FZM Self-Help Protocol: Instructions For Working With Automatic Thoughts

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

Psychologist, Cognitive Behavioral Therapist

Tashkent city (Uzbekistan)

The article was co-authored with

cognitive behavioral therapist:

Yakovleva Irina Viktorovna

One of the main tools in cognitive-behavioral psychotherapy is the protocol "Form of recording thoughts" (FZM) … An earlier version of the form was developed by Aaron Beck (Beck et al., 1979). It is an effective way of responding to automatic thoughts.

Consistent work with the form allows you to:

1. Identify and structure information about automatic thoughts and reactions.
2. Evaluate thoughts for usefulness and realism.
3. Form adaptive responses to dysfunctional thoughts.
4. Identify and structure information about automatic thoughts and reactions.
5. Evaluate thoughts for usefulness and realism.
6. Form adaptive responses to dysfunctional thoughts.

Such work helps to change the perception of situations that cause distress in clients and improves their condition. The use of the form for independent work in between sessions allows the therapy to be carried out more successfully.

With regular use of the form, the skill of functional response to dysfunctional thinking is formed, which helps clients to more effectively cope with problems after the completion of therapy.

Preliminary preparation for working with the protocol

Before you start working with the form, you need to understand how the cognitive model works and the importance of identifying and evaluating automatic thoughts.

In therapy, the protocol is introduced sequentially: at the first stage, clients learn to fill in the first three columns, and at the second stage, the next two.

Therapist: “Today I want to introduce you to a useful tool that helps you effectively work with automatic thoughts. This form is called FZM (form of recording thoughts). With its help, you will be able to disassemble the thoughts that bother you and form adaptive useful responses to them. We'll break it down in two steps. First, we will learn how to fill in the first three columns, and then the next two. Do you agree?"

Client: "Yes good idea".

Therapist: “This is an effective technique, but in order to master it, you need to practice - mistakes can happen, which at the beginning everyone has. Together we will figure out what did not work out for you, and next time it will turn out better."

To increase the likelihood that the client will use the form, I provide the rationale for its application, demonstrate the effectiveness of the method, and practice completing the form with it.

Filling in the first three columns

Working with the protocol begins with filling in the first three columns. In the learning process, we first fill in the first and third columns, and the second, with automatic thoughts, we fill in last. This is done so that the client is aware that it is his thoughts that influence his reactions in certain situations. In the future, the columns can be filled in any order.

To fill in the first three columns, you need to learn how to identify automatic thoughts and clearly distinguish such concepts as: situation, emotion, physiology and behavior.

First column. Situation

(firing trigger event)

In the first column, the client writes down the situation after which his mood worsened. A situation is a simple statement of fact, not an assessment.

A situation can be an actual event that has already happened or is expected in the future. It can also be emotional reactions, bodily sensations, behavior, reflections, images or memories.

The table shows examples of different situations.

It is important to determine not only the problem situation itself, but also the moment when clients experienced emotional discomfort: before the situation, directly in the situation itself or after it. So the therapeutic effect will be more effective.

Therapist: “In the first column, we write down the situation in which your condition worsened. Remember the last time your mood changed?"

Client: "Yesterday afternoon, when I met a girl that I have liked for a long time, and I could not go up to her and get to know her."

Therapist: “The mood worsened immediately after the meeting, or later when you remembered the event?”

Patient: "As soon as I saw her."

Therapist: “Then in the first column, write down the date and the situation:“I saw a girl on the street and wanted to meet her.”

Client: (Writes).

Third column. Reactions:

emotion, physiology and behavior

In the third column, the client records their emotional, bodily, and behavioral responses to dysfunctional AMs. To make it easier for clients to identify their emotions, they can use a table listing common negative emotions.

When a client names his emotions, I ask you to determine the intensity of the manifestation of these emotions as a percentage - this way it is easier for me to understand whether it is necessary to study the situation in more detail. Situations with a high strength of emotional manifestation require attention.

Therapist: “In the third column, we will write down the emotion that you experienced in this situation. How did you feel when you wanted to go up to the girl and meet her?"

Client: "I felt how awful it would be if she refused."

Therapist: “These are important thoughts, and we will definitely appreciate them. Let's see what is the difference between thoughts and feelings."

Client: "Let's".

Therapist: “Feelings are your feelings and experiences, which can be summed up in one word: joy, anger, anger, fear, and others. Thoughts are ideas that appear in your head in the form of words, pictures, and representations. Do you understand this?"

Client: "Yes, now I understand better."

Therapist: "So how did you feel at that moment?"

Client: "I became very anxious."

Therapist: “Imagine that the worst anxiety you have ever experienced is 100%, and zero percent when you feel calm. Try to rate on a scale of 0 to 100%, how anxious were you?"

Client: "Very alarming - probably 70 percent."

Therapist: "Write it down."

Client: (Writes).

Therapist: "Can you remember your feelings in the body at that moment?"

Client: "Yes, I got tension in my body, my hands began to tremble and my heart began to beat faster."

Therapist: "How has your behavior changed in this situation?"

Client: "I dropped my eyes, quickened my pace and walked past."

Therapist: "Let's put this in the third column."

It is useful for clients with high levels of anxiety not to avoid situations that cause fear, but to meet them more often and behaviorally test their predictions in practice.

Second column. Automatic thoughts (AM)

In the second column, the client writes down their automatic thoughts. This can be done in two ways - either write down the words that come to mind, or describe your ideas in the form of images. Automatic thoughts are a personal assessment of various events, views and beliefs, requirements for oneself, the world and other people.

If the first AM is correct, then evaluating that thought will not improve the client's condition. In this case, it is necessary to identify the value of AM, behind which his intermediate and deep beliefs are "hidden", the work with which will significantly reduce the client's distress. The Falling Arrow technique is used to identify such beliefs.

Therapist: “In the second column, we write down the thoughts that caused you anxiety. What did you think when you wanted to meet a girl?"

Client: "What if she refuses?"

Therapist: "And if you reformulate your thought from interrogative to affirmative, how would it sound?"

Client: "I thought she might refuse me."

Therapist: "Suppose she refuses you, what will that mean to you?"

Client: "It will be terrible."

Therapist: "This is really frustrating, but what's so terrible about that?"

Client: "If she refuses me, I will consider myself a failure."

Therapist: “So, you thought,“If a girl refuses to meet me, then I’m a failure,”and this thought led to anxiety. If we take for 100% absolute confidence in the accuracy of a thought, then how much do you believe in its realism?"

Patient: "I have almost no doubt - about 90 percent."

If the client voices not fully formulated (telegraphic) thoughts or thoughts in the form of a question, then such thoughts must be reformulated in a full affirmative form, and then they should be evaluated.

The table provides examples of how to paraphrase interrogative and telegraphic thoughts into statements:

After identifying AM, it is necessary to determine what type of cognitive distortions this thought belongs to. This step helps to reduce client distress faster already at the stage of AM detection.

Identifying cognitive biases

Cognitive errors - This is a repetitive pattern "traps" of thinking associated with a distorted interpretation of reality. They are so natural that we are not aware of their presence and they often cause increased anxiety and depression.

I introduce clients to a list of cognitive biases so that they can learn to identify them on their own so that automatic thoughts are checked for validity and usefulness more efficiently.

Therapist: "Now let's try to define what type of cognitive biases your thought can be attributed to?"

Client: "A loser is most likely a label, so my thought can be attributed to the cognitive error of 'labeling'."

I suggest that clients keep a list of cognitive biases handy and refer to it each time they identify automatic thoughts. This will help them make sure their thoughts are distorted and distance themselves from them.

The result of filling the first three columns

We check the correctness of filling the first three columns

Immediately during the session, I check whether the client can fill in the first three columns on his own. And if difficulties arise, we train together until he learns to fill them.

Therapist: "Let's put another situation on the form that upset you last week."

Client: "I called my father and I felt very sad."

Therapist: “Try to remember that moment again. You called your father and you felt sad. What did you think then? "

Client: “Even my father is not interested in me. Nobody needs me.

Homework # 1

When we are convinced that the client can fill in the first three columns, we suggest that he continue this work at home on his own.

Therapist: "As a homework assignment, I suggest you try to fill in the first three columns of the FZM several times."

Client: Okay, I'll try.

Therapist: “A little explanation: the columns can be filled in any order. For example, it will be easier for you to write down an unpleasant emotion, and only then a thought. In addition, the first time something may not work out - this is normal. Over time, you will learn to do this easily. Try to analyze one situation every day during the week. "

Hometasks - an integral part of therapy. Their regular implementation allows you to quickly achieve positive results. By explaining the benefits of homework and discussing possible difficulties in completing it, the likelihood that the client will want to complete the tasks will increase.

Fourth column. Adaptive response

After identifying an important automatic thought and the client's reaction to this thought, it is necessary to check it for reliability using Socratic questions, and then form an adaptive answer, which we will enter in the fourth column.

Therapist: “So when you wanted to meet a girl, you thought, 'If she refuses me, then I'm a failure.' You are 90% convinced of the truth of this thought, and it causes you great anxiety."

Client: "Yes, that's right."

Therapist: “Remember what we discussed with you last time? Automatic thoughts may or may not be true. And even if they turn out to be true, we often draw distorted conclusions from them. Let's check how true your thought is? To do this, we will use the questions from the list."

I explain to clients that not every question on the list is suitable for evaluating different automatic thoughts. Also, using all the questions will take too much time and effort. Therefore, it is not necessary to answer all the listed questions in a logical sequence.

First group. Questions about evidence and alternative explanations allow us to identify facts for and against AM and then find a more realistic explanation for what happened.

Second group. Questions on "decatastrophization" help to think wider and see different scenarios for the development of events; understand that the worst fears are unlikely to happen and even if the worst does happen, they can deal with it.

Third group. Questions about consequences allow you to see what consequences the belief in AM leads to, and how the reactions change when thinking changes. "Distance" helps to broaden your view of the situation, to look at the problem from the outside and to distance yourself from it.

After answering the Socratic questions, I invite the client to formulate an adaptive response to his AM, and assess the degree of confidence in the answer from 0 to 100%. Then we enter the received answer into the fourth column.

Therapist: “Now let's try to formulate the most realistic and useful answer to your thought. What conclusion have you made for yourself?"

Client: “I realized that there are many reasons why a girl can refuse. Her refusal will not mean that I am a failure. The fact that I am acting already suggests that I am a strong and confident person."

Therapist: "Well done! How convinced are you of the new answer from 0 to 100%?"

Client: "I have almost no doubt, I believe by 90%."

Therapist: "Write your answer in the fourth column and write percentage next to it."

Client: (writes down).

Therapist: “Okay, now let's form together a coping card that will remind you of the conclusion you made in our work today.”

I encourage clients to re-read therapy notes every morning and throughout the day as needed. Regular repetition can help change your habitual mindset to a more rewarding and realistic one more effectively than reading notes only in situations of emotional distress.

Fifth column. Result

When the main work is done, we move on to the final stage, in which we evaluate the client's emotional state and the degree of his conviction in the previous AM. Then we ask how he would like to act in this situation now, and we enter his answers in the fifth column.

The client's responses in this column will show how helpful the therapeutic work has been to him.

Therapist: “Now let's fill in the last fifth column. How much do you believe in your automatic thought now and how do you feel?"

Client: "I believe 10 percent and I'm not so worried anymore."

Therapist: "What would you like to do now?"

Client: "The next time I meet this girl, I will go over and meet her."

Therapist: "Amazing! Let's put this information in the fifth column and indicate the degree of intensity next to it. This will help to see the result of our work."

It is important to understand that all negative thoughts may not immediately disappear. If working with the form helps by 10 percent, this is already a good result.

Fully completed FZM protocol

Homework # 2

After we have learned how to fill out the form together, I instruct clients to try to fill out the form on their own. I draw their attention to the fact that even if something does not work out, it will still be useful and help to collect important information for further work.

Therapist: “Today our work with the form was rewarding - the intensity of anxiety dropped from 70 to 20%. Do you think the FZM can help you in the future?"

Client: "Yes, I'm sure of that."

Therapist: “You know, when my mood gets worse, I sit down to fill out the form myself. It helps me feel better. How do you like this idea, as a homework assignment to try to fill out the form yourself?"

Client: "Good idea, of course I'll try."

Therapist: "What is the probability that you will do this, from 0 to 100%?"

Client: “Most likely I will. 90 percent what I will do."

Therapist: "If you manage to completely fill the FZM - that will be great! But if in the process of work you have difficulties, then it's okay. At the next meeting we will discuss what did not work out for you."

The signal that it is time to fill out the form will be the deterioration of the client's mood. Therefore, at the end of the session, we form a coping card that will remind him of this.

For all the usefulness of CBT techniques and forms, most clients go through a stage where filling out forms does not bring the expected result. Therefore, it is important to explain to them that difficulties always teach us something new. This helps clients avoid negative thoughts about their abilities, form and therapy in general.

Conclusion

Working with the FPM protocol allows clients to independently assess their automatic thoughts and form rational responses to them, this helps them feel better. With prolonged use, the form becomes a kind of trainer for thinking - clients begin to think wider, more rational and more realistic, and their life changes qualitatively for the better.

Bibliography:

1. Beck Judith. Cognitive Therapy: A Complete Guide: Per. from English - M.: OOO "ID Williams", 2006. - 400 s: ill. - Parallel. tit. English
2. Beck Judith. Cognitive Behavioral Therapy: From Basics to Directions. - SPb.: Peter, 2018.-- 416 s: ill. - (Series "Masters of Psychology")