014a).

* Session 3: Fears, avoids, and MDT fear assessment

The MDT Strength of Fears Questionnaire (SOFQ) consists of 60 multiple choice items that are rated on a 4-point Likert scale to indicate whether a fearful situation or object is "never", "sometimes", "almost always", or "always" experienced over the most recent 30 day period. Although the total score is useful as an indication of the individual's overall level of fear and anxiety compared to a benchmark score somewhere between "never" and "sometimes", the questionnaire is applied to identify individual items that elicit a high and frequent feeling of fear.

The questionnaire is completed online during the third session of the program. The patient again prints a copy of his/her results for future review and reference, while the results are available to the online therapist. Together with the problematic beliefs that were identified in the previous session, the highly endorsed fears are noted and incorporated in individualized communications, examples, guidelines, and exercises. During each of the ten weeks of the online MDT program, the therapist should plan to communicate at least two times via email or Moodle room forums with the patient, but maybe more, depending on the patient's individual needs and response style. The third session is devoted to the importance of being aware and monitoring problematic thoughts and feelings as they occur. The Strength of Fears Questionnaire (SOFQ) is available at http://www.apschecenter.com/pdfs/article-5.pdf (Apsche & Ward Bailey, 2003).

* Session 4: Understanding and monitoring thoughts and feelings

After the first three sessions a firm therapeutic relationship is likely established. The patient has a basic understanding of the cognitive behavioral sequence and the importance of thoughts and feelings as it is expressed in behavior and activated by core beliefs in the presence of a contextual trigger. S/he has also identified problematic beliefs and fears and has had time to contemplate their possible consequences. At this time the therapist also has an understanding of the patient's personality characteristics and problematic fears and beliefs that are likely at the core of their behavioral or mood problems, including those that may create life-threatening situations and prevent effective treatment. S/he also has had multiple email or online forum exchanges with the patient, in excess of at least six exchanges.

In session 4 the value and importance of being aware of and monitoring problematic or unpleasant thoughts and feelings is highlighted. Negative thoughts are mostly generated at subconscious levels and instinctively lead to negative emotions and sensations, which are the evolutionary motivators of behavior to protect ourselves from distress and threats. The concepts of internalized and externalized behavior are explained, as well as the importance of mindfulness and acceptance in order to eliminate the need to control or avoid negative experiences. The need for a realistic understanding, awareness, and appraisal of emotional cues is briefly mentioned, as well as the development of emotion regulation skills. Von Scheve (2012) argued that emotion regulation and awareness are two sides of the same coin. The process between situation and response is largely sequential and instinctive (see Figure 3), but a better understanding and awareness of the preceding factors and defining features enables a thoughtful and deliberate management of the process.

Leading to the next session, the patient is asked to keep a daily thought log or record. Its main objective is to foster an awareness of negative or unhelpful thoughts, which is the first step in managing and redirecting those further along in the program. Using a simplified sheet, each negative thought is recorded as it occurs. The preceding or related event/situation is briefly described, together with the patient's response or consequence in terms of emotion and behavior. Emotions are rated between zero and 100, and body sensations mentioned where present.

Using the fourth and final column, the patient reviews his/her list of fears and negative beliefs that were identified in the previous two sessions. S/he asks the question: For each negative thought, did any of those relate? The daily recording of negative thoughts and feelings creates an awareness of the cognitive behavioral sequence and how it specifically relates to dysfunctional beliefs and fears. In later sessions, these beliefs and fears will be examined deeper in order to find and develop functional alternatives. This sense of awareness is closely linked to mindfulness, which forms a core component of the MDT process and it has been briefly explained at this stage in the online program, but is covered in greater depth in the next session and specific exercises are introduced.

* Session 5: Mindfulness

Two common definitions of mindfulness are:

"[Mindfulness is] A kind of nonelaborative, nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that arises in the attentional field is acknowledged and accepted as it is" (Bishop, et al., 2004, p. 282).

"Mindfulness means paying attention in a particular way, on purpose, in the present moment, and non-judgmentally" (Kabat-Zinn, 1994, p. 4).

The ability to be mindful is an essential skill in MDT as it creates an awareness and unattachment to unpleasant thoughts and feelings. It is associated with acceptance and empathy for the self and others, which lessens internal distress. Mindfulness is a skill that can be taught and improve with practice. It is introduced in a simple, non-threatening, and secular way as a relaxation technique. The purpose of teaching mindfulness to patients is to develop skills to develop their awareness of their inner and outer experiences, to recognize their thoughts and feelings as "just thoughts and feelings" that come and go, to understand how emotions manifest in their bodies, to recognize when their attention has wandered, and to provide tools for impulse control. The patient should not be led to excessive expectations of immediate calmness, peace, and other emotional and behavioral improvements. Instead, they are motivated to persevere without pressure, keep it simple, and set realistic expectations. Mindfulness is a journey that is not always pleasant, effortless, and carefree. Sometimes a person may feel worse after meditation than before. A patient needs to appreciate that this is part of the learning and growing process. Benefits may not be easily and quickly noticeable. But, by setting small goals, being patient, and with more practice, the easier and more achievable progress becomes.

One mindfulness exercise is introduced in each session. The patient is requested to complete it at least once or twice before the next session. Short audio clips are provided online to guide the patient through each exercise. The duration of the first sessions are 6 minutes, and extend to 15 minutes later on in the program. Initially the focus is only on breathing and relaxation. In subsequent sessions, guided imagery is utilized to focus the mind. The body scan technique is introduced, which is described as:

The body scan alternates between a wide and narrow focus of attention; from focusing on your little toe all the way through the entire body. The body scan trains your mind to be able to move from detailed attention to a wider and more spacious awareness from one moment to the next. (Alidina, 2015, p. 100).

The final three exercises that are introduced focus on "seeing thoughts as thoughts", the importance of values, and loving-kindness. The concept of the Default Mode Network (DMN) is also briefly described, in particular how our brains are wired to ruminate when our minds are not otherwise focused on a task. Rumination, or excessive worry, is widely associated with mood and behavioral problems, but through mindfulness meditation patients can learn how to disrupt these destructive thought patterns. The exercises are introduced as follows:

1. Sessions 2 and 3: Mindfulness of breathing (6 minutes)

2. Sessions 4 and 5: Ocean meditation (6 minutes)

3. Session 6: Body scan meditation (8 minutes)

4. Session 7: Mindfulness of breathing (10 minutes)

5. Session 8: Mountain meditation (10 minutes)

6. Session 9: Seeing thoughts as thoughts meditation (10 minutes)

7. Session 10: Loving-kindness meditation (10 minutes)

8. Session 11: Meditation on values (15 minutes)

The patient is asked to provide feedback of the experience at each session and given guidance and reassurance where required. Although it is recommended that they complete each exercise once or twice after it is introduced, they are encouraged to repeat it as many times as they feel the need, including repeating favorite exercises from previous weeks. All the audio clips are available online at https://soundcloud.com/user58142754.

* Session 6: Situations, beliefs, thoughts, and feelings

The sixth session is at the half-way mark of the online program and it is expected that the patient and therapist will already notice some improvements. It is an opportune time to review important principles, monitor progress, elicit feedback, and address concerns. The patient is encouraged to describe his/her experiences up to this point in the program, specifically relating to (1) an understanding of the underlying cognitive theory and whether they are able to relate to it in their own lives, (2) their personal experience of the mindfulness exercises, (3) whether they find the thought recording helpful, and (4) understand the value of identifying and being aware of their fears and negative beliefs and how it relates to emotions and behavior. The feedback is utilized to adapt the focus of the remaining sessions to address the individual needs of the patient.

* Session 7: TFAB worksheet

The Triggers, Fears, Avoids, and Beliefs (TFAB) worksheet is a tool in MDT therapy that links specific triggers with fears and core beliefs. Herein a concrete correlation between an event or situation that initiates the fear or avoid, and the belief, thinking, and feelings is established in specific terms. The sequence represents an automatic chain reaction between trigger and belief that precedes dysfunctional behavior that is either internalized or externalized. Frequent and long-term repetition of this process manifests in chronic or acute disorders such as personality disorders, depression, or anxiety, which is persistent and has to be treated at the belief level and by understanding the trigger [right arrow] fear [right arrow] avoid [right arrow] belief [right arrow] behavior sequence.

The TFAB is introduced in Session 7 and its significance explained in the eventual process to develop functional alternative beliefs linked to more helpful and healthier thoughts, feelings, and behavior. The beliefs that are strongly endorsed by the patient on the CCBQ are noted in the Beliefs column of the Triggers, Fears, Avoids, and Beliefs Correlation (TFAB) table (see Figure 5).

By selecting the five most distressing and negative beliefs and fears from the CCBQ and Fear Assessment completed in weeks 2 and 3, the patient is asked to think about and briefly describe the specific event or situation that typically precedes and triggers the fear or negative belief, or preceded it the most recent time of occurrence. Then, exploring the event, fear, and belief, what does the patient believe s/he is trying to avoid? It can be how they feel, how they believe other people see them, etc. By using the Fear Assessment and CCBQ as basis to complete the FTAB table, it is also possible to prioritize the respective trigger [right arrow] fear [right arrow] avoid [right arrow] belief sequences for treatment focus by starting to identify possible life-threatening and self-harm behaviors and other problems that severely affects functioning. The patient can rank the items in order of seriousness or frequency, whichever s/ he thinks impacts them the most.

The objective of completion and submission of the TFAB is two-fold. The patient has the opportunity to consciously explore each of their most consequential fears and beliefs. They then become aware of what it is that precedes and activates each, as well as what it really is that they are trying to avoid in the process. With the information, the online therapist has the opportunity to start formulating how to guide the patient to identify and develop functional alternative beliefs for use in future sessions.

* Session 8: COBB worksheet

The next step in the MDT process and online program is introducing and guiding the patient to complete the Conglomerate of Beliefs and Behaviors (COBB) worksheet. The COBB, in the form of a waterfall or process flow diagram, is constructed by linking the patient's beliefs and behaviors in a sequential, cause-and-effect, neural network format--or combination thereof. The COBB becomes the working plan of action to enable the patient and therapist to make a concerted effort to prevent or redirect undesirable behavior. In conjunction with the Triggers, Fears, Avoids, and Beliefs (TFAB) worksheet, the COBB is utilized by the online therapist to conceptualize the mechanisms of the patient's issues for application and refinement in the active treatment phase.

The Conglomerate of Beliefs and Behaviors, or COBB, takes the compound core beliefs that were originally endorsed in the Compound Core Beliefs Questionnaire (CCBQ) and included in the Triggers, Fears, Avoids, Compound Core Beliefs (TFAB) correlation one step further by linking the corresponding behavior. Hereby the patient and therapist is able to formulate a deeper understanding of the beliefs [right arrow] behavior sequences that are problematic. A single belief, or theme of beliefs, can evoke multiple or a sequence of behavioral responses, but it is important that the pairing is as specific and unique as possible.

The patient is asked to write down the most problematic beliefs identified in the CCBQ and listed in the TFAB worksheet in the left-hand column of the COBB worksheet. Then, describe the behavior that typically follows when each core belief is triggered or activated. Be as specific and descriptive as possible.

The TFAB and COBB worksheets become the patient and therapist's blueprints from here on to continue the online program. Each event/situation, fear, avoid, belief, and behavior pair will now be evaluated and explored with a few important considerations in mind: (1) being aware of the sequence or chain reaction between a situation and dysfunctional behavior, (2) being able to anticipate a potential trigger event and modify it, and (3) develop and implement functional alternative beliefs (FAB's) that will redirect thoughts, feelings, and behavior to helpful alternatives.

* Session 9: VCR-validate

The Validation, Clarification, and Redirection (VCR) process is introduced in session 9. VCR is the active treatment element in the Mode Deactivation Therapy (MDT) design. The approach is different from traditional Cognitive Behavioral Therapy propositions in that acceptance and validation is intentionally projected to the patient, and it is also cultivated within the patient through mindfulness and unconditional positive regard instead of being directly challenged and disputed as illogical and unrealistic.

As such, VCR is the core active treatment phase that is unique to the MDT methodology. The patient's beliefs as identified in the assessments and associated with triggers, fears, avoids, and behavior in the TFAB and COBB worksheets, are first validated to create an atmosphere of awareness, trust, and acceptance with the patient. All aspects thereof are validated as reasonable and logical within the patient's realm of circumstances and experiences by searching for the "grain of truth" in his/her beliefs and behaviors. Then, in the subsequent steps, functional alternative beliefs (FABS) are developed and implemented with the commitment that was cultivated in the process with the family.

The patient is asked to contemplate the possible reasons and contexts of their problematic beliefs. Are they necessary and helpful in his/her current context? Are they perhaps based on misguided perceptions? The activation of beliefs resulting in dysfunctional behavior is largely a subconscious and instinctive process designed to protect an individual from a real or perceived threat. Nevertheless, if it is harmful or problematic for the patient, there has to be a conscious exploration of the real situation and consequences, together with an explicit acceptance and validation of problematic beliefs and their roots. The therapist takes care never to trivialize or dismiss a patient's beliefs. Instead, the validity within a client's response is uncovered, sometimes amplified, and then reinforced.

* Session 10: VCR-clarify

By mutually understanding and confirming the content of responses, the therapist and patient becomes aware of his/her deeply entrenched belief schemas. It is a crucial step to clarify the client's perspective of their reality and beliefs. The patient's perspectives are discussed and clarified to interpret its role in individual functioning within their own contextual environment. In the process, the therapist facilitates and maintains a collaborative and proactive environment in which the patient is actively encouraged to clarify their values and understands their personal motivations and characteristics. This enables the therapist to work with the patient further on in the process to identify goals and develop functional alternative beliefs that would support these goals. The Clarification step utilizes an approach of consensus, mutual understanding, and cooperation that again supports a strong therapist-patient alliance and a commitment to treatment.

Therefore, where the Validation step uncovers and validates the "grain of truth" in the client's beliefs, the Clarification step facilitates the client's ability to understand and agree with these truths in order to redirect responses to functional, pro-social alternatives on the client's continuum of truths. Hereby the patient, together with the MDT therapist, explores how their experiences may have skewed their view of themselves, others, and the world, which provides a clearer understanding that their version or interpretation of the "truth" is not altogether accurate. As such, the clarification offers an alternative explanation of the patient's circumstances and history, which enables the "possible acceptance" of a slightly different (and more positive, functional) belief that is further developed and tested in the following Redirection step.

Patients are often inclined to engage in dichotomous, or all-or-nothing thinking and the Clarification technique offers an alternative explanation of the patient's interpretation of his/her circumstances and history that can fall somewhere within the range of a continuum rather than only at the extremes of the scale. In essence, Clarification is a learning process that forms the basis for Redirection toward new and positive alternatives for the patient. Together, the Validation and Clarification steps balance dysfunctional and Functional Alternative Beliefs (fab) by reducing anxieties, fears, avoidance, and maladaptive personality beliefs, while promoting and strengthening healthier choices. It prepares the patient for the Redirection stage where a possible acceptance of a different belief is explored and implemented. A change in the balancing of beliefs can be measured by the Compound Core Beliefs Questionnaire (CCBQ), which gives an indication of the progress of the client in formulating and accepting new alternative beliefs.

The patient is asked to extend the previously completed COBB worksheet by filling in additional columns. Examining each problematic beliefs and behavior from the COBB, and referring to the TFAB where relevant, the patient briefly describes the negative consequences that each has on themselves and others, and their current functioning, including how it relates to the life goals that s/he has listed in the beginning of the program. Then, formulate an alternative belief that may be more helpful and also acceptable in the specific situation. Examples are:

* "I can't trust anyone" compared to "It is okay to trust someone sometime."

* "I cannot handle feeling bad" compared to "I can deal with unpleasant thoughts and feelings."

* "I always make mistakes" compared to "I sometimes make mistakes. It is normal and not the end of the world."

* "I am unloved and unworthy" compared to "I am important and I belong somewhere."

* "I get what I deserve" compared to "Life is not always fair, but sometimes I get rewarded."

* "Life is always painful and disappointing" compared to "At times life can be okay and I have happy moments and feel satisfied."

At this time, with the guidance of the therapist via email and the Moodle room forum, the patient should realize that no bad feelings, thoughts, and behavior is absolute and the only alternative. It is not to be viewed in terms of extremes, but somewhere on a continuum. By learning to recognize that reality, and notice exceptions from the bad and unpleasantness that sometimes invades everyone's lives, the patient becomes more open and willing to consider alternative beliefs. All that it takes is a glimmer of hope, positivity, prospects, or meaning. The final steps that remain now in the MDT process is to ensure that the patient accepts and is willing to develop and try these alternatives.

* Session 11: VCR-redirect

Following the validation and clarification steps of the VCR process, the objective of the penultimate session is to implement the Functional Alternative Beliefs (FAB's) that were identified and formulated previously. Where Clarification is looking for another possible belief, or an alternative explanation to the client's beliefs, Redirection is looking for an agreement on those possible alternative beliefs--an acceptance and willingness to actively participate in the development of these beliefs, or looking for the possibility in the moment of another possible (and more functional) truth. In other words, on a scale of 1 to 10, is it possible that you could trust me at this time? Even a 1.5 or 2 is good. But, whatever the number, it's not a fact, just a possibility in the moment that something else could be true.

Hereby, the MDT therapist redirects responses to view other possibilities on a continuum of held beliefs. The goal of this step is to help the patient find the exception in his previously held belief system. The redirection involves examining the opposite side of the dichotomous or dialectical thinking. It was crucial to partner with the client to see the "grain of truth" in each of the dichotomous situations presented. It is often the case that patients--especially those with abusive and traumatic backgrounds--are stuck in their script for the content of their lives: How things were bad, how nothing was being done for them, they can't trust anyone, and so forth. Therefore, in the VCR process, the MDT therapist guides the patient to change from the relatively fixated view of the content of his life to looking at the context of beliefs instead, which contains a "grain of truth", but remains a perception and subjective interpretation of events and experiences and is therefore not wholly accurate and not the best functional version.

Referring back to the exercise that was introduced in session 4, the patient is asked to continue filling in their daily thought records, but to add an alternative solution or response in each case, which they try out and rerate their emotional experience afterwards.

This exercise influences the cognitive process from multiple angles. Firstly, a potentially problematic event in the future is anticipated. This allows the patient to give thought to beliefs that may be activated and responses that may be unhelpful. This then allows him or her to modify the circumstances or situation in order to render it more manageable or avoid it altogether. Secondly, it gives the patient the opportunity to formulate and practice alternative and healthier beliefs and responses ahead of time.

By reviewing the daily thought record, repeated or similar events to previous problematic ones can be assessed in terms of resulting thoughts, feelings, and behavior. In many cases an improvement based on the new functional alternative belief and compensatory strategy is noticeable. However, in deep-seated and resistant cases, there may initially only be a small difference, or no improvement at all. In such instances, the patient can look at a new and adjusted strategy, or take more time to practice and get adept with the current one. It is important to realize that some improvements take time to develop and gain momentum.

At this time, the online therapist, in conjunction with the patient, reviews the progress and notes areas that remain problematic. By now the patient should have the skills required to resolve the issues with continued self-maintenance, but in exceptional cases the program can either be extended with a repeat of one or more sessions depending on the specific need, or the patient can be referred for face-to-face therapy. The final session is used to reinforce the principles and process applied up to this point, complete a final review, and ensure that the patient is ready and confident to resume self-management.

* Session 12: reinforcement and wrap-up

Termination of therapy can be traumatic and anxiety is normal. The same applies to an online therapy program. In the three months or longer a bond has formed between the online therapist and patient. At this time, the therapist reviews all the session communications and patient assignments again. Taking time to review materials may help the therapist to recognize major accomplishments the client has made as well as the specific areas in which the client might need to strengthen his or her skills. Discussing the progress a client had made will help to reinforce the behavior change, and will be affirming to the client. The therapist may also find it necessary to express concerns about problem areas in which the client needs additional work.

The main objective of the final session is to celebrate progress, identify areas where continued work is required through self-management, note any shortcoming of skills that the patient may have that are required for effective self-management, and help the patient prepare for the transition. Aftercare, additional treatment, or a follow-up session at a later date are all options to consider after completion of an online program. Motivate the patient to continue with the exercises, including mindfulness meditation, that were done during the program. But, most important of all, ask the patient for feedback:

* Review what they have learned about themselves

* Discuss which goals (if any) they felt they weren't able to accomplish in therapy, and what to do about them

* Develop a post-therapy plan

* Discuss their feelings and experience of the therapeutic relationship and its termination

* Raise any other concerns that may exist

The final session is not one to avoid or rush, it is a very important opportunity to pull everything together, reinforce progress and positive aspects, motivate the patient, and address final concerns. MDT is a validating and mindful approach, which translates equally well onto an online delivery method than in face-to-face therapy. It is important to review the tools, skills, and insights that the patient has acquired during the program, as it will assist them to be self-sufficient after program completion. Also, the patient is reminded of their original therapy goals, improvements and achievements accomplished. If there are additional resources that the patient may benefit from for continued personal growth, the final session can also be used to make the client aware of them.

* Conclusions and recommendations

This article has set out to discuss the potential application of Mode Deactivation Therapy (MDT) as an online program and conceptualized adaptation of the current manualized methodology to a briefer, Moodle-compliant format without compromising its integrity and effectiveness. Given the advantages and potential benefits that online therapy offer, and the mental health need that continues to outweigh available resources, I feel that developing and testing such a system is a worthwhile endeavor to pursue. According to Mitchell and Murphy (1998), the Internet ...

"... can provide important services to clients who might not otherwise be willing or able to meet with professional counselors in their offices. Specifically I am referring to the geographically isolated, or those isolated by their various physical or emotional conditions, including the elderly and physically challenged. Online services can also be incredibly cost effective as they can minimize travel costs and office related expenses." (p. 1).

Mode Deactivation Therapy has already proven consistently effective in a number of research studies where adolescents with behavioral disorders and other complex comorbid condition were treated. The cognitive theory framework and principles of MDT is sufficiently robust to translate well to other conditions and adult populations. The next step is to develop and test a Moodle-based program based on the directives set out above in order to measure its effectiveness with an adult population with behavioral and mood disturbances that are related to maladaptive personality traits and/or trauma experiences.

References

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Author contact information

Joan Swart, Psy.D., MBA

Eisner Institute for Professional Studies

16133 Ventura Blvd, Ste 700

Encino, CA 91436

Email: joan@forensic-psychology.net

Phone: 78-999-9999

Joan Swart

Eisner Institute for Professional Studies

Figure 2. Life goals

goal                  specific          measurable     attainable

What is it that you   Who, what, why,   How much,      Achievable?
want to achieve?      where, & when?    often, many?

goal                  importance               time

What is it that you   How important is it to   When?
want to achieve?      you to achieve, 0-10

Figure 4. Daily thought record sheet

event            thought           consequence       belief or fear
                                   (emotion/
                                   behavior)

What happened?   What went         What emotion      What would you
Where? When?     through your      did you feel?     say the belief
Who with? How?   mind? Memories?   How intense was   or fear is that
                 Images? What is   it, rate 0-       triggered your
                 the meaning to    100? What did     thoughts and
                 you?              you do? What      feelings? What
                                   other             did you try to
                                   sensations did    avoid?
                                   you have?

Figure 5. Triggers, fears, avoids, and beliefs (TFAB) worksheet

trigger          fear              avoid             belief

What precedes    Highly endorsed   What is it that   Highly endorsed
the activation   items on the      is being          items on the
of the fear or   fear assessment   avoided, e.g.     CCBQ
belief? When?                      feeling alone,
Who? Where?                        embarrassed,
                                   weak, unworthy?

Figure 6. Conglomerate of beliefs and behaviors
(cobb) worksheet

core belief          corresponding behavior

Significant belief   When the belief is activated, what is the
items from the       resulting behavior, i.e. get angry, lash out,
TFAB and CCBQ        withdraw, cry, eat, use drugs or alcohol?

Figure 8. Functional alternative beliefs form

core       corresponding   negative            functional
belief     behavior        consequences        alternative

From the   From the COBB   In terms of         Think of a
  COBB                       current             more helpful
                             relationships,      belief in the
                             state of mind,      circumstances
                             and achievement
                             of goals

Figure 9. Daily functional alternative schedule

event            thought             consequence (emotion/behavior)

What happened?   What went through   What emotion did you feel?
Where? When?     your mind?          How intense was it, rate
Who with? How?   Memories? Images?   0-100? What did you do? What
                 What is the         other sensations did you have?
                 meaning to you?

event            belief or fear

What happened?   What would you say the
Where? When?     belief or fear is that
Who with? How?   triggered your thoughts
                 and feelings? What did
                 you try to avoid?

event            alternative belief & action

What happened?   What alternative belief/response
Where? When?     did you or could you have used?
Who with? How?   What was the new outcome?
                 Rerate your experience 0-100.

Figure 10. Redirection examples

problem belief   alternative         functional
                 thoughts            alternative belief

I can't trust    Not everyone        It is okay to trust
  anyone           is bad              someone sometime
I always make    Sometimes I do      I okay to believe in
  mistakes, I      something right     myself and do or
  am useless                           try something new

problem belief   compensatory        reinforcing
                 strategy            behavior(s)

I can't trust    Be more             Show trust sometime
  anyone           accommodating
I always make    Be more assertive   Take initiative
  mistakes, I
  am useless
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Date:Dec 22, 2015
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