Wednesday, June 18, 2014

Cognitive Clock CBT Session Tool

This is an intervention that was shared with me a few years back by my clinical supervisor, Ron Ober, LCSW, CCBT.  At its core the Cognitive Clock is CBT 101, and I have found it to be effective in individual therapy as well as group therapy.  The Cognitive Clock can be downloaded from Utila's Clinical Tool Library.

To demonstrate how it's used, I'll use a clinical vignette of myself as a teenager with performance anxiety.

Step 1: Identify the first chronological event

Here is the scenario:  I was a junior in high school and had signed up with my friends to perform a Phish song in front of the entire school.  I was pretty good at guitar but terrified of performing.  Here is how I would start the cognitive clock.



Step 2: Identify mood, thought, and behavior related to first event

For each event, you are going to identify the mood (scaled from 1-10), thought, and action.  For now, we'll leave the alternative thought or action blank  Here is what I've got so far:

Mood Thought Action Alternative thought/action
1.)  Nervous (5) / Excited (5) I'm going to look so cool if I nail this Phish song Signed up to perform


Step 3: Complete sequence of events chronologically

We will continue with the story chronologically, repeating steps 1 and 2...  I was pretty nervous leading up to the day of the performance, rehearsing a lot by myself, and a few times with my friends.  I thought that if I practiced over and over, that I would be able to overcome my anxiety and perform the song flawlessly.  On the day of the performance, the stress and anxiety were getting to me.  I felt physically tired.  My friends and I went to Burger King before the performance, and I decided to drink a huge Dr. Pepper hoping that I would not feel as tired.  We returned to school, and I started furiously rehearsing my opening guitar lines.  But I couldn't get them right!  I kept trying and trying to get the line just right before we went on stage.  The time came, our song began and...I freeze.  Total humiliation.  I do my best to hide my embarrassment, and finish the song.  I am crushed.

Here is what my Cognitive Clock looks like now:



Mood Thought Action Alternative thought/action
1.) Nervous (5) / Excited (5) I'm going to look so cool if I nail this Phish song Signed up to perform
2.) Nervous (6) / Excited (6) If I just practice enough, then I will overcome my anxiety Practiced by myself, and with my friends
3.) Physically Tired (5) I won't feel tired if I drink some caffeine... Go to Burger King with my friends
4.) Hopeful (3) This is going to make me feel not tired! Drank a huge Dr. Pepper
5.) Starting to panic (7) I can't get the first line of the song right!!! Try it over and over
6.) Panic / frozen (9) The song is starting, and my fingers won't work! Let the drums and base play opening lines


Step 4: Identify alternative thought / action

Up until this point, there have been two therapeutic tasks: exploring the relation between thoughts, feelings, and actions; and, facilitating a structured processing of the event.  The final therapeutic task is to learn new ways of dealing with similar challenges in the future.  The therapist would first ask me if I could think of any different ways of thinking or acting, and then suggest interventions as needed.  Here is how I might have addressed my performance anxiety differently:

Mood Thought Action Alternative thought/action
1.) Nervous (5) / Excited (5) I'm going to look so cool if I nail this Phish song Signed up to perform Maybe choose an easier song to build confidence
2.) Nervous (6) / Excited (6) If I just practice enough, then I will overcome my anxiety Practiced by myself, and with my friends Try practicing in public place
3.) Physically Tired (5) I won't feel tired if I drink some caffeine... Go to Burger King with my friends Caffeine can make anxiety worse!
4.) Hopeful (3) This is going to make me feel not tired! Drank a huge Dr. Pepper Try relaxation and structured breathing to manage stress and anxiety
5.) Starting to panic (7) I can't get the first line of the song right!!! Try it over and over Maybe try distraction? Work on accepting performance mistakes
6.) Panic / frozen (9) The song is starting, and my fingers won't work! Let the drums and base play opening lines Not much else you could do at this point!

Feel free to download Ron Ober's Cognitive Clock.  And if you have therapy tools that you think others could benefit from, please register for Utila and start sharing and rating.

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