Appendix 1

Worksheets and Checklists

Contents
Cognitive-Behavior Therapy Case Formulation Worksheet
Automatic Thoughts Checklist
Thought Change Record
Examining the Evidence for Automatic Thoughts Worksheet
Weekly Activity Schedule
Schema Inventory
Examining the Evidence for Schemas Worksheet
Cognitive-Behavior Therapy Supervision Checklist
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Cognitive-Behavior Therapy Case Formulation Worksheet
Patient Name: Date:
Diagnoses/Symptoms:
Formative Influences:
Situational Issues:
Biological, Genetic, and Medical Factors:
Strengths/Assets:
Treatment Goals:
Event 1 Event 2 Event 3
Automatic Thoughts Automatic Thoughts Automatic Thoughts
Emotions Emotions Emotions
Behaviors Behaviors Behaviors
Schemas:
Working Hypothesis:
Treatment Plan:
Automatic Thoughts Checklist
Instructions: Place a check mark beside each negative automatic thought that you have had in the past 2 weeks.
_____ I should be doing better in life.
_____ He/she doesnt understand me.
_____ Ive let him/her down.
_____ I just cant enjoy things anymore.
_____ Why am I so weak?
_____ I always keep messing things up.
_____ My lifes going nowhere.
_____ I cant handle it.
_____ Im failing.
_____ Its too much for me.
_____ I dont have much of a future.
_____ Things are out of control.
_____ I feel like giving up.
_____ Something bad is sure to happen.
_____ There must be something wrong with me.
Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.
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Examining the Evidence for Automatic Thoughts Worksheet
Instructions:
1. Identify a negative or troubling automatic thought.
2. Then list all the evidence that you can find that either supports (evidence for) or disproves (evidence against) the
automatic thought.
3. After trying to find cognitive errors in the evidence for column, you can write revised or alternative thoughts at the
bottom of the page.
Automatic thought:
Evidence for automatic thought: Evidence against automatic thought:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Cognitive errors:
Alternative thoughts:
Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.
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Schema Inventory
Instructions: Use this checklist to search for possible underlying rules of thinking. Place a check mark beside each schema
that you think you may have.
Healthy Schemas Dysfunctional Schemas
___ No matter what happens, I can manage somehow.
___ If I work hard at something, I can master it.
___ Im a survivor.
___ Others trust me.
___ Im a solid person.
___ People respect me.
___ They can knock me down, but they cant knock me out.
___ I care about other people.
___ If I prepare in advance, I usually do better.
___ I deserve to be respected.
___ I like to be challenged.
___ Theres not much that can scare me.
___ Im intelligent.
___ I can figure things out.
___ Im friendly.
___ I can handle stress.
___ The tougher the problem, the tougher I become.
___ I can learn from my mistakes and be a better person.
___ Im a good spouse (and/or parent, child, friend, lover).
___ Everything will work out all right.
___ I must be perfect to be accepted.
___ If I choose to do something, I must succeed.
___ Im stupid.
___ Without a woman (man), Im nothing.
___ Im a fake.
___ Never show weakness.
___ Im unlovable.
___ If I make one mistake, Ill lose everything.
___ Ill never be comfortable around others.
___ I can never finish anything.
___ No matter what I do, I wont succeed.
___ The world is too frightening for me.
___ Others cant be trusted.
___ I must always be in control.
___ Im unattractive.
___ Never show your emotions.
___ Other people will take advantage of me.
___ Im lazy.
___ If people really knew me, they wouldnt like me.
___ To be accepted, I must always please others.
Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.
Examining the Evidence for Schemas Worksheet
Instructions:
1. Identify a negative or maladaptive schema that you would like to change, and write it down on this form.
2. Write down any evidence that either supports or disproves this schema.
3. Look for cognitive errors in the evidence for the maladaptive schema.
4. Finally, note your ideas for changing the schema and your plans for putting these ideas into action.
Schema I want to change:
Evidence for this schema: Evidence against this schema:
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Cognitive errors:
Now that Ive examined the evidence, my degree of belief in the schema is:
Ideas I have for modifications to this schema:
Actions I will take now to change my schema and act in a healthier way:
Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.
Cognitive-Behavior Therapy Supervision Checklist
a
Therapist _______________________________________________
Supervisor______________________________________________ Date _________________________________
Instructions: Use this checklist to monitor and evaluate competencies in CBT. Listed in Part A are competencies that should
typically be demonstrated in each session. Part B (next page) contains competencies that may be demonstrated over a course
of therapy or therapies. The checklist is not intended for evaluation of performance in first or last sessions.
Part A: Competencies that should typically be demonstrated in each session.
Competency Superior Satisfactory
Needs
improvement
Did not
attempt or N/A
1. Maintains collaborative empirical alliance
2. Expresses appropriate empathy, genuineness
3. Demonstrates accurate understanding
4. Maintains appropriate professionalism and
boundaries
5. Elicits and gives appropriate feedback
6. Demonstrates knowledge of CBT model
7. Demonstrates ability to use guided discovery
8. Effectively sets agenda and structures session
9. Reviews and assigns useful homework
10. Identifies automatic thoughts and/or beliefs
(schemas)
11. Modifies automatic thoughts and/or beliefs
(schemas)
12. Utilizes behavioral intervention or assists patient
with problem solving
13. Applies CBT methods in flexible manner that meets
needs of patient
Part B: Competencies that may be demonstrated over a course of therapy or therapies
Competency Superior Satisfactory
Needs
improvement
Did not
attempt or N/A
1. Sets goals and plans treatment based on CBT
formulation
2. Educates patient about CBT model and/or therapy
interventions
3. Demonstrates ability to use thought record or other
structured method of responding to dysfunctional
cognitions
4. Can utilize activity or pleasant events scheduling
5. Can utilize exposure and response prevention or
graded task assignment
6. Can utilize relaxation and/or stress management
techniques
7. Can utilize CBT relapse prevention methods
Comments:
a
Checklist developed by Donna Sudak, M.D., Jesse H. Wright, M.D., Ph.D., David Bienenfeld, M.D., and Judith Beck, Ph.D., 2001.